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What was your strong subject in school – reading, writing, or math? To bill drugs correctly to Medicare, you need a little of all three.

Based on the physician’s order, 500 mg of Infliximab is administered to a patient. To bill for the Infliximab, a provider would report HCPCS code J1745 which has a description of “Injection, Infliximab, excludes biosimilar, 10 mg.” These means 50 units of J1745 would be reported on the claim to reflect the 500 mg given to the patient (500 mg dose divided by 10 mg description equals 50 units). If a patient requires a dose of 800 mg, then 80 units of J1745 would be billed for the amount of the drug administered and the provider may bill 20 additional units with a JW modifier if a 200 mg portion of a 250 mg single-use vial had to be wasted. The point here is that the units billed do not equal the dose amount; the units billed are based on the dose given and/or wasted and the HCPCS description of the drug. Units of service are reported in multiples of the units shown in the HCPCS narrative description. Furthermore, the physician’s order, the medication administration record, and applicable nursing or pharmacy notes must appropriately document the dosage ordered, the amount of drug administered, and any drug wastage.

Sounds straight-forward but evidently a lot of providers have problems getting this correct. The Medicare Supplemental Medical Review Contractor (SMRC) has issued notice of a new project to conduct post payment review of claims to identify incorrect units of service for outpatient drugs. According to the SMRC announcement, “Correct payments depend on providers’ accurate reporting of the HCPCS codes and units of service for each line item billed.”

The SMRC review project is at least partially in response to a July 2015 Office of Inspector General (OIG) report that identified $35.8 million in overpayments for selected outpatient drugs from July 2009 through June 2012. Eighty-eight percent of the overpayments identified in this OIG report were due to billing “either incorrect units of service or a combination of incorrect units of service and incorrect HCPCS codes.”

Medicare has established prepayment Medically Unlikely Edits (MUEs) to reduce payment errors. MUEs establish a limit for the units billed for a drug HCPCS code based on the maximum number of units a provider would reasonably administer to a patient for that code on that date of service. The OIG identified outpatient drugs that (1) had units of service that exceeded the MUE values or (2) did not have established MUE values but had units of service that exceeded the number of units a provider would reasonably administer to a beneficiary on a single date of service.

In addition to the SMRC review of outpatient drug units, the new Recovery Auditors for Regions 1, 2, and 3 have posted approved issues that address drug units. Those issues include:

• Automated review of drugs and biologicals whose units exceed the only FDA approved dose,
• Complex review of the drug Trastuzumab (Herceptin), J9355 - multi-dose vial wastage, dose vs. units billed. Documentation will be reviewed to determine if the billed amount of Trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines.
• Automated review of the drug Regadenoson (Lexiscan), J2785, billed with units greater than four (4).
• Automated review of the drug Zoledronic Acid billed with units greater than or equal to five (5) to identify excess units of J3489 as either excess units within a single line and/or as excess units across multiple lines/claims for the same beneficiary, the same HCPCS code and the same revenue center date.

A number of Medicare Administrative Contractors (MACs) are conducting medical reviews of drugs. These are generally complex reviews and drug units are only one of the issues considered. Search our knowlegde base for "drug review results" for more on this.

When billing for drugs, providers need to ensure they know the HCPCS code description, divide correctly, have the correct conversion factors in their charge description master (CDM), and have appropriate documentation in their records. A little reading, a little math and a little writing…

“The difference between the almost right word and the right word is really a large matter --- it’s the difference between the lightning bug and lightning.”- Mark Twain: Letter to George Bainton, October 15, 1888

In MMP’s article Case Mix Index: Beyond the Physician's Pen, our readers were introduced to the concepts of Medicare Severity Diagnosis-Related Groups (MS-DRGs), how an MS-DRG is assigned, Principal and Secondary diagnoses, Relative Weight (RW), and Case Mix Index (CMI). CMS defines CMI as a representation of the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. CMIs are calculated using both transfer-adjusted cases and unadjusted cases.

We also likened the way a CMI is calculated to calculating a student’s Grade Point Average (GPA).

Formula for CMI: Sum of RWs ÷ Total Number of MS-DRGs = CMI
Formula for GPA: Sum of Grade Points ÷ Sum of Credit Hours = GPA

A higher CMI reflects a more complex patient population that required higher resource utilization. A higher GPA reflects a higher level of academic achievement by the student which required a higher focus on academic studies resulting in the student having a more complex understanding of the subject matter.

CMI Pain Points for Hospitals

This article focuses on CMI pain points for hospitals including understanding that a successful MS-DRG Program is a collaborative process, there are several reasons that a CMI can fluctuate, and that slight shifts in CMI can have a significant impact on your hospital finances.

Pain Point: Understanding that a successful MS-DRG Program is a Collaborative Process

For a hospital to be successful in obtaining the CMI that truly reflects their patient population is a collaborative effort between the Physician, Clinical Documentation Improvement Specialists and Professional Coders. Here are the specific roles each team member must fill to truly tell the patient’s story.

• The Physician’s Role: Tell the Patient’s Story by providing complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.

• The Clinical Documentation Specialist’s Role: Interpret the documentation by performing concurrent medical record reviews and ask for clarity and/or accuracy of the clinical picture.  

• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also to ask queries when indicated. Ultimately, it is the Coding Professional’s role to translate documentation into codes for MS-DRG assignment.

Before moving on to the next Pain Point, it is important to note that CMS supports this collaborative process. In fact in the 2008 IPPS Final Rule CMS noted that they do “not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.”

AHIMA’s 2016 Practice Brief, Guidelines for Achieving a Compliant Query Practice, also supports the query process. Specifically, they note that a Physician Query is “a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical though processes, documented in a manner that supports accurate code assignment.”

Pain Point: Recognizing Factors Leading to CMI Fluctuations

As a Clinical Documentation Specialist in the hospital, I can remember monthly operational review meetings where inevitably the Chief Financial Officer (CFO) wanted an explanation for the shift (positive or negative) in CMI and placed this responsibility solely on the Clinical Documentation Improvement Team. Quite a few years have passed since then and I am hopeful that this is no longer the case at your hospital. However, if it is, share this article with your CFO to help him/her understand that shifts in CMI can happen that are beyond a Coder or Clinical Documentation Specialists control.

A decrease in CMI may be reflective of:

• Non-specific Physician documentation,
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical MS-DRGs in general are more resource intensive and will have a higher RW,
• Surgeons being on vacation;
• Inpatient admissions that could have been treated as an Outpatient, or
• Physicians being unresponsive to Coder and Clinical Documentation Specialists queries.
• Note, queries are asked to clarify documentation, not to question a physician’s clinical judgment.

An increase in CMI may be reflective of:

• Increase in surgical volume,
• Tracheostomy procedures that have an extremely high RW,
• Ventilator patients, or
• Improved physician response to queries resulting in improved documentation depicting the patient’s story.

Pain Point: Recognizing that Small Variances in CMI can Significantly Impact a Hospitals Finances

CMI shifts of even 0.1000 can have a significant impact on your hospital finances. To illustrate, the following table takes a look at the “We Care for You Hospital” which saw a decrease in their CMI of 0.1000 from FY 2015 to FY 2016.

The above example is just that, an example. In reality, surgeons go on vacation, surgical and medical volumes change, MS-DRGs are reassigned a new RW on an annual basis that may be higher or lower than the prior fiscal year, improved physician documentation can have a positive impact on your secondary diagnoses capture rate, and ICD-10 happened.

To validate there is more to CMI than meets the eye, I turned to our sister company RealTime Medicare Data (RTMD) to analyze Medicare Fee-for-service paid claims data. Specifically, I compared the Fiscal Year prior to ICD-10 implementation to the first full Fiscal Year after the October 1, 2015 ICD-10 implementation date. The following two tables contrasts the Top 10 MS-DRGs by RW, CMI, number of discharges and actual payment for the state of Alabama.

At the end of the day, accurate documentation captures the clinical severity of the patient that in turn can:

• Increase patient safety,
• Increase the accuracy of Quality measures,
• Decrease the risk of medical necessity denials,
• Result in more accurate Readmission and Mortality rates for your hospital,
• Impact physician and hospital profiles; and
• Support that your patients have received the right care, at the right time, at the right cost and in the right setting.

 

Resource:

Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations / page 47180 at https://www.gpo.gov/fdsys/pkg/FR-2007-08-22/pdf/07-3820.pdf

In our modern texting, emailing, and messaging world, numerous acronyms have become common in order to allow us to communicate faster. One example is “LOL” which in texting lingo means “laugh out loud.” But to a Medicare patient or provider, LOL can mean “limitation on liability.” Limitation on Liability is one of the Financial Liability Protection provisions of the Social Security Act which protects beneficiaries, health care providers and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay. Specifically, the LOL protections apply only when a provider believes that a Medicare covered item or service may be denied in a particular instance because it is not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. If a provider believes a service will not be covered by Medicare because it is not medically necessary, they must give advance notice to the patient in order to shift the financial costs to the patient.

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a form given to Fee-for-Service Medicare beneficiaries in situations where Medicare payment is expected to be denied. There are no substantive changes to the form for the latest approval but there is a new expiration date and 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.  The effective date for use of this ABN form is 6/21/2017.

As a reminder, hospitals may issue an ABN for services that are not medically necessary, for therapy services that exceed the therapy cap amount and do not qualify for an exception, for experimental/investigational services, and since 2011 for preventive services when frequency limitations are exceeded. An ABN is mandatory in order to shift liability to the patient for these types of services. ABNs may also be used voluntarily for services that are not a Medicare benefit or are excluded from coverage. The ABN form is also used in certain situations by suppliers, physicians, hospices, home health agencies, CORFs, and SNFs (Part B only).

An ABN may be issued at the initiation of a service such as the beginning of a new patient encounter, start of a plan of care, or beginning of treatment - for example, diagnostic tests that are not medically necessary such as laboratory tests. A notice can also be given when services are reduced or terminated. Examples of this would be when a patient’s progression in rehabilitative therapy supports fewer visits per week but the patient wants to continue at the same frequency or when therapy services are no longer medically necessary but the patient wishes to continue.

Medicare has a number of resources with information about the Advance Beneficiary Notice.

• Medicare Claims Processing Manual, Chapter 30, Section 40.3
• MLN Booklet – Medicare Advance Beneficiary Notices
• ABN Form Instructions
• Medicare FFS ABN webpage with links to the ABN form (English and Spanish)

So be prepared to use the new ABN form in June; you wouldn’t want anyone to laugh at you for using the wrong form – LOL! 

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

• In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
• Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
• High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

• Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
• Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
• Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

• Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
• Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
• Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
• Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
• Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following components:

• An assessment of changes in patient functional or medical status with revised plan of care;
• An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; and
• A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.

Let me start off by saying, there is no denying the importance and need of a physician advisor, especially in this day and time of Medicare compliance audits. Years ago the hiring of a physician advisor seemed more or less optional but as time moves forward the physician advisor’s role has become an integral component within the Clinical Documentation Improvement (CDI) program.

Physician advisors are a great asset to a hospital and they serve as a much needed bridge and advocate between the provider (attending physician) and CDI, coders and HIM. They play a very important role as an inside consultant working as an influential diplomat in accomplishing goals by using their clinical knowledge, their understanding of quality standards & metrics and the importance of coded data to a hospitals present and future reimbursement.

With all this being noted, there are also limits to a physician advisor’s responsibilities. As a licensed physician, they cannot change or add additional documentation in a patient’s record in which they themselves have not provided direct medical care. They also cannot use their own opinion to override a diagnosis provided by the provider. If the physician advisor’s opinion differs from that of the provider, then he/she must contact that particular physician and follow the industry standard guideline for communication (e.g., speaking one on one or querying).

At the end of the day when all is said and done; the provider that has clinically evaluated the patient, developed a therapeutic treatment plan and/or procedure(s) and established a diagnosis is the one responsible for that diagnosis both legally and morally. A provider could possibly deny responsibility should anyone, physician advisor included, override their professionally established diagnosis. Can you imagine the legal ramifications that could bring on the hospital/facility?

There will definitely be times when a physician advisor, CDI and/or coder may feel that clinical indications currently listed in the record need to be specified further in order to give greater support. Of course in these situations a query should be sent. The 2008 AHIMA practice brief titled, “Managing an Effective Query Process” noted the following guideline:

“Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results. For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x-ray may be negative. Queries should not be used to question a provider’s clinical judgement, but rather to clarify documentation when it fails to meet any of the five criteria listed above – legibility, completeness, clarity, consistency, or precision… In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician.”

There are no guidelines which allow an override process when it comes to the attending provider and a patient’s diagnosis. Per Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting, “The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists.  The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Greater detail on the reporting of a diagnosis code is found in Coding Clinic 4th Qtr. 2016 page 147. “Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.”

The physician advisor should help to monitor a provider that may have developed a trend of establishing a diagnosis that consistently results in denials and/or penalties and puts the facility at risk for lost reimbursement. In cases such as this, the established steps should be taken to rectify the situation. It is clearly not the role of the physician advisor to establish that final diagnosis of a patient’s condition.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

References:

Clinical Criteria and code Assignment - Coding Clinic 4th Quarter 2016 Page 147 – Oct. 1, 2016

Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting – October 1, 2016

The Physician Advisor’s Guide to Clinical Documentation Improvement - 2014
https://store.healthleadersmedia.com/aitdownloadablefiles/download/aitfile/aitfile_id/1720.pdf

ICD-10 Monitor: Controversial – Attending Physicians Denying Responsibility? – Nov. 28, 2016
https://www.icd10monitor.com/controversial-attending-physicians-denying-responsibility

Defining the Role of a Physician Advisor - August 15, 2007
http://www.hcpro.com/REV-75168-5354/Defining-the-role-of-a-physician-advisor.html

Who Makes a Good Physician Advisor and What Can They Do For You? – May 6, 2016
https://www.ahcmedia.com/articles/137835-who-makes-a-good-physician-advisor-and-what-can-they-do-for-you

The Value of a Physician Advisor – December 1, 2014
http://www.providentedge.com/the-value-of-a-physician-advisor/        

Taking Coding to the Next Level through Clinical Validation
http://library.ahima.org/doc?oid=300246#.WM_f-2Y2yUk

2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” – April 2013
http://www.hcpro.com/content/290814.pdf

Ask ACDIS: Escalation Policies and Clinical Validation Queries - September 1, 2015
http://www.hcpro.com/HOM-320974-5728/Ask-ACDIS-Escalation-policies-and-clinical-validation-queries.html

 

TRANSMITTALS

Gender Dysphoria and Gender Reassignment Surgery

• MLN Matters® Number: MM9981
• Related Change Request (CR) #: CR 9981
• Related CR Release Date: March 3, 2017
• Effective Date: August 30, 2016
• Related CR Transmittal #: R194NCD
• Implementation Date: April 4, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9981.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.

April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1

• MLN Matters® Number: MM10002
• Related Change Request (CR) #: CR 10002
• Related CR Release Date: March 10, 2017
• Effective Date: April 1, 2017
• Related CR Transmittal #: R3735CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10002.pdf
• Affects providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs for services provided to Medicare beneficiaries.

Summary: Instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

Clarification of Admission Order and Medical Review Requirements

• MLN Matters® Number: MM9979
• Related Change Request (CR) #: CR 9979
• Related CR Release Date: March 10, 2017
• Effective Date: January 1, 2016
• Related CR Transmittal #: R234BP
• Implementation Date: June 12, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9979.pdf
• Affects physicians submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Clarifies the rulemaking language of the Centers for Medicare & Medicaid Services (CMS) as it relates to “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.”

Billing for Advance Care Planning (ACP) Claims

• MLN Matters® Number: MM10000
• Related Change Request (CR) #: CR 10000
• Related CR Release Date: May 17, 2017
• Effective Date: January 1, 2016
• Related CR Transmittal #: R3739CP
• Implementation Date: June 19, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10000.pdf
• Affects providers who submit claims to Medicare Administrative Contractors (MACs) for Advance Care Planning (ACP) services provided as an optional element of the Annual Wellness Visit (AWV) to Medicare beneficiaries.

Summary: Provides billing instructions for ACP when furnished as an optional element of an AWV. CMS has made the CPT code 99497 (Advance care planning) separately payable for Medicare OPPS claims when the service meets the criteria for separate payment under OPPS.

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

• MLN Matters® Number: MM 10005
• Related Change Request (CR) #: CR 10005
• Related CR Release Date: March 3, 2017
• Effective Date: April 1, 2017
• Related CR Transmittal #: R3728CP
• Implementation Date: April 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10005.pdf
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).

Summary: Describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update.

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

• MLN Matters Number: MM10036
• Related CR Release Date: March 17, 2017
• Related CR Transmittal Number: R3738CP
• Related Change Request (CR) Number: CR10036
• Effective Date: October 1, 2016
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10036.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Announces the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services. This is a Recurring Update Notification that applies to Chapter 16, Section 120.2, of the ʺMedicare Claims Processing Manual.”

 

Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

• SE0801 Rescinded March 15, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf

Summary: This article was rescinded on March 15, 2017. Information on the inpatient transfer policy is located in the "Medicare Claims Processing Manual" (100-04), Chapter 3. For questions concerning clarification on the proper usage of patient discharge status codes, providers should be utilizing the "UB-04 Manual" which is maintained by the National Uniform Billing Committee.  

 

OTHER MEDICARE ANNOUNCEMENTS

 

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

• Interim final rule with comment period; delay of effective date
• https://www.gpo.gov/fdsys/pkg/FR-2017-03-21/pdf/2017-05692.pdf

Summary: This interim final rule with comment period (IFC) further delays the effective date of the final rule entitled ‘‘Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model’’ from March 21, 2017 until May 20, 2017. This IFC also delays the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to October 1, 2017 and effective date of the specific CJR regulations itemized in the DATES section from July 1, 2017 to October 1, 2017. We seek comment on the appropriateness of this delay, as well as a further applicability date delay until January 1, 2018.

Proposed Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)

• March 2, 2017
• https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=287&TimeFrame=30&DocType=All&bc=AgAAYAAACAAAAA%3d%3d&

Summary: CMS) proposes that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). 

A recent television commercial shows an older gentleman with whom all the older ladies want to dance. He attributes his popularity with the ladies to his beautiful smile and perfect dentition. Unfortunately, older Americans will not be getting that perfect smile paid for by Medicare. Medicare does not cover dental services except in rare circumstances. That is a shame, because good dental health affects much more than just a person’s popularity. Poor dental hygiene also contributes to an increased risk for heart disease, stroke, dementia, respiratory problems, and diabetic complications.

Per the Social Security Act, Medicare does not cover items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Medicare only covers dental services if they are incident to and an integral part of a procedure or service that is covered by Medicare. For example, tooth extractions performed in preparation for radiation treatment for jaw cancer would be covered, but tooth extractions because of tooth decay are not.

The Office of Inspector General (OIG) has identified improper payments for non-covered dental services as a topic in their annual Work Plan since 2012. This March, the OIG released their report summarizing the results of audits of dental services’ payments for six Medicare Administrative Contractors (MACs). Those MACs are CGS, First Coast, NGS, Noridian, Novitas, and WPS. The audit report also includes recommendations CMS could implement to help ensure that future claims for hospital outpatient dental services meet Medicare coverage requirements.

The OIG selected a sample of 600 claims from a total of 15,690 hospital outpatient dental services for the six contractors, totaling $10,874,814 paid to providers during the period January 1, 2011, through December 31, 2014.  They did not include dental services associated with a diagnosis related to cancer or physical trauma because those services are generally eligible for Medicare payment. On the basis of their results, the OIG estimated that the six contractors improperly paid providers an estimated $9,783,023 for hospital outpatient dental services that did not comply with Medicare requirements. This is approximately 90% of the total dental service payments considered. The types of dental services performed and paid that are not covered by Medicare included:

• tooth socket repairs, generally performed in preparation for dentures,
• routine oral evaluations, x rays, and tooth extractions,
• excisions and gum repair (performed when removing inflamed gums and when reshaping healthy gums for a cosmetic or functional purpose), and
• periodontal osseous surgery (performed when treating gum disease).

The OIG recommended the implementation of national edits for hospital outpatient dental claims, but CMS did not concur with this recommendation since dental coverage is based on the specific clinical needs of the beneficiary. CMS does agree to work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.

It pays to take care of your teeth when you are young, because once you reach Medicare age, you are on your own.

“Learn from the mistakes of others. You can never live long enough to make them all yourself.”― Groucho Marx

Last month, CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, published results of their ongoing service-specific complex medical review of cardiac rehabilitation services. One J15 state improved their charge denial rate but the other state’s denial rate increased. And overall neither of the charge denial rates are that great, ranging this quarter from 46.8% to 55.7% which means about half of the cardiac rehab charges submitted are being denied. The good news here is that the rest of us can learn from the mistakes of others and proactively address the documentation deficiencies identified in the CGS medical review.

In addition to “requested records not submitted,” the main denial reasons in the CGS review were that the cardiac rehab sessions did not include all the required services and the physician supervision requirements were not met. Specifically for the required cardiac rehab service components, the review findings noted “the following components of the cardiac rehabilitation program were not submitted in the medical record:

• Physician-prescribed exercise
• Cardiac risk factor modification
• Psychosocial assessment
• Outcomes assessment
• An individualized treatment plan”

Years ago, CGS published an article that describes the requirements for cardiac rehab (originally published September 24, 2012, but updated August 24, 2016). Here is information from the article that addresses the components identified as missing in the medical review. Please refer to the entire article at the link above for more complete information.

1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.
2. There should be documentation in the chart that the physician prescribed a specific exercise for each day (a note or order from the physician, signed and dated) and a record showing the patient did the exercise.
3. The physician's prescription for exercise should include the mode of exercise (typically aerobic), the target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs), the duration of each session (e.g., "20 minutes") and the frequency (number of sessions per week).
4. The cardiac rehab professional supervising the patient’s exercise should document the patient's name, date, a description of the exercise showing the doctor's prescription was followed, and their signature and credentials.
5. They should also monitor and record the patient's objective and subjective responses to the exercise therapy.
6. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patient's individual needs.
7. The plan of care prescribed and signed by the physician should include a comment that cardiac risk factor modification will be addressed, which risk factors are important to this particular patient (cholesterol lowering for example, or sedentary life-style, or tobacco use) and directing education, counseling and behavioral intervention.
8. The record must contain documentation demonstrating how such risk factors were addressed with concurrent notes, signed and dated by the appropriate individual at the time these services are delivered.
9. A form signed and dated stating, "tobacco cessation education done” is not adequate documentation. There should also be a progress note discussing what intervention is made and its outcome by the person who does the intervention.
10. Psychosocial assessment documentation should be present.
11. Although a psychologist or psychiatrist may conduct this assessment, recognized tools for depression screening, accompanied by the physician's plan of action based on the results is also acceptable.
12. A note stating a standardized test was done and its score is not sufficient documentation of a psychosocial assessment.
13. Documentation should include the dated signature of the health care professional who conducted the assessment; an interpretation of the results; and the dated signature of the physician who utilized the results of the recognized screening tool to prepare the plan of care.
14. Outcomes assessment
15. The outcomes assessment shows whether services did or did not result in benefit to the patient (such as weight loss, walking distance, etc.).
16. If a goal was not met, it is prudent to include what modifications were made to the care plan to address the failure.
17. The assessment must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.
18. An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days
19. A progress note from the treating physician, done at the time of admission to the cardiac rehabilitation program that explains
20. the patient's clinical history,
21. the reason for the prescription of cardiac rehabilitation (covered diagnosis/condition),
22. a discussion of the individual patient's needs and how they would be met by an exercise program, and
23. incorporates components #1-3 above, i.e. description of the exercise program, risk factor modification program, and goals for the psychosocial assessment.
24. Documentation from the treating physician no later than 30 days into treatment that utilizes the outcomes assessment (#4 above) to specify any modifications needed in the plan of care previously prescribed, or reason(s) to continue the present plan.

Direct physician supervision in a hospital department means a physician is immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. Non-physician practitioners may not serve the supervising role for cardiac rehabilitation services.

CGS’s article makes it clear that the required components of cardiac rehab cannot simply be check-boxes that are marked off. Each component serves a purpose in ensuring the patient’s needs are identified, addressed, and met by the cardiac rehab program. By studying the findings of the CGS review and the related education article, providers can learn from the mistakes of others and be better prepared to weather a review themselves.

Medicare requires that practitioners ordering or providing services authenticate their orders and other documentation notes. A simple enough concept, but sometimes it is the simple things that seem to trip us up. Medicare reviews often cite lack of physicians’ signatures on orders, procedure notes, diagnostic reports or progress notes as a documentation deficiency that could result in a denial of payment. A review of Medicare signature requirements is an excellent reminder of the basics of good documentation.

What forms of signatures are acceptable?

Signatures may be handwritten or electronic. Stamped signatures generally are not acceptable, but are permitted in the case of an author with a physical disability who can provide proof to a CMS contractor of inability to sign due to the disability.

Can signatures be added to documentation that is not signed?

No. Providers may not add late signatures to medical records beyond the short delay that occurs during the transcription process.

Medicare does not accept retroactive orders. If an order is unsigned and there are no signed progress notes that specify the tests/services being ordered, a Medicare reviewer will disregard the order. This will result in a documentation error, which may involve recoupment of an overpayment.

For other types of medical record documentation that lack a signature besides orders, an attestation statement from the author of the medical record may be submitted. An attestation may read as follows, though no specific format is required:

            “I, John R. Doe (printed name), hereby attest that the medical record entry for March 9, 2016 accurately reflects signatures/notations that I made in my capacity as M.D. when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Must orders for clinical diagnostic tests be signed?

No - but yes. The order for a clinical diagnostic test does not have to be signed. However, if the order itself is not signed, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the clinical diagnostic test be performed. The documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. It also must specify the tests ordered; simply saying “labs ordered” is not sufficient. And, a copy of this signed documentation must be submitted to the Medicare contractor in the case of a Medicare review.

What if a signature is illegible?

If there is a printed signature below the illegible signature, this is acceptable. Providers can also submit a signature log to address illegible signatures. A signature log should list the typed or printed name of the author associated with the author’s handwritten initials or signature. Note that providers may create and submit a signature log at any time. It is a good practice to maintain a signature log of all practitioners.

Another way to address illegible signatures is an attestation statement. The attestation must be signed and dated by the author of the medical record entry in order to be valid for Medicare medical review purposes. It also must contain sufficient information to identify the Medicare patient/beneficiary.

Must signatures be dated?

It depends. If Medicare regulations specify that a date is required for the particular type of documentation then it must be dated. For example, for rehabilitative therapy services, the Medicare Benefit Policy manual states, “Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.” Therefore, for therapy certifications, a dated signature is required.

If the Medicare regulations do not specify that a date is required, undated documentation may be acceptable. Documentation that is not dated is acceptable for medical review purposes if the reviewer is able to determine the date the service was performed and/or ordered based on other documentation in the record.

Since the issue of missing and illegible signatures continues to be a common error, Medicare provides a variety of resources addressing the requirements. Providers must get back to the basics of documentation by ensuring appropriate signatures are present.

• Medicare Signature Requirements – Educational Resources for Health Care Professionals: SE1419
• Medicare Signature Requirements Fact Sheet: Fact Sheet
• Chapter 3, Section 3.3.2.4, Medicare Program Integrity Manual
• Signature Guidelines for Medical Review Purposes: MM6698 

Q:

What is the appropriate diagnosis code for Pleural Effusion when there is documentation of Pleural Effusion with CHF and the Pleural Effusion requires a Thoracentesis?

A:

Assign J91.8, Pleural Effusion in Other Conditions Classified Elsewhere, when the Pleural Effusion with CHF requires treatment, such as a Thoracentesis or diagnostic testing. Typically, Pleural Effusion with CHF would not be reported because it is minimal and does not require specific treatment. Previously, in ICD-9-CM, we used 511.9, Unspecified Pleural Effusion. Resource: Coding Clinic, Second Quarter 2015, page 15