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The Comprehensive Care for Joint Replacement (CJR) Model is a mandatory model for participants in selected Metropolitan Specific Areas (MSAs) aimed at testing to see if an episode based payment approach for lower extremity joint replacement (LEJR) can incentivize hospitals to reduce cost and concurrently maintain or improve quality.

The first performance year examined LEJR episodes initiated on or after April 1, 2016 and ended December 31, 2016. The Lewin Group with partners was contracted by CMS to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model. On August 31, 2018, CMS posted the First Annual Report to CMS’ CJR webpage.

Key Report Findings

“CJR participant hospitals were able to reduce payments through changes in utilization while maintaining quality of care. At the same time, we found no indication that CJR participant hospitals selected healthier patients to achieve these results.”

• Total episode payments decreased 3.3% ($910) more for CJR episodes than control group episodes. “At the same time, quality of care was maintained, as indicated by claims-based quality measures.”
• Average total payment reductions for CJR episodes occurred in both historically high and low Metropolitan Statistical Areas (MSAs). Historically high MSAs averaged a $1,127 decrease and historically low MSAs averaged a $577 decrease in episode payment as compared to the control episodes.
• Average Total Payments were reduced for both elective and fracture episodes relative to the control group.
• Elective Episodes were reduced by $880, and
• Fracture Episodes were reduced by $1,345

A driver in episode payment reduction by participating hospitals was by reducing institutional Post-Acute Care (PAC) payments. Specifically, fewer Inpatient Rehabilitation Facility (IRF) transfers and patients spending fewer days in a skilled nursing facility (SNF). Key ways participating hospitals changed their PAC use included the following:

• Expanded patient education efforts,
• Starting discharge planning earlier,
• Increasing coordination with PAC providers, and
• Developing preferred provider networks.

Before this model started, there was a concern that participating hospitals would pick healthier patients for participation. Claims data analysis by the Lewin Group “provided no indications of changes in patient characteristics for CJR episodes relative to control group episodes.”

“Possibly the most notable outcome during the first CJR model performance year was that statistically significant changes in utilization and payments occurred so quickly. With approximately nine months of implementation, the CJR model resulted in outcomes that are consistent with what has been achieved in other bundled payment initiatives. More time under the CJR model will help in determining if continued improvements can be achieved.”

The entire report, report appendices and a two page high level “Findings at a Glance” summary can be accessed on the CMS CJR webpage at https://innovation.cms.gov/initiatives/cjr.

Q:

Is there any information available yet concerning the 2019 CPT codes for Radiology services?

A:

Yes. The American College of Radiology (ACR) has released information about the 2019 CPT code changes expected for Radiology. Just like years past, we will see more procedures with bundling of the Radiology component into the surgical procedure; in other words, no separate reporting of the imaging guidance 7xxxx CPT code.  

If your facility performs any of the procedures listed below, you may want to take a closer look. Click here to see ACR’s summary.  

• Fine needle aspirations inclusive of imaging guidance
• Breast MRI with CAD
• Knee arthrography
• Ultrasound elastography
• Contrast enhanced ultrasound
• Deletion of fluoroscopy CPT code 76001
• PICC line insertion inclusive of imaging guidance
• Gastrostomy tube replacement – simple and complex
• Bone density ultrasound
• PET absolute quantitation myocardial blood flow

Q:

Any time a patient is documented with (acute/chronic) congestive heart failure and diastolic or systolic dysfunction, can this be coded as diastolic or systolic heart failure?

A:

No.  In ICD-10-CM, there is no longer an index for diastolic/systolic dysfunction. The provider must now link the heart failure (acute and/or chronic) with the diastolic or systolic dysfunction. 

Refer to Coding Clinic, First Quarter 2017: Page 46

• When provider has linked acute/chronic (congestive) heart failure with either diastolic or systolic dysfunction, it should be coded as “acute/chronic” diastolic and/or systolic heart failure.
• I50.20 – Unspecified systolic (congestive) heart failure
• I50.21 – Acute systolic (congestive) heart failure
• I50.22 – Chronic systolic (congestive) heart failure
• I50.23 – Acute on chronic systolic (congestive) heart failure
• I50.30 – Unspecified diastolic (congestive) heart failure
• I50.31 – Acute diastolic (congestive) heart failure
• I50.32 – Chronic diastolic (congestive) heart failure
• I50.33 – Acute on chronic diastolic (congestive) heart failure
• I50.40 – Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
• I50.41 – Acute combined systolic (congestive) and diastolic (congestive) heart failure
• I50.42 – Chronic combined systolic (congestive) and diastolic (congestive) heart failure
• I50.43 – Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
• If there is not supporting documentation linking the two conditions by the provider; assign code I50.9, Heart failure, unspecified.
• In ICD-10-CM, Congestive heart failure is included in the codes for diastolic and systolic heart failure. When documentation lists congestive heart failure along with either diastolic or systolic heart failure, assign a code for the type of heart failure only (diastolic/systolic).

Example:    

• Congestive heart failure with acute on chronic diastolic heart failure
• Assign code I50.33 only. Code I50.9 would not be reported in addition.

If you are a frequent reader of our newsletter, you often see the acronyms “OPPS” and “IPPS.” These refer respectively to the outpatient and inpatient prospective payment systems. Medicare describes a Prospective Payment System (PPS) as “a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups (DRGs) for inpatient hospital services).” This means for a particular DRG, a hospital always receives the same payment. Well, that is, until they don’t. Under Medicare’s transfer policies, DRG payments are prorated (reduced) when a patient transfers to another hospital or to select post-acute care settings. The specific regulations regarding transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, Section 40.2.4.

The transfer policies bring in yet another acronym - the post-acute care transfer (PACT) policy. In recent weeks, two issues have come up related to the PACT policy. Before discussing these issues, let’s do a quick review of the policy.

• PACT policy only applies to certain MS-DRGs. The list of DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
• PACT policy only applies when the patient is transferred to certain post-acute care settings:
• Inpatient rehab facilities and units (discharge status code 62)
• Long term care hospitals (code 63)
• Psychiatric hospitals and units (code 65)
• Children’s and Cancer hospitals (code 05)
• Skilled nursing facilities (code 03)
• Home with a home health plan of care that begins within 3 days (code 06)
• Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code as needed.
• Payment is only reduced if a patient stays fewer days than expected in the first (transferring) hospital for a particular DRG (the geometric mean length of stay or GMLOS).
• Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2 x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
• There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
• Transfer cases are eligible for outlier payments

Also see MLN Matters Article SE1411 for more information about discharge status and Medicare transfer policies.

The first new PACT issue is that the 2019 IPPS Final Rule added discharges to hospice to the PACT policy. This change was made in accordance with amendments to the Social Security Act by the Bipartisan Budget Act of 2018. The new law requires a discharge to hospice care provided by a hospice program to be a qualified discharge under PACT. This means qualifying DRGs with a Patient Discharge Status code of 50 (Discharged/Transferred to Hospice—Routine or Continuous Home Care) or 51 (Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite) are subject to the post-acute care transfer policy effective for discharges occurring on or after October 1, 2018.

The second issue related to the PACT policy is a new item added to the August update of the Office of Inspector General (OIG) Work Plan:

“Hospitals' Compliance with Medicare's Transfer Policy With the Resumption of Home Health Services and the Use of Condition Codes

Medicare payments to acute care hospitals for inpatient stays under Medicare Part A are made on the basis of prospectively set rates. Normally, Medicare pays a hospital discharging a beneficiary the full amount for the corresponding diagnosis-related group (DRG). In contrast, a hospital that transfers a beneficiary to another facility or to home health services is paid a graduated per diem rate, not to exceed the full DRG payment. When transferring a patient to home health services, the hospital can apply specific condition codes to the claim and receive the full DRG payment. The hospital is responsible for coding the bill on the basis of its discharge plan for the patient or adjusting the claim if it finds out that the patient received postacute care after the discharge. We will determine whether Medicare appropriately paid hospitals' inpatient claims subject to the postacute care transfer policy when (1) patients resumed home health services after discharge or (2) hospitals applied condition codes to claims to receive a full DRG payment.”

The PACT policy applies when patients are discharged to “home under a written plan of care for the provision of home health services from a home health agency and those services occur within 3 days after the date of discharge - Patient Discharge Status Code 06 (or 86 when an Acute Care Hospital Inpatient Readmission is planned)” with some exceptions. One exception is when the home health services are not related to the reason for the inpatient admission hospital stay. In this case, condition code 42 is reported on the claim with a discharge status code 06, and the hospital will receive full payment based on the MS-DRG and not a per diem payment. This may occur when there is a resumption of home care services the patient was receiving before hospital admission, if the reason for the home health services is not related to the reason for hospital care.

A hospital can also receive full payment if the home health services do not begin within 3 days of the inpatient discharge. If home care was started more than three days after discharge from the hospital, the hospital would report condition code 43 on the claim. Again, in this case, the hospital will receive full payment based on the MS-DRG and not a per diem payment.

Hospitals should definitely be reporting these condition codes when applicable so as to receive appropriate Medicare payments. But they also need to be sure they are using the codes correctly and only when the required conditions apply. The tricky part about discharge status coding is that the hospital staff may not always know what actually happens when the patient leaves the hospital. It is a good practice to have someone verify with the patient if and exactly what and when post-discharge care occurred. For example, if home health services were planned to begin on day 4 after discharge, but actually began on day 3, it would not be appropriate to report condition code 43. Or the reverse could happen – home health planned for day 2 but does not begin until day 4 after discharge, in which case reporting condition code 43 could result in a higher, appropriate payment.

Another key is communication between case management/discharge planners, coders, and the billing office. Case management documentation is usually the most reliable source for post-discharge plans. If something changes after discharge, and the case managers have followed up to know that, they need to amend documentation and inform the coders and billers if the account has already been coded and/or billed. One last recommendation is a compliance review of discharge status every now and then. This was a huge issue when I started in hospital compliance many years ago and as you can see by the new OIG Work Plan item, it continues to be so. Here is a list of the tips noted above plus a few more to ensure accurate discharge status coding, billing, and appropriate payments:

• Make sure coders know and understand correct use of the discharge status code,
• Make sure coders know where in the record to find the most accurate information concerning discharge status and whom to ask if they have questions,
• Have a system in place to follow up after discharge to verify what post-discharge care the patient actually received,
• Have processes for clear and timely communication between case management, coders and billers concerning discharge status,
• Have a procedure to handle Medicare requests to change discharge status (this can occur when Medicare receives claims from other hospitals or post-acute care providers for services immediately following a hospital discharge), and
• Perform periodic audits of discharge status.

Following these recommendations may prevent the OIG from NYTTW (nailing you to the wall) should your claims be audited.

Q:

What are the Medicare rules for reporting modifier GG?

A:

Modifier GG is defined as the performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day.

In MMP’s experience, extra mammogram views to further investigate a potential problem seen on a screening mammogram are typically performed on a subsequent day. This allows the radiologist ample time to review the patient’s previous mammograms for comparison. But, additional diagnostic views are sometimes performed on the same day as the screening mammogram, and this creates the scenario for reporting modifier GG.

One of the best CMS references for using modifier GG is in the Correct Coding Initiative (CCI) Policy Manual for Medicare Services, chapter IX, page IX-8, paraphrased here:

Screening and diagnostic mammography are normally not performed on the same date of service. However, when the two procedures are performed on the same date of service, Medicare requires that the diagnostic mammography CPT code be reported with modifier GG and the screening mammography CPT code be reported with modifier 59.

The Medicare Claims Processing Manual, chapter 18, section 20.6 provides some additional information.

• A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. 
• When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.
• Providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “GG” to the diagnostic mammography. 
• A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. 

There is a lot going on this time of year. Students have been back in school for almost a month. Halloween decorations are already popping up in the stores. The SEC 2018 football season “kicks off” in three days on Saturday September 1st and, wait for it, it is thirty-three days until the start of the CMS 2019 Fiscal Year on October 1st.

As for struggles with homework, what new Halloween decorations you may need and what time your team is playing, I will leave that up to you to decide. As for the new CMS Fiscal Year, this article winds down our series of articles focusing on the 2019 IPPS Final Rule. If you will, this article begins with a Meaningful Measures Initiative pre-game show, and then provides four quarters of excitement with a high level review of finalized proposals for the Hospital Inpatient Quality Reporting Program and the three programs CMS views as a collective set of hospital value-based programs (the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program, and Hospital Readmission Reduction Program). 

Meaningful Measures Initiative

CMS launched the Meaningful Measures Initiative in October 2017 to “reduce” the regulatory burden on the healthcare industry, lower health care costs, and enhance patient care.” The aim of this Initiative is to identify “the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.”

According to the CMS Meaningful Measures Hub this Initiative “is not intended to replace any existing programs, but will help identify and select individual measures. Meaningful Measure areas are intended to increase measure alignment across CMS programs and other public and private initiatives. Additionally, it will point to high priority areas where there may be gaps in available quality measures while helping guide CMS’s effort to develop and implement quality measures to fill those gaps.”

Hospital Inpatient Quality Reporting (IQR) Program

The Hospital IQR Program is a pay-for-reporting quality program established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. FY 2019 Proposals for the IQR Program are a result of CMS conducting an overall review of the Program under the “Meaningful Measures Initiative.” Current IQR Program measures were evaluated in the context of measures used in the Hospital Value Based Purchasing Program, Hospital Acquired Conditions Reduction Program and the Hospital Readmissions Reduction Program.

New “Measure Removal Factor”

Currently there are seven previously adopted “Removal Factors” that are taken into consideration when making the decision to remove a measure. CMS finalized the proposal to add the following factor:

• Factor 8: The costs associated with a measure outweigh the benefit of its continued use in the program. Note: CMS has clarified that using this factor would be on a case-by-case basis and provides the example of deciding “to retain a measure that is burdensome for health care providers to report if we conclude that the benefit to beneficiaries justifies the reporting burden.”

Removal of Hospital IQR Program Measures

CMS finalized their proposal to remove a total of 39 measures from across Fiscal Years (FYs) 2020, 2021, 2022, and 2023 payment determinations, with some modifications. In general, measures proposed for removal were due to the measure being duplicative of a measure in another program (i.e. Value Based Purchasing Program) or the cost of the measure outweighing the benefit of its continued use. A table summarizing the measures finalized for removal from the IQR Program can be found on page 41575-41577 of the Federal Register/Vol 83, No. 160 / Friday, August 17, 2018 / Rules and Regulations.

Hospital Value Based Purchasing (VBP) Program

The Hospital VBP Program is a budget neutral program. This program is funded by reducing the base operating DRG payment amount for a hospital for each discharge in a fiscal year by an applicable percent to fund this program. The applicable percent for FY 2019 and subsequent years is 2.00 percent. CMS estimates the total amount available for value-based incentive payments for FY 2019 to be approximately $1.9 billion.

CMS believes as part of their “holistic quality payment program strategy” that this Program should continue to focus on measures related to:  

• Clinical Outcomes (i.e. mortality and complications),
• Patient and Caregiver Experience (i.e. HCAHPS survey),
• Healthcare costs (i.e. Medicare Spending per Beneficiary measure).

Retention and Removal of Quality Measures

CMS finalized their proposal “to revise our regulations at 42 CFR 412.164(a) to clarify that once we have complied with the statutory prerequisites for adopting a measure for the Hospital VBP Program (that is, we have selected the measure from the Hospital IQR Program measure set and included data on that measure on Hospital Compare for at least one year prior to its inclusion in a Hospital VBP Program performance period), the Hospital VBP statute does not require that the measure continue to remain in the Hospital IQR Program.”

This finalized proposal is part of CMS’ efforts to evaluate and streamline regulations and specifically “would reduce costs…by allowing us to remove duplicative measures from the Hospital IQR Program that are retained in the Hospital VBP Program.”

Program “Measure Removal Factors”

CMS finalized their proposal to adopt for the Hospital VBP Program the current Hospital IQR Program measure removal factors used to determine whether to remove a program measure. They also finalized the following two scenarios for removing a measure:

• When the costs associated with a measure outweigh the benefit of its continued use in the program (Removal Factor 8), or
• When CMS believes the continued use of a measure poses specific patient safety concerns, they can promptly remove the measure without rulemaking and notify hospitals and the public of the removal of the measure along with the reason for its removal through routine communications channels.

Measures Finalized for Removal from the VBP Program

CMS efforts to review existing VBP Program measures “to identify how to reduce costs and complexity across programs while continuing to incentivize improvement in the quality and value of care provided to patients” resulted in ten measures being proposed for removal from the VBP Program.

Many commenters did not support the proposal to remove the five Healthcare-Associated Infection (HAI) measures and Patient Safety and Adverse Events (Composite) (PSI 90) because they “believe patient safety measures should remain in all payment programs to sufficiently incentivize continued improvement on these measures and prioritize practices that ensure safe care.” CMS agreed and did not remove these six patient safety measures that are also in the Hospital-Acquired Condition Reduction program measure set due to their critical importance to quality improvement and patient safety in the hospital setting.  The following table includes the four measures finalized for removal from the VBP Program.

Additional information about the VBP Program can be found on the CMS Hospital VBP webpage. 

Hospital Acquired Conditions (HAC) Reduction Program

The HAC Reduction Program requires payments be adjusted to hospitals ranking in the worst-performing quartile with respect to the risk-adjusted HAC quality measures. This group of hospitals are subject to a 1 percent payment reduction.

This Program “focuses on patient safety measures, which address the Meaningful Measures Initiative quality priority of making care safe by reducing harm caused in the delivery of care.” Per CMS, “measures in the HAC Reduction Program, generally represent “never events” and often, if not always, assess preventable conditions. By including these measures in the Program, we seek to encourage hospitals to address the serious harm caused by these adverse events and to reduce them.”

 

CMS finalized the following policies specific to the HAC Reduction Program:

• Adopt administrative processes to receive and validate National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) data that is submitted by hospitals to the Centers for Disease Control and Prevention (CDC) beginning CY 2020
• Adjust the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure score in order to improve fairness across hospital types in the Program; and
• Established the data collection period for the FY 2021 Program Year.

Additional information about this program can be found on the CMS HAC Reduction Program webpage.  

Hospital Readmissions Reduction Program (HRRP)

The HRRP “focuses on care coordination measures, which address the quality priority of promoting effective communication and care coordination within the Meaningful Measures Initiative.”

A hospital can be penalized by up to 3 percent for excess hospital readmissions in the following six clinical conditions:

• Acute Myocardial Infarction (AMI),
• Heart Failure (HF),
• Pneumonia (PN),
• Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA),
• Chronic Obstructive Pulmonary Disease (COPD); and
• Coronary Artery Bypass Graft (CABG) Surgery.

Applicable Periods for FY 2019, FY 2020, and FY 2021

The HRRP Applicable Period is defined “as the 3-year period from which data are collected in order to calculate excess readmissions ratios and payment adjustment factors for the fiscal year, which includes aggregate payments for excess readmissions and aggregate payments for all discharges used in the calculation of the payment adjustment.” The following table outlines the Finalized “Applicable Periods” for FY 2019, FY 2020, and FY 2021.

The FY 2019 readmissions payment adjustment factors were not available at the time the Final Rule was released. CMS notes that after hospitals have been given time to review their hospital-specific data, they  will post Table 15 (via the Internet on the CMS website) to display the final FY 2019 readmissions payment adjustment factors that will be applicable for discharges occurring on or after October 1, 2018. CMS expects this table to be posted in the fall of this year.

Additional information about this program can be found on the CMS HRRP webpage.

While admittedly not as exciting as a football game in the deep South, for hospitals this information is definitely part of the play book for what is to come in the 2019 IPPS Fiscal Year. 

Some bundles are great – a bundle may refer to a “bundle” of money; you can have bundles of fun; or expecting parents look forward to their little bundle of joy. Other bundles – not so great. One such bundle that is not a bundle of fun is the bundled payment Medicare makes for Intensity-Modulated Radiation Therapy (IMRT) planning services. Payment bundles are fairly common in the Medicare world, but the onus is on providers to understand appropriate billing rules so they are not overpaid for bundled services. A recent Office of Inspector General (OIG) report found errors in IMRT planning billing that resulted in over $25 million in Medicare overpayments for the audit period (2013-2015). The report recommended education for providers on billing IMRT planning services correctly, and edits in Medicare’s billing system to prevent overpayments.

IMRT uses advanced computer programs to plan and deliver radiation to difficult-to-reach tumors with high precision while reducing exposure to surrounding healthy tissue. IMRT includes planning and delivery services. IMRT planning is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan. Radiation is then delivered to a patient’s tumor at the various intensity levels prescribed in the IMRT treatment plan.

The basic rule for the bundling of IMRT planning services is found in section 200.3.1 of Chapter 4 of the Medicare Claims Processing:

• “Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.”

As evidenced by the OIG’s recommendations, the primary reasons for overpayments were that hospitals were unfamiliar with or misinterpreted CMS guidance and claim processing edits did not prevent overpayments. One of the biggest challenges for both hospitals and CMS is the bundling applies even to services billed on a different date of service than the comprehensive IMRT planning code (CPT 77301). CMS’s NCCI procedure-to-procedure edits applicable to IMRT planning services only applied to planning services billed on the same date of service as the billing of CPT code 77301 for the bundled payment. This application of bundling to different dates of service may also have caused some confusion for hospitals. The services in the OIG sample were billed on a different date of service from the IMRT planning CPT code 77301.

In analyzing payment data, the OIG noted that complex simulations billed using CPT code 77290 made up approximately 84% of the potential overpayments so that is the code they reviewed. They found that “In each case, a complex simulation was billed with CPT code 77290 on a different date of service from the IMRT planning code (i.e., up to 14 days before CPT code 77301 was billed). However, both services were performed for the same treatment site (e.g., the prostate). According to the independent medical review contractor, for each sampled line item, the complex simulation was performed as a part of the beneficiary’s overall IMRT treatment planning and therefore should not have been billed separately.”

The Claims Processing Manual guidance quoted above was updated after the OIG audit period to clarify that complex simulations are included in the APC payment for IMRT planning services “when provided prior to or as part of the development of the IMRT plan” (emphasis added). That was a step in the right direction but the OIG further recommended that CMS:

• Implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) IMRT planning CPT code 77301 is billed, and
• Work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.

Hospitals need to evaluate their billing practices for IMRT services now and verify they are not inappropriately billing separately for services included in IMRT planning. After all, a little OIG audit would not be a bundle of joy.

MEDICARE TRANSMITTALS

Updating Language to Clarify for Providers Chapter 3, Section 20 and Chapter 5, Section 70 of the Medicare Secondary Payer Manual

Additional clarification regarding when and where to obtain information from Medicare beneficiaries, or authorized representatives, for inpatient admissions or outpatient encounters

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10863.pdf

User CR: FISS to Add Additional Search Features to Provider Direct Data Entry (DDE) Screen

Allows providers who use DDE to look up the claims associated with an Accounts Receivable (AR) by using the invoice number on the AR to find the Document Control Number (DCN), and then using the DCN to look up the claims.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10542.pdf

International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)

A maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10859.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10898.pdf

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10631.pdf

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

Effective with dates of service on or after July 12, 2018, the Q5108 (Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg)  is payable by Medicare.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10834.pdf

Quarterly Influenza Virus Vaccine Code Update - January 2019

This update includes one new influenza virus vaccine code: 90689.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10871.pdf

Update to Medicare Claims Processing Manual, Chapter 24, Section 90

Clarifies the Administrative Simplification Compliance Act (ASCA) waiver process guideline in the Medicare Claims Processing Manual (for requesting waiver to submit non-electronic claims).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10559.pdf

Updates to the Medicare Claims Processing Manual, Chapter 24, ASCA Waiver Review Form of Letters, Exhibits A-H

Update to the language contained in the Form Letters the MACs use to inform certain providers of Administrative Simplification Compliance Act (ASCA) waiver reviews. The CR gives you clear directions for communicating with your MACs regarding ASCA waiver review-related questions when you receive a review Form Letter.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10858.pdf

System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claims

Updates the list of supplies, drugs, and labs included in the End Stage Renal Disease (ESRD) consolidated billing list and therefore included in the base rate payment for Acute Kidney Injury (AKI).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10839.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2019

Required changes as part of the annual IPF PPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10880.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10899.pdf

Internet Only Manual (IOM) Update to Publication 100-02, Chapter 11 - End Stage Renal Disease (ESRD), Section 100

This revision does not represent a policy change. Specifically, the manual has been updated to state that Erythropoietin Stimulating Agents (ESAs) are included in the bundled payment amount for treatments administered to patients with Acute Kidney Injury (AKI).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10809.pdf

New Waived Tests

Describes the latest laboratory tests approved by the FDA as waived tests under CLIA.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10819.pdf

Quarterly Update to 2018 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

Updates the lists of HCPCS codes that are excluded from the CB provision of the SNF PPS.

Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10852.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10873.pdf

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

Effective January 1, 2018, CLFS rates will be based on weighted median private payer rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. These rates are updated quarterly.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10875.pdf

Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in Publication (Pub.) 100-08

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R819PI.pdf

 

MEDICARE RULES

2019 Medicare Inpatient Prospective Payment System Final Rule

Addresses Hospital IPPS for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2019 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Promoting Interoperability Programs) Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Medicare Cost Reporting Requirements; and Physician Certification and Recertification of Claims

https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf

2019 Medicare Outpatient Prospective Payment System Proposed Rule

Addresses Proposed Changes to Hospital OPPS and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Requests for Information on Promoting Interoperability and Electronic Health Care Information, Price Transparency, and Leveraging Authority for the Competitive Acquisition Program for Part B Drugs and Biologicals for a Potential CMS Innovation Center Model

https://www.gpo.gov/fdsys/pkg/FR-2018-07-31/pdf/2018-15958.pdf

 

OTHER MEDICARE UPDATES

 

Redesigned Medicare Recovery Audit Program Website

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

Patients Over Paperwork July Newsletter

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/July2018Newsletter.pdf

CMS Review Contractor Interactive Map

Updated map available.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/#al

2019 ICD-10-CM Official Guidelines for Coding and Reporting released

“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of classification take precedence over guidelines…Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”

https://www.cdc.gov/nchs/icd/icd10cm.htm

KEPRO’s Case Review Connections Summer 2018 Newsletters

A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

Acute Care Edition: https://www.keproqio.com/providers/summer-2018-acute-newsletter/

Post-Acute Care Edition: https://www.keproqio.com/providers/summer-2018-post-acute-newsletter/

 

MEDICARE EDUCATION

CMS YouTube Presentation: Provider Minute: Physician Orders/Intent to Order Laboratory Services and Other Diagnostic Services

https://www.youtube.com/watch?v=GLnXayr3GsE&feature=youtu.be

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Reporting Changes in Ownership – Reminder
• Cochlear Devices Replaced Without Cost: Bill Correctly -- Reminder

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

A few weeks ago, when CMS released the 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule, we addressed some of the major proposed changes from that rule in Wednesday@One articles. Specifically, our August 1st newsletter included an article on the proposed changes to payments for off-campus provider-based departments and an article on the proposed changes to the inpatient only list. This week I will review some of the other more modest proposals from that rule.

Increased Payment Rate

CMS is proposing for CY 2019 an OPPS fee schedule increase factor of 1.25%.

• This increase factor is based on proposed hospital inpatient market basket percentage increase of 2.8% minus the proposed multifactor productivity (MFP) adjustment of 0.8%, and minus a 0.75% adjustment required by the Affordable Care Act.
• CMS estimates total payments to OPPS providers for CY 2019 would be approximately $74.6 billion, an increase of approximately $4.9 billion compared to estimated CY 2018 OPPS payments.
• The statutory 2.0% reduction in payments for hospitals failing to meet the hospital outpatient quality reporting requirements would continue for 2019.

Comprehensive APCs

As a reminder, the comprehensive APC (C-APC) payment policy packages payment for adjunctive and secondary items, services, and procedures into the most costly primary procedure under the OPPS at the claim level.

• Services identified by a status indicator (SI) of “J1” are designated as primary services.
• When a primary service is reported on a hospital outpatient claim, Medicare makes a single payment for the claim. Payment for all adjunctive and secondary items, services, and procedure is included in this single payment for the primary service.
• Services with “packaged” payment under C-APCs include diagnostic tests and procedures, visits, DME, therapy services provided during the perioperative period, and drugs, biologicals, and radiopharmaceuticals.
• Services excluded from the C-APC include mammography and ambulance services, brachytherapy seeds, pass-through drugs and devices, self-administered drugs, and certain preventive services.
• Medicare makes an increased payment for complexity adjustments when certain multiple “J1” codes or certain add-on codes are present on the claim.

For CY 2019, CMS is proposing to create three new C-APCs involving ears, nose, and throat (ENT) and vascular procedures: proposed C-APC 5163 (Level 3 ENT Procedures); proposed C-APC 5183 (Level 3 Vascular Procedures); and proposed C-APC 5184 (Level 4 Vascular Procedures).  This proposal would increase the total number of C-APCs to 65.

Also related to C-APCs, CMS is proposing to exclude payment for any procedure that is assigned to a New Technology APC from being packaged when included on a claim with a “J1” service assigned to a C-APC.

Device-Intensive Procedures

Currently, device-intensive procedures are those procedure that involve surgically inserted or implanted devices that remain in the patient’s body after surgery and for which the portion of the APC payment attributed to the device (device off-set amount) exceeds 40%. This means the following device-intensive policies apply to these procedures:

• There is a procedure/device edit that requires a device code to be reported on a claim with a device-intensive procedure. Any device code will satisfy the edit and CMS created HCPCS code C1889 to report devices furnished during a device-intensive procedure that are not described by a specific HCPCS code.
• OPPS payment for device-intensive procedures is decreased by the full or partial credit a provider receives for a replaced device, when a hospital furnishes a specified device without cost or with a full or partial credit. Hospitals report on the claim the amount of the credit in the amount portion for value code “FD” when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device.

For CY 2019, CMS is proposing to modify the device-intensive criteria to 1) allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure and 2) allow procedures with a device offset percentage of greater than 30 percent to qualify as device-intensive procedures. They are making these proposals because:

• They “no longer believe that whether a device remains in the patient’s body should affect its designation as a device-intensive procedure because such devices could, nonetheless, comprise a large cost of the applicable procedure”
• The lower 30% threshold “allow(s) a greater number of procedures to qualify as device-intensive.”
• “Allowing these additional procedures to qualify for device-intensive status will help ensure these procedures receive more appropriate payment in the ASC (ambulatory surgical center) setting, which will help encourage the provision of these services in the ASC setting.”
• “This proposed change would help to ensure that more procedures containing relatively high-cost devices are subject to the device edits, which leads to more correctly coded claims and greater accuracy in our claims data.”

The most interesting of the above reasons is CMS’s obvious hope that these policy changes would shift more of these procedures from the hospital setting to the lower-cost ASC setting. Addendum P to the proposed rule includes a full list of the proposed CY 2019 OPPS device-intensive procedures. All of the above noted device-intensive policies would apply to these procedures.

Separately Payable Drugs and Biologicals

For CY 2019, CMS is proposing to continue to pay for pass-through drugs and biologicals and separately payable non-pass-through drugs, biologicals, and therapeutic radiopharmaceuticals not purchased through the 340B drug program at ASP (average sales price) +6 percent. The proposed packaging threshold for CY 2019 is $125 a slight increase from the CY 2018 threshold of $120. This means payment for drugs with a per day cost less than or equal to $125 will be packaged and not paid separately.

They are proposing to continue to pay for separately payable Medicare Part B drugs (assigned status indicator “K”), other than vaccines (SI = “L” or “M”) and drugs on pass-through payment status (SI = “G”), acquired with a 340B discount at a rate of ASP minus 22.5 percent when billed by a hospital paid under the OPPS that is not excepted from the payment adjustment. Hospitals to which the payment reduction applies will continue to report modifier “JG” for applicable status “K” drugs. Rural sole community hospitals (SCHs), children’s hospitals, and PPS-exempt cancer hospitals are proposed to continue to be excepted from the 340B payment adjustment. These hospitals would continue to report informational modifier “TB” for 340B-acquired drugs, and continue to be paid ASP+6 percent.

One slight change is for drugs or biologicals for which ASP data is not available. For these drugs/biologicals CMS is proposing to pay WAC (wholesale acquisition cost) +3%, rather than WAC+6% whenever WAC-based pricing is used for a drug or biological. WAC minus 22.5% would continue to apply for drugs acquired under the 340B Program.

Those are some of the more interesting proposals for 2019, but as usual CMS has asked for input on a number of proposals, one related to skin substitutes. Currently CMS assigns skin substitutes to a low cost or high cost category based on either a product’s geometric mean unit cost (MUC) or the product’s per day cost (PDC) exceeding specified thresholds. Payment for skin substitutes is packaged, but application of high cost substitutes is reported with HCPCS codes 15271 through 15278, which receives a higher payment rate than application of low cost substitutes reported with HCPCS codes C5271 through C5278.

Significant fluctuations in the MUC or PDC thresholds from year to year may result in the reassignment of several skin substitutes from the high cost group to the low cost group which, under current payment rates, can be a difference of approximately $1,000 in the payment amount for the same procedure. One solution for CMS has been to maintain assignment of a product to the high cost group if it was in the high cost group the prior year, regardless of whether it exceeds or falls below the CY 2019 MUC or PDC threshold.

However, CMS continues to seek input on other ways to handle the payment of skin substitutes. They have identified four potential methodologies that have been raised and they encourage the public to review and provide comments on these. They “are especially interested in any specific feedback on policy concerns with any of the options presented as they relate to skin substitutes with differing per day or per episode costs and sizes and other factors that may differ among the dozens of skin substitutes currently on the market.” The four potential methodologies include:

• A lump-sum “episode-based” payment for a wound care episode,
• One payment category and set of procedure codes for all skin substitute products,
• Payment of current add-on codes or new additional procedure codes for larger size graft services, or
• A different threshold used to assign skin substitutes in the high-cost or low-cost group.

The discussion of these options can be found on page 37119 of the  OPPS 2019 Proposed Rule.

One last thing that hospitals need to know, even though this is not from the OPPS section of the proposed rule. CMS is proposing to add heart catherization and coronary angiography procedures described by CPT codes 93451-93462 to the list of ASC surgical procedures for 2019. This would allow Medicare patients having these procedures to elect to have them in an ASC instead of in a hospital setting.

For hospitals, some of these proposals may not be as modest as they first appear.

It has been a while since we have reviewed the issues approved for audit by the Recovery Auditors (RACs). Since CMS has banned the review of the medical necessity of inpatient admissions by RACs (other than upon referral from the QIO), the impact of RAC reviews is greatly diminished from their prior Statement of Work. This does not mean they have been idle. Currently, there are 105 CMS approved RAC Topics across all types of providers. Between the RAC reviews and reviews by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) reviewers, and other Medicare entities, providers may still feel overwhelmed by the enormity of the task of ensuring appropriate billing, accurate coding, and complete documentation for Medicare services. When you are overwhelmed, we all know that you have to eat that elephant one bite at a time.

You can see a listing of the approved topics and proposed review topics on CMS’s Recovery Audit Program website. The website also includes links to the websites of the various Recovery Auditors where you can find your specific state RAC’s active review topics. Hospital inpatient and outpatient review topics approved by CMS since the beginning of this year are discussed below. Topic posting dates and claim types may vary from RAC to RAC so providers need to review their RAC’s website to see if the claim type is applicable to them. As a reminder, automated reviews can result in automatic denials based solely on claims data. The RAC will request medical record documentation from the provider for complex reviews and coverage/payment decisions are based on that documentation.

0074 - Excessive or Insufficient Drugs and Biologicals Units Billed (complex review)

Drug and biological units should be reported in multiples of the dosage specified in the HCPCS code long descriptor. Units are determined by dividing the amount of the drug administered by the dosage in the HCPCS descriptor. If there is drug wastage that meets Medicare requirements for billing and is appropriately documented, it can also be billed with the JW modifier and units determined the same as for the administered drug. If the amount of drug used is not a multiple of the HCPCS code dosage descriptor, round up to the next highest unit. Claims will be reviewed to determine the actual amount administered and the correct number of billable/payable units. (Affected Codes - C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894, J0897, J1300, J1459, J1561, J1566, J1569, J1572, J1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034)

0078 - Complex Cardiac Pacemaker Review (complex review)

Medicare coverage for pacemakers is defined in National Coverage Determination NCD 20.8.3 and in numerous Medicare Administrative Contractor (MAC) coverage articles (e.g. Palmetto's Cardiac Pacemaker Coverage Article). Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. (Affected Codes - 33206, 33207, 33208)

0083 - Cataract Removal Excessive Units (Partial)

0084 - Cataract Removal Excessive Units (Full) (automated reviews)

Medicare will only pay for one cataract removal performed on the same eye on the same date of service. Claims with more than one unit of cataract removal for the same eye, on the same claim line, will be partially denied and payment will only be made for one cataract removal. This may be the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”

If there are multiple claims for cataract removal for the same patient for the same eye, only one will be paid and the others fully denied. (Affected Codes - CPT 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984)

0085 - Lab Services Rendered During an Inpatient Stay (automated review)

Laboratory services provided to a patient during an inpatient admission are paid as part of the DRG payments and are not separately billable to Medicare. These services should be denied as unbundled services. (Affected Codes - 80048-80076, 80150-80203, 80400-80439, 81000- 81050, 82009-84830, 85002- 85810, 86602- 86804, 87003-87905)

0092 - Percutaneous Implantation of Neurostimulator Electrode Array (complex review)

NCD 160.7.1 describes Medicare coverage of percutaneous electrical nerve stimulation. Documentation in the medical record must support the code billed was actually the service rendered and that all coverage criteria were met. (Affected Codes - 64553, 64555)

0093 - Automatic Defibrillators (complex review)

Medicare has a long and complex NCD (NCD 20.4) for implantable automatic defibrillators, electronic devices designed to detect and treat life-threatening tachyarrhythmias. Prior reviews by the Department of Justice (DOJ) and other Medicare entities have found numerous claims billed that did not meet Medicare requirements. The RACs will be reviewing documentation to support medical necessity and validate that implantable automatic cardiac defibrillators are used only for covered indications. (Note: there is a pending update to this NCD that should be finalized soon.) (Affected Codes - 33240, 33241, 33242, 33243, 33249)

0095-Facet Injections (complex review)

Facet Joint Injections are reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Medical documentation will be reviewed to determine that services were medically reasonable and necessary. Although this issue has been approved by CMS, so far none of the RACs have added this to their approved issues list. (Affected Codes - 64490-64495, 64633-64636, 0213T-0218T, G0260)

0099-Skilled Nursing Facility (SNF) Consolidated Billing (automated review)

Most services provided to a Skilled Nursing Facility (SNF) inpatient (skilled stay) are part of the SNF consolidated billing prospective payment. This means the Medicare Part A payment made to the SNF includes payment for these services. Other outpatient providers that furnish these services to a SNF inpatient must receive payment from the SNF. A few select services are exempt from consolidated billing and the rendering provider can bill Medicare directly for these exempt services. Refer to the Medicare SNF Consolidated Billing website for information and lists of exempt categories and codes. (Affected Codes - CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A.)

0101-Outpatient Hospital Comprehensive APC Coding (complex review)

For comprehensive APCs, Medicare makes one inclusive payment for the primary procedure and all adjunctive services. This means payment for most services is not made separately but bundled into the payment for the primary service. If the primary service is not billed properly or not supported by documentation, the entire claim may be denied. According to CMS’s explanation of the issue, “Comprehensive APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.” (Affected Codes – Codes with an OPPS status indicator (SI) = J1)

The good news about the RAC issues under the current scope of work is that the limited number of issues makes it easier for providers to internally review their processes and documentation to ensure they are meeting Medicare requirements. It is also easier to make improvements if deficiencies are found and limit future recoupments. Providers may still feel like they are eating an elephant one bite at a time, but at least the bites are smaller.