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A common mnemonic device to aid memory is to come up with a short sentence or phrase using the first letters of what you are trying to remember. Since it is spring and we are planning our vegetable garden, for PGATO I came up with “please gather all the okra.” If you have never grown okra, you may not realize the gathering demands of okra in the miserably hot, sultry days of late summer. The reward however is the delicious, Southern dish of fried okra. For Medicare services, rewards are two-fold – one is helping patients to recover or improve and two is the Medicare reimbursement you receive if you have followed all of Medicare’s requirements for billing, coding, and documentation. Like okra plants can be prickly, so can Medicare requirements.

PGATO is my memory tool for remembering all of the components for proper documentation to support billing of psychotherapy - plan, goals, activity, time, and outcomes. CPT codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy. Reviews by the Comprehensive Error Rate Testing (CERT) contractors have identified issues with missing documentation.

Plan and Goals

A recent CERT review (see Cahaba Article Psychotherapy Codes) has identified errors in outpatient psychotherapy CPT codes 90832 and 90834, Type of Bill 13X. The primary issue identified on review was the absence of a signed, individualized plan of care for the services billed.

The individualized treatment plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. Treatment goals should be measurable and objective. Documentation should include specific therapeutic interventions planned and an estimated duration of treatment.

Services must reasonably be expected to improve the patient’s condition. The treatment must be designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient’s level of functioning. Psychotherapy services are not covered for severe and profound intellectual disabilities. Also, psychotherapy services are not covered for dementia patients when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective. When a patient has dementia, the capacity to meaningfully benefit from psychotherapy must be documented in the medical record.

Activity and Time

Another CERT review as described in MLN Matters Article SE1407 identified the main error as not clearly documenting the amount of time spent only on psychotherapy services.

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy.

A variety of techniques are recognized for coverage under the psychotherapy codes; however, the services must be performed by persons authorized by their state to render psychotherapy services (such as physicians, clinical psychologists, registered nurses with special training, and clinical social workers). Medicare coverage of procedure codes 90832-90838 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.

Psychotherapy codes 90832-90838 are timed codes and the documentation must support the time billed as a psychotherapy encounter. The time associated with these codes is for face-to-face services only with the patient (or patient and family). In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:

• Code 90832 (or + 90833) 30 minutes: 16 to 37 minutes
• Code 90834 (or + 90836) 45 minutes: 38 to 52 minutes, or
• Code 90837 (or + 90838) 60 minutes: 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

CPT codes 90833, 90836, and 90838 are add-on codes for psychotherapy services provided with an evaluation and management (E&M) service. Both services are payable if they are significant and separately identifiable and billed using the correct codes. Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.

Outcomes

A periodic summary of goals, progress toward goals and an updated treatment plan must be included in the medical record. The general expectation is that the treatment plan will be updated at least every three months.

There are no specific limits on the length of time that services may be covered, but the duration of a course of psychotherapy must be individualized for each patient. As long as the evidence shows that the patient continues to show improvement in accordance with their individualized treatment plan, and the frequency of services is within the norms of practice, coverage may be continued. However, prolonged periods of psychotherapy must be well-supported in the medical record and include a description of the necessity for ongoing treatment.

You may want to come up with your own memory tool for remembering to include all the required documentation components of psychotherapy. However you choose to remember, meeting Medicare’s prickly requirements will help guarantee appropriate payments.

“I don’t know why my brain has kept all the words to the Gilligan’s Island theme song and has deleted everything about triangles.”- Jeff Foxworthy

This month CMS appears to have stuck with their “theme” from past transmittals as a lot of the newly released transmittals are periodic updates of different CMS edits and systems. In contrast, this month, we are broadening our “theme” of bringing you monthly transmittal updates by making this an “all inclusive” Medicare Updates article (i.e., Transmittals, Conditions of Participation, Code of Federal Regulations).

Transmittals

April 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.1

• Transmittal 3477, Change Request 9553, MLN Matters MM9553
• Issued March 22, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries
• Updates Chapter 4, section 40.1; Medicare Claims Processing Manual

Summary of Changes: This notification providers the Integrated OCE instructions and specifications for the Integrated OCE that will be effective April 1, 2016.

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.2, Effective July 1, 2016

• Transmittal 3482, Change Request 9516, MLN Matters MM9516
• Issued March 18, 2016; Effective: July 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries
• Updates Chapter 23, section 20.9; Medicare Claims Processing Manual

Summary of Changes: This is the normal update to the CCI procedure to procedure edits.

April 2016 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal 3478, Change Request 9557, MLN Matters MM9577
• Issued March 11, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects Ambulatory Surgical Centers (ASCs) who submit claims to MACs
• Updates Chapter 14, section 10; Medicare Claims Processing Manual

Summary of Changes: This Recurring Update Notification describes changes to billing instructions for various payment policies implemented in the April 2016 ASC payment system update. As appropriate, this notification also includes updates to the Healthcare Common Procedure Coding System (HCPCS).

Telehealth Services

• Transmittal 221, Change Request 9428, MLN Matters MM9428
• Issued March 11, 2016; Effective: January 1, 2015; Implementation date April 11, 2016
• Affects providers submitting claims to MACs for telehealth services provided to Medicare beneficiaries
• Updates telehealth language has been removed from the Medicare Benefit Policy Manual, Chapter 15, Section 270 and a reference added in text to see the Medicare Claims Processing Manual, Chapter 12, section 190 for further information regarding telehealth services (see related Transmittal 3476)

Summary of Changes: The purpose of this change request is to display the list of telehealth services that were once available through the manual updates to now be displayed via a web-link going forward. CMS is also adding CRNAs to the list of Medicare practitioners who may bill for covered telehealth services.

July Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

• Transmittal 3473, Change Request 9561, MLN Matters MM9561
• Issued March 4, 2016; Effective: January 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries during a SNF stay.
• Changes to CPT/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in Chapter 6, section 20.6; Medicare Claims Processing Manual

Summary: This notification provides updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

April 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3471, Change Request 9549, MLN Matters MM9549
• Issued February 26, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to MACs for services provided to Medicare beneficiaries paid under the OPPS.
• Updates Chapter 4, section 50.8; Medicare Claims Processing Manual

Summary: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the April 2016 OPPS update.

Coding Revisions to National Coverage Determinations

• Transmittal 1630, Change Request 9540
• Issued February 26, 2016; Effective: July 1, 2016; Implementation date July 5, 2016

Summary of Changes: This is the 6th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. Some are the result of revisions required to other NCD-related CRs released separately.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.

Conditions of Participation (CoPs)    

Advance Copy – Interpretive Guidelines for the Organ Transplant CoPs at 42 Code of Federal Regulations (CFR) §§ 482.68 through 482.104

• Memo # 16-10-Transplant
• Posting Date March 11, 2016

Summary: CMS has updated the Organ Transplant Interpretive Guidelines to incorporate previously-published changes, clarify certain areas, and address feedback received based on previously-released drafts. New Appendix X Interpretive Guidelines supersede all previous versions and will be published in a new Appendix X of the State Operations Manual (SOM).

When medical emergencies occur in public places, such as restaurants, movie theaters, or on airplanes, we often hear “is there a doctor in the house?” For certain diagnostic outpatient hospital procedures, Medicare wants to know if there is a doctor in the room. Descriptions of Medicare physician supervision requirements for both diagnostic and non-diagnostic services can be found in the Medicare Benefits Policy Manual, Chapter 6, sections 20.4 and 20.5.

Therapeutic Services

In 2010, CMS caused quite a ruckus when they “clarified” the physician supervision requirements for hospital therapeutic services. After several more clarifications, the final Medicare guidelines, from 2011 forward, for most hospital outpatient non-diagnostic services is “direct supervision” which means the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be in the room, on the campus, or within any other physical boundary as long as he or she is immediately available. Other factors for “direct supervision” of therapeutic services are:

• In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services.
• Immediate availability requires the immediate physical presence of the supervisory physician or non-physician practitioner.
• The supervisory physician or non-physician practitioner may not be performing another procedure or service that he or she could not interrupt.
• The supervisory physician or non-physician practitioner must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure.

Diagnostic Services

The type of supervision required for diagnostic services furnished in an outpatient hospital setting is determined by the supervision levels listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found at PFS Relative Value Files. Select the appropriate year and quarter (A correlates to 1st quarter, B to 2nd quarter, etc.). You will want to select the spreadsheet that starts with PPRRVU. The pdf document in the folder explains the various designations within the file. For example, some of the definitions related to Physician Supervision of Diagnostic Procedures are:

• 01 = Procedure must be performed under the general supervision of a physician.
• 02 = Procedure must be performed under the direct supervision of a physician.
• 03 = Procedure must be performed under the personal supervision of physician.
• 09 = Concept does not apply.

See the complete document for explanations of all the assignments.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Direct supervision for outpatient hospital diagnostic services has the same requirements that are described above for direct supervision of therapeutic services except that diagnostic services require supervision by a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

As stated above, diagnostic services require supervision by a physician and in general may not be supervised by non-physician practitioners. There are exceptions that allow some diagnostic tests furnished by certain non-physician practitioners to be furnished without physician supervision. When these non-physician practitioners personally perform a diagnostic service they must meet only the physician supervision requirements for that type of practitioner when they directly provide a service. For example, nurse practitioners must work in collaboration with a physician, and assistants must practice under the general supervision of a physician. Non-physician practitioners, including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives, cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

Hospitals need to be aware of the supervision requirements for diagnostic services, particularly those services that require personal supervision where the physician must be in the room during the performance of the procedure. There are over 200 CPT codes in the 2016 PFS RVU file that require personal supervision, with almost 150 of those being radiology procedures in the 70010-79999 CPT code range. This includes radiology procedures such as myelography, arthrography, angiography and venography, among others. Medicare allows payment for diagnostic services only when those services are furnished under the appropriate level of supervision.

Hospitals need to ensure that venograms, arthrograms and other relevant radiology services are only performed when a physician is in the room. Lack of appropriate supervision can result in an inappropriate Medicare payment. When personal supervision is required, there must be “a doctor in the room.”

The month of March is National Nutrition Month and March 9, 2016 was Registered Dietitian Nutritionist Day.   According to the Academy of Nutrition and Dietetics website - “As the nation’s food and nutrition experts, registered dietitian nutritionists are committed to improving the health of their patients and community.” We at MMP, Inc. would like to acknowledge dietitians, nutritionists, and all those who work in the field of nutrition and thank them for their commitment to helping hospital patients. We also want to take this opportunity to look at some guidelines and information related to hospital dietitian services allowed and covered by Medicare.

Ordering Therapeutic Diets

Several years ago, a deficiency report released by CMS identified 147 deficiencies for hospitals related to dietary standards. In response to these deficiencies and to minimize regulatory requirements for hospitals, CMS revised the Hospital Conditions of Participation at section 482.28(b)(2) effective July 11, 2014 as follows:

§482.28(b)(2) -All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

The final rule can be read at Federal Register Final Rule May 12, 2014

The revision allows registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner, if allowed by State law and hospital privileging.

CMS made the following comments related to this change:

“[T]he addition of ordering privileges enhances the ability that RDNs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”

“We believe that the greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed will allow them to meet the needs of their patients most efficiently and effectively.”

The problem many hospitals may face with the revised rule relates to State law. Another

link from the Academy of Nutrition and Dietetics website shows the status of State laws for allowing therapeutic diet orders by dietitians, including a color-coded map. Therefore hospitals and dietitians must be familiar with the laws for their particular State before seeking hospital privileging for RDNs to order patient diets. For example, Alabama State law states in section 420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients." The Academy of Nutrition and Dietetics will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Medical Nutrition Therapy (MNT) Services

Medicare covers medical nutrition therapy (MNT) upon physician referral for beneficiaries with diabetes or renal disease when furnished by a registered dietitian or nutrition professional meeting certain requirements. Basic coverage includes initial assessment visit, follow-up visits for interventions, and reassessments within the year for a total of 3 hours for the first calendar year of a diagnosis of diabetes or renal disease and 2 hours for subsequent years for a renal disease diagnosis.

Important points about MNT services include:

• The treating physician must make a referral and indicate a diagnosis of diabetes or renal disease.
• Renal disease means chronic renal insufficiency (not severe enough to require dialysis or a transplant; GFR of 13-50) or successful renal transplant within the last 36 months.
• Diabetes Self Management Training (DSMT) and MNT can be provided within the same time period, but not on the same day.
• The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician.
• Additional covered hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary.
• Hours may not be carried over into the following calendar year.
• MNT can be provided individually (one-to-one) or in a group setting.

Dietitians and nutritionists must meet the profession standards as described in Section 300.3 of the Medicare Claims Processing Manual, Chapter 4 and be enrolled as a provider in the Medicare program.

The following codes can be paid if submitted by a registered dietitian or nutrition professional who meets the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. Payment is only made for MNT services actually attended by the beneficiary and documented by the provider. MNT is not covered for inpatients of a hospital or skilled nursing facility.

• 97802 – MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (only for the initial visit)
• 97803 - Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
• 97804 - Group (2 or more individual(s)), each 30 minutes
• G0270 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
• G0271 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (2 or more individuals), each 30 minutes

So here’s to eating right for everyone, but especially hospital patients, diabetic patients, and patients with renal disease. The knowledgeable advice and direction of a dietitian/nutritionist can make a critical difference.

“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”- Mark Twain

On January 26th, 2015 Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” This was the first time that CMS had set the following explicit goals for Alternative Payment Models (APMs) and Value Based Payment goals.

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

On March 3, 2016 CMS announced in a Fact Sheet that it estimates that the first target of 30 percent of Medicare payments being tied to APMs has been met 11 months ahead of schedule. CMS indicates that “when it comes to improving the way providers are paid, we aim to reward value and care coordination – rather than volume and care duplication.”

Alternative Payment Models by the Numbers

• $411 million is the amount that Medicare Accountable Care Organizations (ACOs) saved the program in 2014 alone through markedly improved quality and patient experience over previous years.
• $3,000 saved per Medicare beneficiary on average is what was saved in just one year through the Independence at Home Demonstration.
• 17% is the reduction from 2010 to 2014 in the number of hospital acquired conditions (HACs). This represents over 87,000 lives saved and $20 billion in cost savings.
• 565,000 is the estimated number of readmissions prevented across all conditions between April 2010 and May 2015.
• Medicare spent $315.9 billion less on personal healthcare expenses between 2009 and 2013 than what would have been spent if the 2000-2008 average growth rate had continued through 2013.

Health Care Payment Learning and Action Network

CMS created the Health Care Payment Learning and Action Network (LAN) March of 2015 “to help align the important work being done across the private, public, and non-profit sectors.”

CMS notes that this network has accelerated the transition to APMs by “fostering collaboration between Department of Health and Human Services (HHS), private payers, large employers, providers, consumers, and state and federal partners.”

Ready or not, the shift in payment is happening. To learn more about LAN you can visit the LAN web page at the CMS Innovation Center as well as the LAN website where you can join the network, view their Work Products, participate in webinars and sign up for the LAN e-newsletter.

“Mortality rates from sepsis are higher than heart attack, stroke, or trauma. Sepsis needs to be viewed with the same urgency as these other life-threatening conditions because we know early treatment can decrease mortality.”- Craig M. Coopersmith, MD, FCCM, Task Force Member and Immediate Past President of the Society for Critical Care Medicine (SCCM)

On February 22, 2016 the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was released at SCCM’s 45th Critical Care Congress. The new recommendations are the result of extensive efforts by a Task Force of 19 leaders in the field of sepsis that was convened by the SCCM and the European Society of Intensive Care Medicine (ESICM). According to the SCCM announcement “the group’s recommendations have been endorsed by more than 30 medical societies from six continents, spanning disciplines from critical care and emergency medicine to infectious disease and family practice.”

Sepsis-3 Definitions

The Sepsis-3 definitions were published in the February 2016 issue of the Journal of American Medical Association (JAMA). “The task force recommended that its report be designated “Sepsis-3,” recognizing the two iterations to define sepsis (1991 and 2001) and signaling the need for future study.”  

Sepsis is now defined as “life threatening organ dysfunction due to a dysregulated host in response to infection.”

SOFA (Sequential [Sepsis-related] Organ Failure Assessment) is a tool to be used to clinically characterize the septic patient.

qSOFA (quick Sequential [Sepsis-Related] Organ Failure Assessment) is a new diagnostic tool that clinicians can conduct for patients outside a hospital, in an Emergency Department or General Hospital floor setting to identify patients at risk for sepsis. The three warning signs to assess for are:

• An alteration in mental status,
• A decrease in systolic blood pressure of less than 100mm Hg; and
• A respiration rate greater than 22 breaths/min.

Two or more of the warning signs increases the risk of a hospitalized patient having a longer length of stay in an ICU or to die in the hospital.

The task force stresses that SOFA and qSOFA are not intended to be used as a “stand alone definition of sepsis.”

Septic Shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.” The task force identified the following two new criteria for diagnosing septic shock:

• “Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg;” and
• “Blood lactate level ≥2 mmol/L despite adequate volume resuscitation.”

Sepsis (lay definition) the recently published definition that “sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues,” was endorsed by the task force as it is consistent with the new Sepsis-3 definition.

Severe Sepsis was deemed “redundant” by the task force, “as sepsis has a mortality rate of 10 percent or higher, making the condition already severe.”

Systemic Inflammatory Response Syndrome (SIRS) “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”

While SIRS due to a localized infection can no longer be coded as sepsis in ICD-10, Coding and CDI Professionals need to be mindful that at this time the code set definitions of sepsis and severe sepsis remain the same.

Q:

Since payment for observation services has changed from a composite payment to a comprehensive APC payment (see MMP article Observation Payment for 2016), have the requirements for reporting observation hours changed?

 

A:

No. The reporting of observation services remains the same as described in the Medicare Claims Processing Manual, Chapter 4, section 290.2.2. Some of the key information from this manual is:

• Observation services are only covered when provided by the order of a physician or other individual authorized to admit patients or to order outpatient services.
• Observation services are generally reported with revenue code 762.
• Other ancillary services performed while the patient is receiving observation care are separately reported.
• Observation time is reported per hour, rounded up to the nearest hour.
• Observation time begins at the clock time documented when observation care is initiated in accordance with a physician’s order.
• Observation time ends when all medically necessary services related to observation care are completed.
• Although 8 or more hours of observation care are required for an observation payment, all hours of observation should be reported.
• Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure. This means providers may have to “carve out” procedure time from the total stay to calculate observation hours.
• Standing orders for observation services following outpatient surgery are not appropriate.
• When observation services span more than one day, all observation hours are reported as a single line item for the date observation care began.

Dilemma:

An elderly female presented to the hospital with shortness of breath and chest pain. The patient was admitted and Acute Coronary Syndrome was ruled out.   The patient was also noted to have a Hematocrit of 26.4, Acute Renal Failure, Diabetes Mellitus, Hypothyroidism, and Diverticulosis with recent hemorrhage. The attending physician documented Anemia of Chronic Disease to be the reason for admission and the principal diagnosis. Can Anemia of Chronic Disease (D63.8) be sequenced as a principal diagnosis in this case?

 

Solution:

No, Anemia of Chronic Disease has been designated as a manifestation; therefore, D63.8 cannot be sequenced as a principal diagnosis. Coding instructions state to code the underlying disease first. Therefore, if the documentation of the cause of the anemia is not clear, then querying the physician is recommended.

Resource: ICD-10-CM Codebook, TruCode

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

Before the era of most moms working outside the home and pre-school daycare, the school playground was the first place for serious socialization outside of family for many American children. All over the nation, the school playground foretold of the inevitable societal cliques – there were city kids, country kids, in-crowd, outsiders, do-gooders, trouble makers, and even bullies. One scene that played out during numerous recesses was the bully taking lunch money from a less rambunctious playmate. If the victim wasn’t the pushover the bully thought, he or she might raise their clenched fist and yell, “Give it back now!” Hopefully this outburst attracted the attention of teachers or classmates, a fight was averted, and the wrong righted.

The Centers for Medicare and Medicaid Services (CMS) may seem more like the bully than the victim to many in healthcare, but sometimes providers and suppliers receive monies from CMS to which they are not entitled. In a recent Final Rule, CMS clarified the requirements of their version of “give it back now” or at least within 60 days.

The requirement for refund of overpayments within 60 days of identification has been a law since enactment of the Affordable Care Act (ACA) on March 23, 2010. The sub-regulatory guidance explaining and defining the requirements was finalized in a Final Rule published in the Federal Register on February 12, 2016. According to CMS, this rule provides needed clarity and consistency in the reporting and returning of self-identified overpayments.

Even without this rule, providers and suppliers are subject to the statutory requirements of the Act and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment. The ACA requires a person (defined as a provider or supplier) who has received an overpayment to report and return the overpayment by the date which is 60 days after the date on which the overpayment was identified (for claims-based overpayments) or the date any corresponding cost report is due (for cost reporting issues) and to notify Medicare in writing of the reason for the overpayment. Any overpayment retained by a person after the deadline for reporting and returning the overpayment is an obligation that has the potential to trigger FCA liability.

Meaning of Identification

The rule clarified that a provider/supplier has identified an overpayment when they have or should have, through the exercise of reasonable diligence, determined they received an overpayment and quantified the amount of the overpayment. This definition of “identified” allows time for an investigation and quantification of the overpayment amount before the 60 day clock begins. CMS expects a period of six months is sufficient for most investigations unless there are extraordinary circumstances which would be rare. Not all inquires should take six months – providers should prioritize these inquires and complete as soon as possible.

Reasonable Diligence

The definition of “identified” includes an expectation of “reasonable diligence” on the part of providers. CMS discusses two aspects of reasonable diligence - investigations in response to credible information of a potential overpayment and proactive compliance activities.

If a provider obtains credible information concerning a potential overpayment, they should investigate to determine whether an overpayment has been received and to quantify the amount. Credible information supports a reasonable belief that an overpayment may have been received. Examples of information that may be credible and support an investigation to determine if an overpayment occurred include but are not limited to:

• Hotline complaints
• A significant increase in Medicare revenue
• Knowledge of violation of the anti-kickback statute
• RAC audit findings, as well as other Medicare contractor and OIG audit findings

According to CMS, “failure to make a reasonable inquiry, including failure to conduct such inquiry with all deliberate speed after obtaining the information, could result in the provider or supplier knowingly retaining an overpayment because it acted in reckless disregard or deliberate ignorance of whether it received such an overpayment….The 60-day time period begins when either the reasonable diligence is completed or on the day the person received credible information of a potential overpayment if the person failed to conduct reasonable diligence and the person in fact received an overpayment.”

CMS advises providers to maintain documentation of their reasonable diligence efforts to demonstrate their compliance.

The second aspect of reasonable diligence is proactive compliance activities. CMS states that “providers and suppliers have a clear duty to undertake proactive activities to determine if they have received an overpayment or risk potential liability for retaining such overpayment.” A robust and active Compliance Program would include this in the form of an annual compliance risk assessment and compliance work plan. CMS encourages providers to use publicly available information to assist in planning their compliance monitoring activities and reviews, such as the OIG’s annual work plan and CMS notices.

Overpayment

Overpayment is defined as any funds that a person has received or retained under Title XVIII of the Act to which the person, after applicable reconciliation, is not entitled under such title. These funds might be received or retained due to fraud or due to more inadvertent reasons. An overpayment must be reported and returned regardless of the reason it happened – be it a human or system error, fraudulent behavior or otherwise. Overpayment examples given in the rule include:

• Medicare payments for non-covered services
• Medicare payments in excess of the allowable amount for an identified covered service (for example, providers must report and return overpayments resulting from up-coding, whether the inappropriate coding was intentional or not)
• Increases in reimbursement from errors and non-reimbursable expenditures in cost reports
• Duplicate payments
• Receipt of Medicare payment when another payer had the primary responsibility for payment

Overpayment may be the difference between what was paid and the amount that should have been paid or in the case of non-covered services the entire amount. Rules and regulations in effect at the time of the original payment apply, therefore payments that were proper at the time the payment was made do not become overpayments at a later time due to changes in law or regulation, unless otherwise required by law.

Providers may use statistical sampling and extrapolation to calculate an overpayment amount. Where the overpayment amount is extrapolated based on a statistical sampling methodology, the overpayment report must explain how the overpayment amount was calculated.

CMS declined to adopt a minimum monetary threshold related to this rule. They are considering establishing a minimum monetary threshold for cost report-related overpayments that would be published in program guidance or future rulemaking.

Lookback Period

The rule sets the lookback period for self-identified overpayments to six years from the date the overpayment was made. This is a relief from the ten years suggested in the proposed rule, but longer than the lookback period for Recovery Auditors (3 years) or for Medicare contractors (48 months or 4 years). This means that if an overpayment issue is discovered by one of these contractors or through an internal review that could potentially have affected prior claims, providers and suppliers need to determine whether they have received overpayments going back 6 years as stated in this rule.

Reporting and Returning Overpayments

Providers and suppliers may use existing processes, such as an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments. Refunds must be sent to the appropriate Medicare contractor according to the applicable administrative process. Overpayment cannot be reported and returned directly to the Department. The reason for the overpayment will likely affect the provider’s decision on which method to use to return the overpayment.

CMS also amended the reopening rules to provide for a reopening period that accommodates the 6-year lookback period for reporting and returning overpayments, and to ensure that the reopening rules do not present an obstacle or unintended loophole to compliance and enforcement of this Act. Providers may request that contractors reopen initial determinations for the purpose of reporting and returning an overpayment.

Medicare contractors are required to process all voluntary refunds and should not return voluntary refund checks. According to CMS there is no reason for a contractor to refuse a refund because a different company was the contractor during the period covered by the refund. CMS may consider a processing deadline for contractors in the future.

CMS accepts the CMS Voluntary Self-Referral Disclosure Protocol (SRDP) and the OIG Self-Disclosure Protocol (SDP) as an appropriate means for returning an overpayment. As indicated in the final rule, “providers and suppliers need to decide who is the most appropriate recipient of the overpayment report and refund as provided in § 401.305(d) – the applicable Medicare contractor, the SDP, or the SRDP. Providers and suppliers should review the SDP and SRDP to determine whether either of those avenues is available.”

In the event that a SDP settlement is not reached, the provider or supplier has the balance of the 60-day time period remaining, from identification to the suspension of that 60-day period when OIG acknowledged receiving the SDP submission, to report and return any overpayment to the contractor.

Cost Reporting, PIP, Outliers, and Overpayments

Below are excerpts from the Final Rule concerning cost reporting and other related overpayment issues.

In the context of cost reporting, the “applicable reconciliation” is the provider's year-end reconciliation of payments and costs to create the cost report. The cost report must be filed within 5 months of the end of the provider's fiscal year end, which allows time to reconcile payments and costs and identify any funds to which the provider is not entitled. This overpayment should be returned at the time the cost report is filed.

If the provider self-identifies an overpayment after the submission and applicable reconciliation of the Medicare cost report, it is their responsibility to follow the procedures in this rule, and report and return the overpayment within 60 days of identification. The provider must use the applicable reporting process for cost report overpayments (submit an amended cost report) along with the overpayment refund. The amended cost report must include sufficient documentation and data to identify the issue in order for the MAC to adjust the cost report.

If the overpayment is identified by the MAC during the cost report audit, the MAC will determine and demand the exact amount of the overpayment at final settlement of the cost report. If the MAC notifies a provider of an improper cost report payment, the provider has received credible information of a potential overpayment and must conduct reasonable diligence on other cost reports within the lookback period to determine if it has received an overpayment.

Overpayments as a result of PIP payments would be reported and returned at the time the initial cost report is due. There is no applicable reconciliation until the PIP payments are dealt with in the cost report process. However, if a provider is aware that their PIP payment may not be accurate, they should continue with normal business practices and inform its MAC of the issue.

An overpayment as a result of an outlier reconciliation would be identified once the provider receives that information from its MAC as part of the cost report settlement process. The provider is not responsible for attempting to identify the cost report outlier reconciliation overpayment in advance of the MAC's reconciliation calculation. However, for claims, if the provider identifies an inaccurate outlier claim payment, the provider must follow the overpayment payment reporting process for claims, as noted in this final rule.

Provider Liability

The Final Rule makes it clear that an overpayment refund does not negate any potential liability the provider or supplier may have for the overpayment issue. Although CMS will not recover an overpayment twice, they do not exempt claims that form the basis for a returned overpayment from subsequent audit by CMS, a CMS contractor or the OIG. In addition Medicare contractors may refer potential fraudulent conduct to law enforcement.

This is certainly a lot of information to simply say “give it back now” but that is the government for you. I have tried to relay some important aspects of the Reporting and Returning Overpayments Final Rule, but encourage financial, compliance and legal personnel of providers and suppliers to read the entire rule for the best understanding.