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How do you go from laboratory technologist to compliance professional? You see it often because the detail oriented mind of laboratorians fits well into the myriad details of compliance requirements. For me, I happened to be the manager of a hospital outpatient laboratory at the time the Office of Inspector General (OIG) released the Compliance Program Guidance for Clinical Laboratories. In short order, it fell upon my shoulders to “do something” about this Compliance Guidance. The OIG guidance was in part a response to recent concerns about laboratory billing practices. A prominent national laboratory had at the time been under scrutiny for adding one more laboratory test to a large, frequently ordered lab profile that consisted of a significant number of different lab tests. According to the government, this caused physicians to unknowingly (or at least without careful consideration of medical need) order “medically unnecessary” lab tests.

I often refer to this as “the original compliance sin” and the issue of medical necessity is still a major concern for compliance, and not only for laboratory tests. Medical necessity now involves various types of medical services – from ambulances, to cardiology procedures, to high-cost drugs, to joint replacements, to many other services and even back to laboratory tests. Two recent enforcement actions posted on the OIG’s website are related to medically unnecessary laboratory pathology services.

The first case involves Poplar Healthcare located in Memphis, Tennessee, which paid nearly $900,000 to resolve False Claims Act allegations. According to the Department of Justice (DOJ) Press Release, “The government alleges that Poplar, directly and through a subsidiary known as GI Pathology, promoted and billed the government for diagnostic tests that the government contends were not medically necessary.” Poplar conducted an extensive, multi-year promotional campaign promoting the use of a special pathology stain they claimed could definitively diagnose “mast cell enterocolitis.” The government contended Poplar’s claims about the stain were not supported by scientific evidence and were not consistent with FDA approval requirements.

A similar case against Piedmont Pathology in Hickory, N.C also involves the medically unnecessary use of pathology stains. In this case, the pathology laboratory was performing and billing for special stains on certain gastric biopsies. The special stains were performed before a pathologist reviewed routinely stained specimens to determine if there was a medical need for the additional special stains. Piedmont Pathology has agreed to pay the United States $601,000 to settle allegations that it violated the False Claims Act by submitting false claims to Medicare and Medicaid for medically unnecessary procedures. The DOJ press release provides further details.

Another similarity between these two cases is that both were “whistleblower” cases where a private citizen can bring suit on behalf of the government for false claims under provisions of the False Claim Act. The government can decide to take over the case and the whistleblower shares in any monetary recovery. In these cases, the relator’s share was $205,841 and approximately $120,200, respectively.

There are important take-aways for all providers from these settlements:

• The government is serious about the medical necessity of services (for all types of healthcare services);
• No service is too big or too small for government attention;
• Be careful what a vendor tries to sell you;
• Verify the medical need for the services you provide; and
• Watch out for the whistleblowers!

Q:

If a patient is diagnosed with encephalopathy secondary to gram negative pneumonia, which ICD-10-CM codes would be appropriate to report? J15.6 & G93.49 or J15.6 & G94?

A:

Per AHA Coding Advisor (question submitted by MMP) the “EAB (Editorial Advisory Board) recommends assigning codes G93.40, Encephalopathy, unspecified and a code for Gram-negative pneumonia” (J15.6).According to the AHA Coding Advisor, “the EAB of Coding Clinic recently resolved the issue of coding encephalopathy in diseases classified elsewhere”.

“Code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94 for certain etiologies”.

Look for information, in regards to encephalopathy and/or code G94, to be published in the upcoming Coding Clinic 2nd Qtr. 2017.

Another thing you want to keep in mind; encephalopathy is generally a manifestation from a source such as pneumonia, sepsis, UTI etc. Quite often this could reflect a metabolic type encephalopathy that temporarily may affect a patient’s electrolytes, vitamin or other chemical type balance that would adversely alter or affect brain function.   In order to give greater specificity, be sure to query the provider if there is lack of supporting documentation. 

TRANSMITTALS

Update FISS Editing to Include the Admitting Diagnosis Code Field

• MLN Matters® Number: MM9753
• Related Change Request (CR) #: CR 9753
• Related CR Release Date: April 28, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1832OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9753.pdf
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Updates various system edits to look at the admitting diagnosis field. FISS editing is now being updated to ensure that all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx that are tied to the diagnosis code fields (other than the primary diagnosis field) include the admitting diagnosis field for Inpatient claims on Types of Bill (TOB) 011x, 012x, 018x, 021x, and 022x.

Screening for Hepatitis B Virus (HBV) Infection

• MLN Matters® Number: MM9859
• Related Change Request (CR) #: CR 9859
• Related CR Release Date: April 28, 2017
• Effective Date: September 28, 2016
• Related CR Transmittal #: R3761CP and R195NCD
• Implementation Date: January 1, 2018
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries

Summary: Medicare will cover screening for Hepatitis B Virus (HBV) infection for certain individuals when performed with an FDA approved/cleared laboratory tests

REVISED: Revision to clarify language on page 3, under the “Professional Billing Requirements.” It now reads, only when services are ordered by the following provider specialties found on the provider’s enrollment record…

Implementing the Remittance Advice Messaging for the 20 Hour Weekly Minimum for Partial Hospitalization Program Services

• MLN Matters® Number: MM9880
• Related Change Request (CR) #: CR 9880
• Related CR Release Date: April 28, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1833OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9880.pdf
• Affects Outpatient Prospective Payment System (OPPS) providers submitting Partial Hospitalization Program (PHP) claims to Medicare Administrative Contractors (MACs) for PHP services provided to Medicare beneficiaries.

Summary: Implements informational messaging, effective October 1, 2017, that conveys supplemental and educational information to the provider submitting claims for PHP services where the patient did not receive the minimum 20 hours per week of therapeutic services his plan of care indicates is required, on claims with line item date of service (LIDOS) on or after October 1, 2017.

New Physician Specialty Code for Advanced Heart Failure and Transplant Cardiology, Medical Toxicology, and Hematopoietic Cell Transplantation and Cellular Therapy

• MLN Matters® Number: MM9957
• Related CR Release Date: April 28, 2017
• Related CR Transmittal #: R283FM and R3762CP
• Related Change Request (CR) #: CR 9957
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9957.pdf
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries

Summary: Establishes new physician specialty codes for Advanced Heart Failure and Transplant Cardiology (C7), Medical Toxicology (C8), and Hematopoietic Cell Transplantation and Cellular Therapy (C9).

Payment for Moderate Sedation Services Furnished with Colorectal Cancer Screening Tests

• MLN Matters Number: MM10075
• Related CR Release Date: April 28, 2017
• Related CR Transmittal Number: R3763CP
• Related Change Request (CR) Number: 10075
• Effective Date: January 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10075.pdf
• Affects physicians and other providers submitting claims to Part A and B Medicare Administrative Contractors (MACs) for sedation services furnished with colorectal cancer screening tests.

Summary: Ensures accurate program payment for moderate sedation services furnished in conjunction with screening colonoscopy services for which the beneficiary should not be charged the coinsurance or deductible.

Office of Inspector General Report: Stem Cell Transplantation

• MLN Matters® Number: SE1624 Revised
• Article Release Date: May 1, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1624.pdf

Summary: This article was revised on May 1, 2017, to make a number of clarifications and to delete the table that had been in the article.

Update FISS Editing to Include All Three Patient Reason for Visit Code Fields

• MLN Matters® Number: MM9672 - Revised
• Related Change Request (CR) #: CR 9672
• Related CR Release Date: May 17, 2017
• Effective Date: Claims received on or after October 1, 2017
• Related CR Transmittal #: R1852OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9672.pdf
• Affects providers submitting outpatient hospital claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: FISS edits to ensure all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx are tied to the diagnosis code fields including all three Patient Reason for Visit (PRV) fields for outpatient hospital claims on Types of Bills (TOB) 013x and 085x. CR9672 makes no policy changes.

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare SetAside Arrangements (NFMSAs)

• MLN Matters® Number: MM9893
• Revised Related Change Request (CR) #: CR 9893
• Related CR Release Date: May 10, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1845OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Establishes two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA).

Clarifying Medical Review of Hospital Claims for Part A Payment

• MLN Matters Number: MM10080
• Related CR Release Date: May 12, 2017
• Related CR Transmittal Number: R716PI
• Related Change Request (CR) # 10080
• Effective Date: June 13, 2017
• Implementation Date: June 13, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10080.pdf
• Affects providers that submit institutional claims to Medicare Administrative Contractors (MACs) for inpatient hospital services provided to Medicare beneficiaries.

Summary: Clarifies the medical review requirements for Part A payment of short stay hospital claims (more commonly referred to as the "Two-Midnight" Rule) for MACs, Supplemental Medical Review Contractors (SMRC), Recovery Audit Contractors and the Comprehensive Error Rate Testing (CERT) contractors.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2017 Update

• MLN Matters Number: MM10107
• Related CR Release Date: May 18, 2017
• Related CR Transmittal Number: R3776CP
• Related Change Request (CR) Number: CR 10107
• Effective Date: July 1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10107.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries

Summary: The HCPCS code set is updated on a quarterly basis. Change Request (CR) 10107 informs MACs of updating specific drug/biological HCPCS codes.

July 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.2

MLN Matters Number: MM10115

• Related CR Release Date: May 18, 2017
• Related CR Transmittal Number: R3777CP
• Related Change Request (CR) Number: 10115
• Effective Date: July1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10115.pdf
• Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary: The I/OCE is being updated July 1, 2017. The I/OCE routes all institutional outpatient claims (which includes non-Outpatient Prospective Payment System (OPPS) hospital claims) through a single integrated OCE.

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR); Delay of Effective Date

• Published in Federal Register May 19, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-05-19/pdf/2017-10340.pdf

Summary: This final rule finalizes May 20, 2017 as the effective date of the rule. It also finalizes a delay of the applicability date of the regulations from July 1, 2017 to January 1, 2018.

Q:

Several of our physicians sometimes have scribes do their documentation for them.  Do both the scribe and the physician have to sign this documentation?

A:

No; only the physician’s signature is required.  CMS recently released Transmittal 2017 updating the Medicare Program Integrity Manual to provide instructions to providers regarding signature requirements when scribe services are used by a physician/non-physician practitioner (NPP).

According to the Transmittal, “Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.” 

In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.

Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.

With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.

CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.

Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”

For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.

Code Groups

First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group. 

Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.  

‍

Key Takeaway from the Data:

• For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
• MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
• MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
• Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.

MS-DRG Shift from Surgical to Medical

Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely. 

In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:

• Patient A
• Dates of Service: 3/29/2016 – 4/19/2016
• Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
• Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
• MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
• Relative Weight: 17.657
• CMS FY 2016 National Average Reimbursement $95,944.77.
• Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
• MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
• Relative Weight: 1.0427
• CMS FY 2016 National Average Reimbursement $5,665.86
• Patient B
• Dates of Service: 5/3/2016 – 5/13/2016
• Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
• Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
• MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
• Relative Weight: 6.1746
• CMS FY 2016 National Average Reimbursement: $33,551.79 
• Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
• MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
• Relative Weight: 1.1925
• CMS FY 2016 National Average Reimbursement: $6,479.85
• Patient C
• Dates of Service: 7/18/2016 – 7/23/2017
• Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
• Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
• MS-DRG Assigned: 572 Skin Debridement without CC/MCC
• Relative Weight 1.0391
• CM FY 2016 National Average Reimbursement: $5,646.30
• Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
• MS-DRG 603: Cellulitis without MCC
• Relative Weight: 0.8429
• CMS FY 2016 National Average Reimbursement: $4,580.18

MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.

Resource:

2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html

In life, sometimes you win and sometimes you lose. The same goes for dealings with Medicare although most of us probably think we lose more than we win in this arena. But every now and then the providers come out to the good. At the beginning of last year, CPT code 96416 was the appropriate code to bill for prolonged chemotherapy infusions using a portable or implantable infusion pump. Last year, some Medicare Administrative Contractors (MACs) instructed to use an unlisted code for this service. Now there is a new code. Why have there been so many coding changes for this service and what is included in the current code?

The definition for CPT code 96416 is “Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump” and it was at one time the appropriate code to bill for these prolonged infusions. In April, 2016, CMS released MLN Matters Article SE1609. The main point of this article seemed to be to emphasize that the pump used for these prolonged infusions should not be billed separately as a DME item. The article stated, “Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit.”

The article went on to say that the MACs could direct use of a specific CPT or HCPCS code to be used to report the service, even a miscellaneous code “if there is no specified code that describes the drug administration service that also accounts for the cost of equipment that the patient takes home to complete the infusion that they later return to the physician or hospital.” Some MACs did instruct their providers to use the miscellaneous chemotherapy CPT code, CPT 96549. This caused great angst for providers because the Medicare OPPS unadjusted payment rate for 2016 for CPT 96549 was $30.87 as opposed to $280.27 for CPT 96416. The payment rate for the miscellaneous code failed to even cover the cost of providing the service.

Luckily for providers, this unfair payment situation was remedied with the creation of a new HCPCS code to describe the administration service and also account for the equipment cost. In the April 2017 OPPS Update, Medicare instructed the use of HCPCS code G0498 for these prolonged chemotherapy infusions “where the facility incurred a facility expense specific to the provision of the non-implantable, external infusion pump.” It is good to note that HCPCS code G0498 has the same OPPS status indicator (“S”) and payment rate ($279.45 for 2017) as CPT code 96416. And, CMS made the code retroactive to January 1, 2016.

The full description of HCPCS code G0498 is “Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living).” The code includes the chemotherapy administration service (the IV infusion of the drug), any supplies used, and the cost of using the pump. Providers should not report another code for the chemotherapy infusion – it is covered by this HCPCS code. The chemotherapy drug can be billed separately in addition to the administration code, G0498.

It feels good to win!

Q:

Sometimes patients are provided with orthoses they will carry home with them (such as a back brace) while they are an inpatient in the hospital. How do we determine if the hospital absorbs the cost of the orthosis or if the DME company can bill the patient’s Medicare?

A:

Medicare provides good information about this in the Fact Sheet Provider Compliance Tips for Spinal Orthoses. For orthoses provided to patients before or during an inpatient stay, the key is whether the patient will be using the orthosis for medically necessary treatment or rehabilitation during the inpatient stay. Payments for orthoses are included in payments to hospitals if the patient uses the orthosis during the admission. In these situations, the supplier should not submit claims to the DME MAC. The applicable situations are stated as follows in the Fact Sheet:

• The supplier provides the orthosis to the beneficiary prior to an inpatient admission or Part A covered SNF stay and the medical necessity begins during the stay (for example, after spinal surgery)
• The supplier provides the orthosis to the beneficiary during an inpatient stay prior to discharge and the beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.

However, if the orthosis is given to the patient for home use within two days prior to discharge and is not used during the hospitalization, then the DME may bill the patient’s Medicare. Per the Fact Sheet, “Payments for spinal orthoses are eligible for coverage by DME MACs if the orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay and the supplier provides the orthosis to the beneficiary within two days prior to discharge home, and the orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.” 

As of the writing of this article, there are 344 Medicare National Coverage Determinations (NCDs), 1,207 Local Coverage Determinations (LCDs) and 1,197 local Articles. From the Medicare Coverage Determination Process webpage, “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).” LCDs may also be developed when there is a need to further define an NCD. LCDs only contain reasonable and necessary language. Other information related to an item or service that does not deal with the medical necessity of the item/service is communicated through an article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.

When I first became aware of LCDs in my Compliance career, they were called LMRPs (Local Medical Review Policies). The main concept of LMRPs at the time was of a list of covered diagnoses (defined by, at that time, ICD-9 diagnosis codes). If an item, test, or service that had an LMRP was performed and one of the “covered” diagnosis codes was not on the claim, the line item for the item, test, or service was denied. LCDs still have lists of diagnosis codes (now ICD-10 codes) that support the medical necessity of the services. However, today’s policies go beyond the diagnosis codes and describe the indications and limitations for coverage. And although some LCDs are retired and others created, it seems that LCDs as a whole are addressing a wider range of services than ever before.

For example, National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdictions J6 and JK, retired their existing policy for Nerve Blocks for Peripheral Neuropathy (L35029) and added a new policy for Peripheral Nerve Blocks (L36850). The older policy only addressed the limitation that nerve blocks for multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases were not considered medically necessary and therefore not covered.

The new policy defines coverage for all possible uses of nerve blocks. This includes a list of seven indications that are reasonable and necessary for coverage and a long discussion of limitations (this includes the original limitation concerning neuropathies). Covered conditions for peripheral nerve blocks include the following. These are shortened descriptions, so please see the policy for complete descriptions.

• classic mononeuritis where neuro-diagnostic studies have failed to provide a structural explanation
• complex regional pain syndrome from peripheral nerve injuries/entrapment or other extremity trauma
• diagnostically for cases in which the clinical picture is unclear
• occipital neuralgia
• suspected entrapment of the suprascapular nerve
• blocked trigeminal nerve
• preemptive analgesia for post-surgical pain control

The limitations discuss frequency, total number of injections, and injections of multiple sites among other issues.

The caution to providers is to no longer rely simply on the presence or absence of a particular diagnosis code to determine coverage of a service. Yes, the diagnosis (and corresponding code) must be present, but coverage requirements go way beyond that. The patient’s condition must meet the indications for a particular service, there must be no limitations to coverage, and the documentation in the patient’s medical record must support the required indications. If not, the service is likely to be denied should a Medicare contractor perform a medical review.

Determining if services provided to Medicare patients meet all the indications of a coverage policy is a lot harder than simply looking for a diagnosis code, both for Medicare and for the provider. This requires a complex medical review by Medicare and internal evaluation of processes and documentation by the provider. It definitely goes beyond the diagnosis code list.

Back in September, 2016, an article was published concerning coding acute renal failure with ESRD. (Click here to see that article.) In answering the question I stated that a question had been submitted to the AHA Coding Advisor regarding patients diagnosed with both acute renal failure and ESRD. I finally received an answer on 4/12/17 and have added an update to the question.

Q:

Can acute renal failure be coded (ARF) with end stage renal disease (ESRD). Our PA has advised us not to code ARF with ESRD. He stated that once a patient has developed ESRD their kidneys are basically dead and no longer have the capability to function or produce any urine output so therefore would not be able to go into acute failure.

A:

This makes total sense but as coders we have to follow the Official Coding Guidelines and instructions given in the AHA Coding Clinic. MMP has re-submitted this question to the AHA Coding Clinic Advisor for further clarification. For the time being, until we receive a response back from them, you should follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both ARF and ESRD are both documented by the provider, code each condition separately.

Update – April 12, 2017
Confirmation was received from the AHA Coding Clinic Advisor. Continue to follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both acute renal failure and ESRD are clearly documented in the record, both conditions are to be coded. 

Transmittals

FISS Implementation of the Restructured Clinical Lab Fee Schedule

• MLN Matters® Number: MM9837 Revised
• Related Change Request (CR) #: CR 9837
• Related CR Release Date: March 23, 2017
• Effective Date: January1, 2018
• Related CR Transmittal #: R3740CP
• Implementation Date: July3 , 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9837.pdf
• Affects clinical laboratory providers submitting claims to Medicare Administrative Contractors (MACs) for services paid under the Clinical Lab Fee Schedule (CLFS) and provided to Medicare beneficiaries.

Summary: Informs MACs about the changes to the Fiscal Intermediary Shared System (FISS) to incorporate the revised CLFS containing the National fee schedule rates.

Payment for Moderate Sedation Services

• MLN Matters® Number: MM10001
• Related Change Request (CR) #: CR 10001
• Related CR Release Date: April 14, 2017
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3747CP
• Implementation Date: May 15, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10001.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for moderate sedation and anesthesia services provided to Medicare beneficiaries.

Summary: Revises existing Medicare Claims Processing Manual language to bring the manual in line with current payment policy for moderate sedation and anesthesia services.

Providers should refer to the revised Medicare Claims Processing Manual, Chapter12 (Physicians/Non-physician Practitioners), Sections 50 and 140 for information regarding the reporting of moderate sedation and anesthesia services.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.2, Effective July 1, 2017

• MLN Matters Number: MM10082
• Related CR Release Date: April 14, 2017
• Related CR Transmittal Number: R3748CP
• Related Change Request (CR) Number: CR10082
• Effective Date: July1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10082.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs about the quarterly update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP).

Other Medicare Announcements

Final Rule Correction – Medicare Physician Fee Schedule

• Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements; Corrections
• March 22, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-03-22/pdf/2017-05675.pdf

Summary: Corrects technical errors in the addenda to the final rule published in the November 15, 2016, Federal Register.

CMS Voluntary Self-Referral Disclosure Protocol and Form

• Revision date March 27, 2017
• Use of the form is mandatory effective June 1, 2017. Parties submitting self-disclosures to the SRDP are encouraged, but not required, to use the SRDP Form now.
• https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Self_Referral_Disclosure_Protocol.html

Summary: New protocol and form to self-disclose actual or potential violations of the physician self-referral statute and/or noncompliant financial relationships with physician(s).

Renewal of Advance Beneficiary Notice of Non-coverage, Form CMS-R-131

• March 28, 2017
• Effective Date for use of this ABN form is June 21, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Summary: The ABN form and instructions have been approved by the Office of Management and Budget (OMB) for renewal. While there are no changes to the form itself, providers should take note of the newly incorporated expiration date on the form.  With the 2016 PRA submission, a non-substantive change has been made to the ABN. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

Clinical Laboratory Data Reporting: Enforcement Discretion

• March 30, 2017
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/2017-March-Announcement.pdf

Summary: CMS will exercise enforcement discretion until May 30, 2017, regarding the data-reporting period for reporting applicable information under the Clinical Laboratory Fee Schedule and the application of the Secretary’s potential assessment of civil monetary penalties for failure to report applicable information. This discretion applies to entities that are subject to the data reporting requirements adopted in the Medicare Clinical Diagnostic Laboratory Tests Payment System final rule published on June 23, 2016 (81 FR 41036).

Decision Memo for Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Oxygen) (CAG-00060R)

• April 3, 2017
• https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=286&TimeFrame=7&DocType=All&bc=AgAAYAAACAAAAA%3d%3d&

Summary: Decision memo for HBO therapy that removes the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C. CMS has decided that no National Coverage Determination is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds and will amend NCD 20.29 by removing Section C, Topical Application of Oxygen. Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.

New Mailbox for BNI Notices Questions

• Effective April 13, 2017

Questions regarding any of the Fee For Service Beneficiary Notice Initiative (BNI) notices may be sent to the new mailbox:  BNImailbox@cms.hhs.gov. 

The BNI notices are:

• FFS Advance Beneficiary Notice of Non-coverage (FFS ABN)
• FFS Home Health Change of Care Notice (FFS HHCCN)
• FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN) and SNF Denial Letters
• FFS Hospital-Issued Notices of Non-coverage (FFS HINNs)
• FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility  (FFS Expedited Determination Notices)
• Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) (Hospital Discharge Appeal Notices)
• FFS Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (FFS NEMB SNF) 

There is an exception for the Medicare Outpatient Observation Notice (MOON). Continue to send questions regarding the MOON to MOONMailbox@cms.hhs.gov.

Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule

• April 14, 2017
• Fact Sheet - https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-04-14.html

Summary: Updates 2018 Medicare payment and polices when patients are admitted into hospitals. The rule updates payment rates, quality initiatives, and code sets. In addition to the payment and policy proposals, CMS is soliciting ideas for regulatory, sub-regulatory, policy, practice and procedural changes to improve the health care delivery system, make it less bureaucratic and complex, and reduce burden for clinicians, providers and patients in a way that increases quality of care and decreases costs.