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Oh, the sounds of summer – waves crashing on the beach, birds chirping, bees buzzing, crickets filling the night with their chirping, and lawn mowers humming. Yes, lawn care is very much a necessary part of our summer routine and Americans love their pristine lawns. We even pay lawn care companies to spray our yards with fertilizers, weed control, insect and grub control, pre-emergents, and chemicals to prevent lawn diseases. The lawn care technician leaves a receipt listing the treatments which were applied that day. But what if you received your bill and there were charges for treatments that the technician did not include on your receipt? The receipt is all you have to verify what was done and you know what they say – “if it’s not documented, it wasn’t done.”  This is not necessarily true, but for payment and legal purposes it is the standard. Those of us working in healthcare are very familiar with this adage, but Medicare review contractors still deny numerous claims for insufficient documentation.

Here are some tips about proper documentation to support the Medicare services provided that I present as Know, Respond, Gather, and Sign.

1. KNOW – It is the provider’s responsibility to know the Medicare documentation requirements to support provision and billing of services. Providers should not wait until they receive an Additional Documentation Request (ADR) to review the coverage and documentation requirements. Instead, providers should have processes in place to ensure the services meet Medicare’s requirements prior to the provision of the services. Coverage and documentation rules can be found in various Medicare publications, such as Medicare coverage policies – national coverage determinations (NCDs) and local coverage determinations (LCDs). In addition to explaining the conditions for which a service is covered, these policies often explain what documentation is required in the medical record to substantiate the medical necessity of the service. Some requirements, such as the need for a signed certification of a plan of care for rehabilitative therapy services, can be found in the Medicare manuals. Other sources of information target those services for which Medicare reviewers have identified ongoing errors. Since the ongoing errors may result in continuing audits of these services, providers need to carefully review educational materials which address these. The Medicare Quarterly Provider Compliance Newsletter, facts sheets such as Complying with Medical Record Documentation Requirements, and audit findings from the individual Medicare Administrative Contractors (MACs) on their websites all offer great guidance for documentation of services at higher risk of review.
2. RESPOND – There are often a large number of denials for Medicare reviews because of a lack of a timely response to the ADR. For example, in a review by the Supplemental Medical Review Contractor (SMRC) for SPECT scans 65% of denials were because providers did not respond to the ADR timely. Providers need to have systems in place to identify ADRs, route them to the appropriate hospital department, and respond with complete records in the appropriate time frame.
3. GATHER – In responding to an ADR request, providers must have the knowledge discussed above about the documentation needed to support the services. Knowing what is required will allow you to gather the relevant information in your response to Medicare. And you may have to look outside your own medical record to find what is needed to support your billing. The fact sheet referenced about states, “it is the billing provider’s responsibility to obtain supporting documentation as needed from a referring physician’s office (for example, physician order, notes to support medical necessity) or from an inpatient facility (for example, progress note).” Here are some examples that occur often:
4. A laboratory test is performed and billed based on a lab requisition form that is not signed (per Medicare rules, it doesn’t have to be), but Medicare does require a signed order from the referring physician to support the billing. This may be a signed note in the physician’s office record stating that this particular lab test be ordered.
5. Some services require that the patient first receive and fail conservative treatments before having this more extensive or invasive service. Medicare requires details of which conservative treatments were tried. Again, this information may be found in the physician’s office notes and the billing provider (such as the hospital) may have to obtain and send this documentation with their ADR response. It is advisable to require the physicians provide this information to the facility before performing the service. Then you are not scrambling on the back end to locate the documentation that is needed to support your services.
6. The need for some services is supported by previously performed diagnostic studies, such as x-rays or laboratory tests findings. The results of these tests may be in the physician’s office record, at another testing entity, or in a prior hospital record. You must gather this information to include in your ADR response.
7. SIGN – Medicare requires that services that are ordered or provided must be authenticated by the ordering practitioner. Sounds easy enough but evidently, based on Medicare review findings, remains a challenge for providers. Signatures can be legible handwritten signature or electronic authentication. Signatures should happen in a timely manner so your options in responding to an ADR are limited if orders and other documentation are not already signed. Medicare does not allow late signatures, but will accept a signature attestation for certain types of unsigned documentation (other than orders). An unsigned order is considered invalid during a Medicare review. Illegible signatures may be accepted if accompanied by an attestation or a signature log.  For complete information regarding Medicare signature requirements, see the Fact Sheet Complying with Medicare Signature Requirements and section 3.3.2.4 of the Medicare Program Integrity Manual. 

Those are my tips for responding to Medicare ADRs so hopefully your hospital can avoid the “not documented, not done” and the “not signed, not valid” snares of Medicare reviewers.

Back in June when the Office of Inspector General (OIG) changed the process and publication of their Work Plan, they used the word “dynamic” to describe their work planning process.  The Merriam-Webster dictionary defines dynamic as “marked by usually continuous and productive activity or change.”  So far, the OIG is remaining true to this definition by posting numerous new issues each month.  For July, the OIG posted 14 new issues all focused on the CMS agency.  The OIG is responsible for oversight for all agencies of Health and Human Services (HHS), but a review of active issues shows that most of their efforts are related to CMS.

I understand the OIG’s responsibility “to provide independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS.” But having worked in hospitals for years, I also understand the challenges of complying with all of the Medicare rules. If it were easy we might not need the OIG, but it is definitely not an easy task. 

Since MMP’s focus is hospital Medicare issues, I will only describe the new OIG Work Plan items related to hospitals and Medicare.  For a list of all the new issues, see the OIG’s Recently Added updates.

Nationwide Medicare Electronic Health Record Incentive Payments to Hospitals

Hospital can receive incentive payments for adopting electronic health record (EHR) technology. The OIG is concerned about potential incentive overpayments. Their concerns are based on the following:

• The Government Accountability Office (GAO) identified improper incentive payments as the primary risk to the Medicare EHR incentive program.
• An OIG report found CMS faces obstacles in oversight of the EHR program.
• OIG reviews showed that State agencies have and will continue to overpay hospitals millions of dollars due to inaccuracies in the hospitals’ calculations.

The OIG will be reviewing hospitals’ incentive payment calculations to ensure appropriate payment amounts and prevent future overpayments.  This is a hospital finance issue which is not my area of expertise, but I bet it is not that easy.  Calculations never are.

Review of Medicare Payments for Nonphysician Outpatient Services Provided Under the Inpatient Prospective Payment System

Medicare pays hospitals a prospective payment amount for inpatient services – we know this as the DRG payment.  The DRG payment is payment for all the hospital’s operating costs associated with the inpatient admission. This also includes diagnostic and related therapeutic outpatient services provided the day of admission or within the 3 days prior to admission under Medicare’s 3-day payment window rule.  Identifying those outpatient services that should be bundled with the inpatient claim and then billing correctly in compliance with the 3-day payment window is not an easy task either. Prior OIG reviews have found overpayments where hospitals billed inappropriately and Medicare contractors paid for outpatient services provided during or before the inpatient admission. The OIG will review to determine if outpatient payments during an inpatient admission and under the payment window rule were correct.

Medicare Payments for Unallowable Overlapping Home Health Claims and Part B Claims

Home Health (HH) agencies are also paid a Medicare prospective payment which covers all of their costs for providing services to the patient.  This includes services furnished by the home health agency and certain items or services provided under arrangement. The home health consolidated billing requirements mandate that certain items, supplies, and services are part of the home health payment and should not be billed separately to Medicare Part B from other entities. The OIG will be looking to see if Part B payments were allowable and followed the consolidated billing requirements.  From my experience, the major area of concern related to HH consolidated billing for hospitals is rehabilitative therapy services.  Medicare patients may present to a hospital’s therapy department for services even though they are receiving HH services. Hospitals should check Medicare eligibility systems and question the patient carefully to determine if they are currently under a home health plan of care.

Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims

Once a Medicare beneficiary elects hospice care, all services related to the terminal illness are handled by the hospice.  Hospitals must seek payment for services provided to a hospice patient and related to the terminal illness from the hospice agency and not from Medicare. The OIG is reviewing to make sure any separate Part B payments were appropriate. Hospitals are often caught unaware when a hospice patient shows up in their emergency department. The hospital must determine if the patient has elected hospice and if so, is the medical condition for which they are seeking treatment related to the terminal illness.  If the answer to both is yes, the hospital must coordinate with the hospice agency to determine appropriate treatment and billing.  Not an easy task, especially in an emergency department setting. The same applies to non-emergency hospital services – reference laboratory testing is one example, but your clue here should be that the specimens are brought in by a hospice nurse.  In MMP’s experience, edits in the Medicare claims processing system catch most of these overlaps with hospice agencies and deny the hospital’s payment. It is then up to the hospital to spend extra time and effort to determine the circumstances and obtain payment from the hospice agency.  Not an easy task on the back end either.

One last issue somewhat related to hospitals:

Review of Medicare Payments for Telehealth Services

One of the Medicare requirements for telehealth payment is that the services be between a beneficiary located at a rural originating site and a practitioner located at a distant site.  An eligible originating site must be the practitioner’s office or a specified medical facility, such as a hospital.  The OIG will be looking for telehealth payments where there was not a corresponding claim from the originating site to ensure the payments were correct.  More information on billing telehealth services can be found in the Medicare Telehealth Fact Sheet.

Not much about health care and hospital services is easy, but the OIG work plan gives us some areas on which to focus our scrutiny when it comes to billing Medicare.

Dilemma:

Why can’t the Root Operation, ‘Destruction’ be used when cauterization is performed in the nose to stop bleeding instead of ‘Control’? For instance, a patient was admitted for surgery due to multiple failed attempts to stop epistaxis.  The surgeon saw no active bleeding; but did see some suspicious sites so he cauterized the right turbinate and the nasal septum. 

Also, using ‘Destruction’ grouped the case to an ENT DRG (see table) which appears to be an appropriate clinical representation of the admission.  However, using ‘Control’ grouped the case to Extensive OR Procedure Unrelated to Principal Diagnosis. 

FY 2017 ICD-10-PCS Coding Guideline:

• Control
  Stopping, or attempting to stop, postprocedural or other acute bleeding. If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

Solution:

The Root Operation, ‘Control’ was broadened to include these types of cases, so regardless of the method, the coding reflects the main objective of these types of procedures, which is to control bleeding.

The above procedure grouping is a DRG shift that has been reported to CMS and should be corrected in the next October 1st update. 

Resource:  Rhonda Butler, Clinical Research Manager for 3M Health Information Systems

FY 2017 ICD-10-PCS Coding Guidelines

CMS is known for their novel-length explanations of their calculations and reasoning for rate setting.  This year is no different as they take over 20 pages of the Medicare Physician Fee Schedule (MPFS) Proposed Rule for 2018 to explain why they chose an adjustment of 25% versus last year’s 50% adjustment for the PFS payment rates for nonexcepted off-campus hospital provider based department payment rates.  Then they say based on comments, they may consider a middle ground such as 40% - maybe they should just spin a wheel.

In compliance with Section 603 of the Bipartisan Budget Act of 2015, CMS began paying nonexcepted hospital provider based departments under a different payment system than the Outpatient Prospective Payment System (OPPS) beginning January 1, 2017.  Nonexcepted PBDs are new off-campus hospital provider-based departments that began furnishing and billing for services on or after November 2, 2015.  The payment system CMS selected for payment of nonexcepted services was the Physician Fee Schedule (PFS).  For 2017, Medicare set PFS rates at 50% of the OPPS payment rates. This 50% adjustment is known as the PFS Relativity Adjuster. In the 2018 MPFS Proposed Rule, CMS proposes revising the PFS Relativity Adjuster for nonexpected hospital PBDs for CY 2018. 

Background

First, let’s look at a little background on the payment system.  CMS originally proposed to pay only the physicians at a non-facility rate for these services and provide no payment to the hospital. There were many concerns with this approach so CMS selected the PFS as the payment system for nonexcepted PBDs.  They set new PFS rates at 50% of OPPS rate, which allowed hospitals to continue to bill on an institutional UB claim form. CMS required nonexcepted services to be appended with a PN modifier so the appropriate payment rate could be applied.  This also allowed the claims to process through the Outpatient Code Editor (OCE) so OPPS packaging rules (such as comprehensive APCs, packaged and conditionally packaged services) could be applied to the claims. Services assigned to an OPPS status indicator of “A” continued to be paid under the “other” appropriate fee schedules. That included therapy services paid under the MPFS, laboratory services when separate payment criteria is met under the Clinical Lab Fee Schedule, separately payable drugs at ASP + 6%, preventive services, etc. For more information on the 2017 payment system see last year’s article.

In 2017 CMS attempted to strike an appropriate balance that avoided potentially underestimating the relative resources involved in furnishing services in nonexcepted off-campus PBDs.  CMS arrived at a 50% reduction of OPPS rates by comparing the OPPS rate to the technical component portion of PFS rate and to the ASC rate for 22 high volume services. Although there was considerable variation in the differences, per CMS “the overall total payment made for services is more relevant to the goal of site neutrality than the quantity of individual payments made.” It is important to note that the data analysis did not include the most frequently billed service furnished in nonexcepted off-campus hospital PBDs, outpatient visits.

2018 Proposed Payment

Precise data to identify and value nonexcepted services billed by hospitals is still not available for 2018 rate setting, so again CMS must estimate payment rates to reflect overall relativity between PFS and OPPS payments. 

The bad news is that in the 2018 proposal, CMS shifts their focus from making sure rates do not underestimate the relativity to ensuring rates do not overestimate the appropriate overall payments for these services.  Since the majority of services currently billed in off-campus PBDS are visit services, for 2018 CMS performed a comparison of only the clinic visit code, G0463 to the weighted average of outpatient visits (CPT codes 99201-99205 and CPT codes 99211-99215) billed by physicians and other professionals in an outpatient hospital place of service.  Based on this comparison, CMS arrived at a proposed PFS Relativity Adjuster of 25%.  This means nonexcepted services provided in a nonexcepted off-campus hospital PBD will be paid at 25% of the OPPS rate for that service. This is a significant payment decrease for 2018 from the 2017 payment rate.

CMS is requesting comment on whether they “should adopt a different PFS Relativity Adjuster, such as 40 percent, that represents a relative middle ground between the CY 2017 PFS Relativity Adjuster, selected to ensure adequate payment to hospitals and our proposed CY 2018 PFS Relativity Adjuster, selected to ensure that hospitals are not paid more than others would be paid through the PFS nonfacility rate.”

Other payment policies for nonexcepted off-campus PBDs that are not proposed to change from last year include:

• OPPS packaging rules will continue to apply
• Services with an OPPS status indicator of “A” will continue to be paid under the appropriate fee schedule

• Partial hospitalization program (PHP) will be paid at the Community Mental Health Centers (CMHCs) per diem rate for APC 5853, for providing three or more partial hospitalization services per day
• Hospitals will report radiation treatment delivery procedures with the HCPCS “G” codes appended with the PN modifier, which will be paid at the MPFS technical component rate
• Hospitals will bill clinic visits at nonexcepted off-campus PBDs with HCPCS code G0463 (which will be paid at 25% of the OPPS rate)
• Outlier payments, the rural sole community hospital (SCH) adjustment, the cancer hospital adjustments, transitional outpatient payments, the hospital outpatient quality reporting payment adjustment, and the inpatient hospital deductible cap to the cost-sharing liability for a single hospital outpatient service are not being adopted into the new payment system
• The supervision rules that apply for hospitals will continue to apply for off-campus PBDs that furnish nonexcepted items and services
• Beneficiary cost-sharing under MPFS of 20% will apply
• Geographic adjustments used under the OPPS continue to apply

Moving Forward

CY 2017 claims data for services reported using the “PN” modifier will be available for use in PFS rate setting for CY 2019.  CMS plans to use these data to determine the appropriate PFS Relativity Adjuster and additional adjustments if appropriate.  They want to equalize payment rates as much as possible but still allow straight-forward billing.  CMS’s ultimate goal is to attain “site neutral payments to promote a level playing field under Medicare between physician office settings and nonexcepted off-campus PBD settings, without regard to the kinds of services furnished by particular off-campus PBDs.”

TRANSMITTALS

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2015 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCH)

• MLN Matters Number: MM10026
• Related CR Release Date: June 30, 2017
• Related CR Transmittal Number: R1863OTN
• Related Change Request (CR) Number: CR10026
• Effective Date: July 31, 2017
• Implementation Date: July 31, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10026.pdf
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about updated data for determining the disproportionate share adjustment for Inpatient Prospective Payment System (IPPS) hospitals and the low income patient (LIP) adjustment for IRFs as well as payments as applicable for Long Term Care Hospitals (LTCH) discharges (for example, discharges paid the IPPS comparable amount under the short-stay outlier payment adjustment).

Implementing FISS Updates to Accommodate Section 603 Bipartisan Budget Act of 2015 - Phase 2

• MLN Matters®Number: MM9907
• Related Change Request (CR) #: CR 9907
• Related CR Release Date: February 2, 2017
• Effective Date: January 1, 2017
• Related CR Transmittal #: R1783OTN
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9907.pdf
• Affects Hospital providers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: If a hospital claim is submitted with a service facility location that was not included on the CMS 855A enrollment form, the claim will be Returned to the Provider (RTP) until the CMS 855A enrollment form and claims processing system are updated.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.3, Effective October 1, 2017

• MLN Matters Number: MM10183
• Related CR Release Date: July 14, 2017
• Related CR Transmittal Number: R3807CP
• Related Change Request (CR) Number: CR10183
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10183.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs the MACs about the update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP). This notice applies to Chapter 23, Section 20.9 of the Medicare Claims Processing Manual

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017

• MLN Matters Number: MM10156
• Related CR Release Date: June 16, 2017
• Related CR Transmittal Number: R3797CP
• Related Change Request (CR) Number: CR 10156
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10156.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about the changes that will be included in the October 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

Clarifying the Instructions for Amending or Correcting Entries in Medical Records

• CR Release Date: July 21, 2017
• CR Transmittal Number: R732PI
• Change Request (CR) Number: CR 10120
• Effective Date: August 22, 2017
• Implementation Date: August 22, 2017
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R732PI.pdf

Summary: Clarifies the requirements for a practitioner to authenticate an alteration or revision in the medical records. The contractor shall also accept initials in instances when the author of the alteration must sign and date a revision made.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2017

• CR Release Date: July 13, 2017
• CR Transmittal Number: R291FM
• Change Request (CR) Number: CR 10227
• Effective Date: July 18, 2017
• Implementation Date: July 18, 2017
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R291FM.pdf

Summary: Medicare Regulation 42 CFR Section 405.378 provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.125 percent.

 

REVISED TRANSMITTALS

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

• In the article, the CR release date, transmittal number, and the Web address of CR9911 are revised. Clarifications are also made to the second paragraph of the Background section.
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf

Screening for Hepatitis B Virus (HBV) Infection

• Reflects an updated Change Request (CR) 9859
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf

Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

• Transmittals 196 and 3787, dated May 26, 2017, is being rescinded and replaced by Transmittals 199 and 3805 dated, July 11, 2017 to
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R199NCD.pdf
• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3805CP.pdf

Summary: Update references in the CPM and NCD manuals and to add clarifying language.  In the NCD manual, the reference to Pub 100-04, Chapter 32, and Section 68 needs to be changed to Section 69. In the CPM manual, the reference in Pub. 100-04, Chapter 32, Section 68 needs to be changed to Section 69 and clarifying language needs to be added to indicate that CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved randomized and non-blinded clinical trial.  All other information remains the same.

OTHER MEDICARE ANNOUNCEMENTS

Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2018

• July 13, 2017
• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-2.html

Summary: The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

CMS Proposes Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Changes for 2018, and Releases a Request for Information (CMS-1678-P)

• July 13, 2017
• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13.html

Summary: The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1678-P) that includes updates to the 2018 rates and quality provisions, and proposes other policy changes. CMS is proposing a number of policies that would support care delivery; reduce burdens for providers, especially in rural areas; lower beneficiary out of pocket drug costs for several drugs; enhance the patient-doctor relationship; and promote flexibility in healthcare.

Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool

• July 07, 2017
• Memorandum

Summary: This policy memo replaces S&C Memo 15-16-NH. When noncompliance exists, enforcement remedies, such as civil money penalties (CMPs), are intended to promote a swift return to substantial compliance for a sustained period of time, preventing future noncompliance. To increase national consistency in imposing CMPs, the Centers for Medicare & Medicaid Services (CMS) is revising the CMP analytic tool.

Medicare Quarterly Provider Compliance Newsletter [Volume 7, Issue 4]

• July 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN907797.pdf

Summary: Educational newsletter.  This quarter’s focus is on Cert Findings regarding Skilled Nursing Facility (SNF) Certification and Re-certification and OIG Findings regarding Studies of Hospital Billings of use of Modifier 59 on Heart Biopsy Claims and Procedure Coding for Ventilation Support Claims 

Q:

What information will a Review Contractor accept when reviewing a record for medical necessity of the services provided?

A:

The answer can be found in Chapter 3 of the Medicare Program Integrity Manual. Specifically, Section 3.3.2.1 – Documents on Which to Base a Determination indicates that “The MACs, CERT, Recovery Auditors, and ZPICs shall review any information necessary to make a prepayment and/or postpayment claim determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted with the claim and any other documentation subsequently requested from the provider or other entity when necessary. Reviewers also have the discretion to consider billing history or other information obtained from the Common Working File (in limited circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among others.

For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.”

This guidance applies to Medicare Administrative Contractors (MACs), the Comprehensive Error Rate Testing (CERT), Recovery Auditors, and Zone Program Integrity Contractors (ZPICs).

A Medicare patient presents to your hospital’s Emergency Department late one evening and immediately requires emergency surgery.  The procedure performed in the operating room is on Medicare’s inpatient-only list.  Due to the focus on the medical care and treatment of the patient, an order to admit the patient as an inpatient is not obtained until the next morning.  Can the inpatient-only procedure be reported on the inpatient claim according to the policy for the payment window for outpatient services treated as inpatient services?

This question was recently posed to Medical Management Plus by one of our clients.  I was sure I remembered that Medicare changed an older instruction and now allows the billing of an inpatient-only procedure on the inpatient claim under the 3-day payment window rule.  To confirm this, I read the relevant sections in Chapter 4 of the Medicare Claims Processing Manual, which are Section 10.2 about the payment window and Section 180.7 about inpatient-only services.  Neither section states that combining an inpatient-only procedure performed on an outpatient basis into the succeeding inpatient admission for payment is allowed.  But I am sure I remembered that - have I lost my mind?

I started back-tracking through old transmittals.  I noticed Section 180.7 was last updated January 1, 2016, but a review of that transmittal (Transmittal 3425, CR9486) shows the update was related to the comprehensive payment when a patient has an inpatient-only procedure performed and then expires or is transferred prior to an inpatient order being written. After further searching, I finally located Transmittal 3238, CR 9097.  This transmittal states:

“Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.” (emphasis added)

This is definitely what I was looking for, but the danger in relying on prior transmittals is they may no longer be effective.  That is why I always confirm any transmittal guidance against the actual manuals.  And remember, I did not find this verbiage in the manuals.  I noticed in the updated manual instructions accompanying this transmittal that there is no “red text” (updated instructions) for these two manual sections other than the ‘update’ dates.  As Alice in Wonderland would say, my investigation was getting “curiouser and curiouser.”  If nothing was added or changed for these manual sections, was something removed?  Exactly what was updated? My search continued.

I finally found (thanks to some old email correspondence) Transmittal 2234, CR 7443 from way back in 2011. It is the July 2011 OPPS Update transmittal and it includes the following revisions.  Added to both manual sections noted above is the statement – “inpatient only procedures that are provided to a patient in the outpatient setting on the date of the patient’s inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission are not paid for by CMS and must be submitted on a no-pay claim (Type of Bill (TOB) 110).”  Now the April 2015 update made sense!  Nothing was added or changed, but the above statement was removed from both manual sections.  And since it is still absent from the manual instructions, its removal stands.

So I wasn’t crazy after all – at least not about this issue.  It is acceptable to report an inpatient-only procedure performed on an outpatient basis on the ensuing inpatient admission (within the 3 day payment window) and Medicare will cover this related procedure.  In fact, I think the scenario I described above is the perfect example of when this bundling is appropriate.  I do not think CMS changed this policy simply to allow hospitals to obtain a late inpatient admission order when they failed to do so in a timely manner.  I think this rule change was intended to allow appropriate payment in the case of emergencies or when the outpatient surgical procedure intended must be changed to one that is on the inpatient-only list during the surgery.

I am glad CMS made this change, but I wish they had ‘included’ rather than ‘excluded’ instructions in the manual updates.  Then I would not have gone looking for something that was not there.

As we approach the 4th of July Holiday it is a time to reflect on the history of our great nation. It is also a time to say a prayer of thanks and gratitude for all those who have served and continue to serve to protect the personal freedoms and rights guaranteed to us by the Bill of Rights.

While there has been much debate as to whether healthcare is a right, Medicare beneficiaries, Medicare Advantage (MA) plan enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible beneficiaries who are hospital inpatients have long had a statutory discharge appeal right.

Effective July 1, 2007, hospitals were required to begin delivering a revised version of the Important Message from Medicare (IM) form informing Medicare beneficiaries about their appeal rights. This second form was and still is to be given within two days of discharge. Additionally, beneficiaries who choose to appeal a discharge decision must also be provided the Detailed Notice of Discharge (DND) form from the hospital or his/her Medicare Advantage plan, if applicable.

Frequently Asked Questions

Over time, MMP has received questions regarding the process for delivering the IM form. On April 3, 2007 CMS released a Q&A document that in general has answered specific IM questions posed to us by our clients. Below are two of the most frequently asked questions and a link to the entire CMS document.

Question: Are we required to provide the IM and DND forms to all patients, regardless of payment source?

Answer: “This rule applies to all Medicare beneficiaries, including enrollees in Medicare Advantage (MA) plans and other Medicare health plans subject to MA regulations. Section 1154 of the Social Security Act applies to all patients who are under Medicare, regardless of where Medicare falls in the sequence of payment. Thus, all Medicare beneficiaries, no matter where in the sequence of payers Medicare falls, must receive these notices.”

Question: “Does the follow-up copy of the IM need to be signed again? If the follow-up copy is delivered and the patient ends up staying several more days, does another follow up copy need to be delivered?”

Answer: “The regulations do not require that the follow-up copy be signed. It serves as a reminder of the information that was given on the initial IM. However, while the beneficiary’s signature is not required, a hospital must be able to document that the notice has been delivered. One way to accomplish this would be to have the beneficiary initial the form to indicate that he or she has received it. We intend to provide an “Additional Information” area for an entry on the latest version of the IM. If the follow-up copy of the IM has been delivered and a beneficiary remains in the hospital for more than 2 additional calendar days, another follow-up copy should be issued according to the required timeframes.”

CMS Document Final Rule: Notification of Hospital Discharge Appeal Rights (CMS-4105-F) Qs And As (April 3, 2007) at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/CMS4105FINALRULEQsandAs2007.pdf

Appeal Notice Updates Timeline

As mentioned earlier, on July 1, 2007 hospitals were required to begin delivering a second copy of the IM letter within two days of the beneficiaries discharge. Since that time there have been updates to the IM Form CMS-R-193 and DND Form CMS 10066 as outlined below.

July 2010 IM Form Update

In 2010 the OMB released an updated form approved 07/10 that added a place to put the time the letter was signed in addition to the date.

August 2014 QIO Contact Information Change

With the 11th Scope of Work for the Quality Improvement Organizations (QIOs), responsibilities were split into two separate QIOs. The Quality Innovation Network (QIN) QIOs and the Beneficiary and Family Centered Care (BFCC) QIOs. Hospital Discharge Appeals are managed by the BFCC-QIOs. With this change, in August of 2014, CMS required hospitals to update their forms with the correct BFCC-QIO contact information no later than September 1, 2014.

June 2017 Form Update

A few weeks ago on June 6th CMS posted updated IM and DND forms to their Hospital Discharge Appeal Notices webpage. Comparing the new forms to the previous forms, MMP only noted the following form updates:  

• IM Form CMS-R-193:
• At the bottom left corner of the first page “Form CMS-R-193 (approved 07/10)” has been changed to “Form CMS-R-193 (Exp. 03/31/2020), and
• Above the “Additional Information” box on the bottom of page two the following verbiage has been added, “CMS does not discriminate in its programs and activities. To request this publication in an alternate format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.”
• DND Form CMS 10066:
• At the bottom of the form the following verbiage has been added, “CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov, and
• At the bottom left corner for the form “CMS 10066 (approved 07/10)” has been changed to “CMS 10066 (Exp. 10/31/2019).”

Additional information about Hospital Discharge Appeals can be found at the following resources.

BFCC-QIO Appeals webpages

• KEPRO at https://www.keproqio.com/providers/appeals.aspx
• Livanta at https://bfccqioarea5.com/casetypes.html

Medicare Claims Processing Manual, Chapter 30 – Financial Liability Protections, Section 200 – Expedited Review Process for Hospital Inpatients in Original Medicare at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, §482.13(a)(1) at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

TRANSMITTALS

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

• MLN Matters Number: MM10040
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R3780CP
• Related Change Request (CR) Number: 10040
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10040.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Updates the remittance advice remark code (RARC) and claims adjustment reason code (CARC) lists and also instruct ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print.

Claim Status Category and Claim Status Codes Update

• MLN Matters Number: MM10043
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R3782CP
• Related Change Request (CR) # 10043
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10043.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about system changes to update, as needed, the Claim Status and Claim Status Category Codes.

July 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• MLN Matters Number: MM10122
• Related CR Release Date: May 30, 2017
• Related CR Transmittal Number: R3783CP
• Related Change Request (CR) Number: 10122
• Effective Date: July 1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10122.pdf
• Affects providers and suppliers that submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS).

Summary: Describes changes to the OPPS to be implemented in the July 2017 update.

Guidance to Providers that Submit Outpatient Facility Claims and Those That Enter Claims Data via Direct Data Entry (DDE) Screens to Reduce Incidence of Claims Not Crossing Over

• MLN Matters Number: SE17015
• Article Release Date: June 6, 2017
• Related CR Transmittal Number: N/A
• Related Change Request (CR) Number: 10103
• Effective Date: August 7, 2017
• Implementation Date: August 7, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17015.pdf
• Affects institutional provider billers including those who submit HIPAA Accredited Standards Committee (ASC) 837 X12N institutional claims for outpatient hospital facility services to Medicare, and those who submit claims to Medicare via Direct Data Entry (DDE).

Summary: Instructs provider billing offices to correctly submit HIPAA ASC X12N 837 institutional claims to Medicare to reduce the incidence of receiving Return-to-Provider (RTP) edits on incoming 837 outpatient hospital facility claims as well as DDE claims due to edits that will be enforced as of August 7, 2017.

Screening for the Human Immunodeficiency Virus (HIV) Infection

• MLN Matters® Number: MM9980
• Related Change Request (CR) #: CR 9980
• Related CR Release Date: May 24, 2017
• Effective Date: April 13, 2015
• Related CR Transmittal #: R3778CP
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9980.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: MACs shall recognize the specified HCPCS codes for services related to the Screening for the Human Immunodeficiency Virus (HIV) Infection.

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

• MLN Matters Number: MM10086
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R1854OTN
• Related Change Request (CR) Number: 10086
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017, shared system edits, July 14, 2017, local edits
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10086.pdf
• Affects physicians, providers and suppliers billing Medicare Administrative Contractors
• (MACs) for services provided to Medicare beneficiaries.

Summary: A maintenance update of 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.

“Medicare Benefit Policy Manual” - Chapter 10, Ambulance Locality and Advanced Life Support (ALS) Assessment

• MLN Matters Number: MM10110
• Related CR Release Date: June 16, 2017
• Related CR Transmittal Number: R236BP
• Related Change Request (CR) Number: 10110
• Effective Date: September 18, 2017
• Implementation Date: September 18, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10110.pdf
• Affects ambulance providers and suppliers submitting Medicare Part B claims to the Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Clarifies the definitions for locality and ground ambulance services for ALS assessment. The term “locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. Your MACs have the discretion to define “locality” in their service areas.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017

• MLN Matters Number: MM10156
• Related CR Release Date: June 16, 2017
• Related CR Transmittal Number: R3797CP
• Related Change Request (CR) Number: CR 10156
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10156.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The October 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

 

OTHER MEDICARE ANNOUNCEMENTS

5 Ways for Healthcare Providers to Get Ready for New Medicare Cards

• https://www.cms.gov/Medicare/SSNRI/5-Things-What-to-do-Now-Drop-In-English.pdf

Summary: Educates providers about steps for removing Social Security numbers from Medicare cards. 

New Medicare Forms

ABN Form

• Effective June 21, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Hospital Discharge Appeal Notices

• Important Message from Medicare and Detailed Notice of Discharge
• June 7, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html

Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-29.pdf

Summary: The Centers for Medicare & Medicaid Services (CMS) is releasing a new Appendix Z of the State Operations Manual (SOM) which contains the interpretive guidelines and survey procedures for the Emergency Preparedness Final Rule. Appendix Z applies to all 17 providers and suppliers included in the Final Rule.

OFFICE OF INSPECTOR GENERAL (OIG) NEWS

2017 Compendium of Unimplemented Recommendations

• https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2017.pdf

Summary: Identifies significant recommendations to Congress with respect to problems, abuses, or deficiencies for which corrective actions have not been completed. Focuses on the top 25 unimplemented recommendations that, in OIG’s view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and quality improvements and should, therefore, be prioritized for implementation.

OIG Spring 2017 Semiannual Report to Congress

• https://oig.hhs.gov/reports-and-publications/semiannual/index.asp#sar

Summary: Summarizing activities of the Office of Inspector General (OIG), Department of Health and Human Services (HHS or the Department), for the 6-month period that ended March 31, 2017.

Updates to the OIG Work Plan

• https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Summary: OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Also, completed Work Plan items will be removed. Recently published reports can be found on OIG’s What’s New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.

I do not usually write articles about Medicare Coverage Decision Memorandums. This is because Coverage Decision Memos are not binding on contractors or Administrative Law Judges (ALJs) until they are implemented in a CMS-issued program instruction. Formal program instructions are supposed to occur within 180 days of the end of the calendar quarter in which the memo was posted on the Web site. If there are specific coding and billing instructions, they will also be published at the same time in a transmittal that updates the Medicare Claims Processing manual. The effective date of Medicare coverage of a particular service finalized in a National Coverage Determination (NCD) appears to always be made retroactive back to the date of the decision memo. So although the coverage of a service begins at the time of the Decision Memo, providers shouldn’t attempt to bill for the service until a final NCD and any associated billing/coding instructions are released.

This time I am going to make an exception because I think it is very interesting and an excellent Medicare benefit that CMS has decided to cover exercise therapy for patients with peripheral artery disease (PAD). PAD is the buildup of plaque in the arteries causing narrowing and affecting the lower extremities. Approximately 12% of Americans have PAD, but the prevalence increases with age. PAD causes pain and discomfort in the legs when walking or exercising but resolves with rest. This is known as intermittent claudication (IC). IC can dramatically affect patients’ functional independence and quality of life. As with all things Medicare, the minutiae are in the explanation of the coverage requirements.

Medicare will cover supervised exercise therapy (SET) when the following requirements are met:

• For beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD);
• Up to 36 sessions over a 12 week period;
• Sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
• In a hospital outpatient setting, or a physician’s office;
• Delivered by qualified auxiliary personnel trained in exercise therapy for PAD to ensure benefits exceed harms; and
• Under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques.

The patient must have a face-to-face visit with and obtain a referral for the SET from the physician treating their PAD. At this visit, the patient must receive information on cardiovascular disease and PAD risk factor reduction. This could include education, counseling, behavioral interventions, and outcome assessments. The Medicare Administrative Contractor may approve 36 additional sessions of SET for PAD based on a second referral. Medicare will not cover SET if a patient’s primary physician determines the patient has an absolute contraindication to exercise.

Exercise therapy is an effective way to alleviate the pain of PAD. SET may also prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. Greater access to SET programs could decrease the need for endovascular revascularization (ER) procedures so that ER can be reserved for cases where the patient is too functionally impaired for SET.

Providers should be on the lookout for the NCD and any associated claims processing instructions related to this decision memo.