This month the focus is on national news instead of the local news. But this national news is not from one of the major television networks, such as NBC, CBS, ABC, or even FOX. It comes to you from the studios of CMS. In February, CMS manualized four National Coverage Determinations (NCDs) ranging from PETs and pacemakers to oral anti-emetics. These NCDs have different effective dates, but all are set for implementation on July 7, 2014.

Pacemaker NCD

The Pacemaker NCD removes the differential coverage requirements for single versus dual chamber pacemakers. Under the revised policy, both single chamber and dual chamber implanted permanent cardiac pacemakers are covered for the same indication - treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion). The effective date of the policy is August 13, 2013. See MLN Matters Article MM8525 for more information including non-covered indications, affected CPT codes, specific diagnosis codes required for coverage, and billing instructions. Of particular note is the requirement to include a KX modifier on the claim line(s) as an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia.

PET Aβ for Alzheimer’s Disease

Effective with dates of service on and after September 27, 2013 CMS will cover beta amyloid PET scans (PET Aβ) through coverage with evidence development (CED) during a clinical trial to:

1. develop better treatments or prevention strategies for Alzheimer’s Disease (AD), or, as a strategy to identify subpopulations at risk for developing AD, or
2. resolve clinically difficult differential diagnoses (e.g., frontotemporal dementia

Claims for PET Aβ imaging, through CED during a clinical trial, must contain the following:

• Condition code 30, (for institutional claims only);
• Modifier Q0 and/or modifier Q1 as appropriate;
• ICD-9 dx code V70.7 / ICD-10 dx code Z00.6 (on either the primary/secondary position);
• A PET HCPCS code 78811 or 78814;
• A covered diagnosis code; and
• Aβ HCPCS code A9586 or A9599.

Coverage of PET Aβ is limited to one scan in a patient’s lifetime. See MLN Matters Article MM8526 for more information and a list of the covered diagnosis codes.

FDG PET for Solid Tumors

The second NCD addressing PET scans, effective June 11, 2013, revises the coverage of FDG PET scans for solid tumors to remove the requirement for coverage with evidence development (CED). Providers will no longer have to report data to the National Oncologic PET Registry (NOPR) for FDG PET or FDG PET/CT. Also these claims will no longer require the elements indicating CED: modifier Q0, condition code 30 or diagnosis V70.7. See MMP July Article "Changes to PET Coverage"for a coverage table by cancer type.

Modifiers PI and PS, indicating initial or subsequent treatment strategy are still required.  The NCD allows coverage of three subsequent treatment strategy PET scans after an initial treatment strategy PET. Coverage of any additional FDG PET scans (that is, beyond three) used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis will be determined by the local MACs. Cahaba GBA has indicated that they do not currently have a policy capping the allowed number of FDG PET scans beyond three. They stated that providers should rely on the medical judgment of the clinicians and ensure that documentation clearly supports the need for any additional scans. Providers not within Cahaba’s jurisdiction should check with their local MAC for guidance.

Billing instructions in MLN Matters Article MM8468 explain that:

• a KX modifier is required for subsequent treatment strategy FDG PET scans exceeding three (claims for fourth or more oncologic FDG PET for same diagnosis)
• claims with subsequent treatment strategy (-PS) oncologic FDG PET scans without an initial treatment strategy (-PI) claim present in claims history will be denied (Exception: prostate cancer does not require initial since it is non-covered).
• Alemtuzumab (J9010);

Aprepitant for Chemotherapy Induced Emesis

The final NCD manualized in February concerns aprepitant for chemotherapy induced emesis. Since 2005, Medicare has covered the use of the oral three-drug regimen of aprepitant, a 5HT3 antagonist, and dexamethasone for patients who are receiving certain highly emetogenic chemotherapeutic agents when the antiemetic therapy fully replaces an IV antiemetic. Effective for services on or after May 29, 2013, the following anticancer chemotherapeutic agents have been added to the list of anticancer chemotherapeutic agents for which the use of the oral antiemetic 3-drug combination of oral aprepitant, an oral 5HT3 antagonist, and oral dexamethasone is deemed reasonable and necessary:

• Azacitidine (J9025);
• Bendamustine (J9033);
• Carboplatin (J9045);
• Clofarabine (J9027);
• Cytarabine (J9098, J9100, J9110);
• Daunorubicin (J9150, J9151);
• Idarubicin (J9211);
• Ifosfamide (J9208);
• Irinotecan (J9206); and
• Oxaliplatin (J9263)

MLN Matters Article MM8418 contains all the details including a complete list of all chemotherapeutic agents.

Now the local news – Cahaba did not have any coverage updates this month, while Novitas (both JH and JL) continues to be prolific with new and revised policies and Palmetto has some updates. See the links below for the local coverage updates for your region.

Novitas JH Coverage Updates

February 27, 2014

The following JH MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L32723)

The following JH MAC LCD has been revised:

Pain Management (L32702)

February 6, 2014

The following JH MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L32619)

Frequency of Dialysis (L32755)

Infrared Photocoagulation (IRC) of Hemorrhoids (L34350)

Intraoperative Neurophysiological Testing (L32605)

Outpatient Sleep Studies (L32711)

Qualitative Drug Testing (L34352)

Surgery: Blepharoplasty (L32715)

Vascular Access for Hemodialysis (L32708)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L32687) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L32735)

The following JH MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JL MAC LCDs. The following LCDS will also become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L32690)

Glaucoma Treatment with Aqueous Drainage Device (L32733)

Lacrimal Punctum Plugs (L32607)

Wireless Capsule Endoscopy (L32686)

Novitas JL Coverage Updates

February 27, 2014

The following JL MAC LCD has been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2014 and has also been revised due to a reconsideration request:

Nerve Conduction Studies and Electromyography (L29547)

February 6, 2014

The following JL MAC Local Coverage Determinations (LCDs) have been posted for notice. They will become effective March 27, 2014:

Cataract Extraction (including Complex Cataract Surgery) (L34344)

Frequency of Dialysis (L34388)

Glaucoma Treatment with Aqueous Drainage Device (L34355)

Intraoperative Neurophysiological Testing (L27499)

Lacrimal Punctum Plugs (L34358)

Outpatient Sleep Studies (L27530)

Surgery: Blepharoplasty (L34396)

Vascular Access for Hemodialysis (L32465)

Wireless Capsule Endoscopy (L34342)

Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L27547) (formerly titled Wound Care and Bioengineered Skin Substitutes)

Comments Received and Contractor Responses

Hemophilia Factor Products (L33658)

The following JL MAC LCDs have been revised to create uniform LCDs with the corresponding Novitas Solutions JH MAC LCDs.  The following LCDS will also become effective March 27, 2014:

Bariatric Surgical Management of Morbid Obesity (L34495)

Qualitative Drug Testing (L32050)

Palmetto J11 Coverage Updates

Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.

 

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.

Q:

Is it appropriate for a testing laboratory to provide a copy of lab results directly to the patient or their representative?
 

A:

Yes. On February 6, 2014, CMS released a final rule that allows laboratories, upon the patient’s request (or upon the request of the patient’s personal representative), to provide access to completed lab tests results directly to the patient or their personal representative under the Clinical Laboratory Improvement Act (CLIA) and HIPAA privacy regulations. Laboratories that are HIPAA covered entities (i.e. conduct covered health care transactions electronically) are required to provide patients with access to their lab results upon request under this new rule. This final rule is effective April 7, 2014 and HIPAA covered entity laboratories have until October 6, 2014 to comply with the new rule. Prior to this new regulation, CLIA regulations limited the release of laboratory tests results to persons authorized under state law to order and/or receive test results, the person responsible for using the test results in the treatment context, and the laboratory that initially requested the test.

Hospital-based laboratories have a big advantage over independent laboratories in the implementation of this rule. Most hospital laboratories will likely handle the new requirement by directing patients to the Hospital HIM Release of Information (ROI) department. These hospital ROI departments are already knowledgeable concerning the HIPAA regulations and have processes in place to address the requirements of HIPAA, such as positive identification of the person requesting a copy of the medical record, pricing for copies, documentation of the release, etc.

For complete information, please see the CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports; Final Rule.

Over the next several months a lot of information will be posted concerning the do’s and don’ts of ICD-10-CM. At times it may be overwhelming. You will find the transition to be easier and less stressful the earlier you start training.

This week the focus will be on the Respiratory System. Many familiar conditions are identified in this chapter such as Asthma, COPD and Pneumonia.

The Respiratory System is made up of organs and tissues that enable us to breathe.

Airways

• Mouth
• Nose and Nasal Cavities
• Pharynx
• Larynx
• Trachea
• Bronchial Tubes or Bronchi, and their tubes

Lungs

• Right Lung – 3 lobes
• Upper
• Middle
• Lower
• Left Lung – 2 lobes
• Upper
• Lower

Lower Linked Vessels – Provide pulmonary circulation

Muscles

• Diaphragm
• Intercostal
• Abdominal
• Muscles in the Neck and Collarbone area – (accessory muscles)

Here is a list of common signs and symptoms seen in the Respiratory System that may be indicative of a more severe condition. Keep in mind, you always want to be as specific as possible when coding for appropriate reimbursement and data quality.

• Cough
• Dyspnea
• Asphyxia
• Shortness of breath
• Epistaxis
• Hemoptysis
• Rales
• Hypoxemia
• Intercostal pain
• Tachypnea
• Hyperventilation
• Respiratory arrest

Categories J00 – J99

• J00 – J06 Acute Upper Respiratory Infections
• J09 – J18 Influenza and Pneumonia
• J20 – J22 Other Acute Lower Respiratory Infections
• J30 – J39 Other Diseases of Upper Respiratory Tract
• J40 – J47 Chronic Lower Respiratory Diseases
• J60 – J70 Lung Diseases due to External Agents
• J80 – J84 Other Respiratory Diseases Principally Affecting the Interstitium
• J85 – J86 Supportive and Necrotic Conditions of the Lower Respiratory Tract
• J90 – J94 Other Diseases of the Pleura
• J95 Intraoperative and Postprocedural Complications and Disorders of Respiratory System, Not Elsewhere Classified
• J96 – J99 Other Diseases of the Respiratory System

Classification changes in ICD-10 will provide greater specificity.

While the overall organization of ICD-10 is similar to ICD-9, diseases have been rearranged. Certain diseases/disorders have been removed from other chapters and placed in Chapter 10.

• Streptococcal Pharyngitis (J02.0) now classified in Chapter 10, no longer will be classified with the Infectious and Parasitic Disease Chapter.
• Ventilator Associated Pneumonia (J95.851) was previously found in the “Injury and Poisoning” Chapter in ICD-9-CM.
• Intraoperative and post-procedure complications pertaining to the Respiratory System have been grouped together in Chapter 10 – J95.

Some codes in Chapter 10 have been expanded to include notes indicating that an additional code should be assigned or an associated condition should be sequenced first. Example:

• Use additional code to identify the infectious agent
• Use additional code to identify the virus
• Code first any associated lung abscess
• Code first the underlying disease
• Use additional code to identify other conditions such as tobacco use or exposure

As with any chapter in ICD-10, coders must be familiar with the Official Coding Rules and Guidelines. Refer to http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

COPD and ASTHMA

Many of the instructions in ICD-9-CM pertaining to COPD have been eliminated in ICD-10-CM. Here are the two hair splitting requirements in ICD-9 that have been eliminated in ICD-10:

• Physicians will no longer have to distinguish Asthma as Intrinsic or Extrinsic.
• Will no longer need separate codes for “Chronic Obstructive Asthma”, as opposed to “Chronic Obstructive Bronchitis” or plain ole “COPD”.
• In ICD-10-CM, Asthma is just Asthma and COPD is just COPD.

If a patient is documented with both COPD and Asthma, two codes will be required to show each condition.

EXAMPLE
Patient presented to ER with gradual increase in shortness of breath which was unresponsive to home nebulizer treatments. In the ER, patient received more respiratory treatments; however, the patient was admitted after he failed to improve. Theophylline level was 5.9 upon admission. Chest x-ray showed no evidence of active infiltrates. The patient was bolused with IV Steroids and started on frequent respiratory therapy treatments. IV Aminophylline boluses and drip were used to increase his theophylline level to therapeutic range. The patient gradually cleared and by the next day was much better. IV Aminophylline was changed to PO. The Ventolin treatments were decreased to q 4 hr. and his Steroids were rapidly tapered back to 10 mg of Prednisone.

Discharge Diagnosis: Moderate persistent Asthma with Status Asthmaticus – J45.42
Acute Exacerbation of COPD – J44.1

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.a

The Codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Terminology terms have been updated and added to reflect current the clinical classification of Asthma – J45. Asthma must be documented as mild, moderate or severe. Mild Asthma must be documented as intermittent or persistent.

DEFINITON

‍

• Mild intermittent Asthma
• Uncomplicated – J45.20
• With (Acute) Exacerbation – J45.21
• With Status Asthmaticus – J45.22
• Mild persistent Asthma
• Uncomplicated – J45.30
• With (Acute) Exacerbation – J45.31
• With Status Asthmaticus – J45.32
• Moderate persistent Asthma
• Uncomplicated – J45.40
• With (Acute) Exacerbation – J45.41
• With Status Asthmaticus – J45.42
• Severe persistent Asthma
• Uncomplicated – J45.50
• With (Acute) Exacerbation – J45.51
• With Status Asthmaticus – J45.52

Intrinsic (non-allergic) and Extrinsic (allergic) Asthma will both be classified to J45.909 – Unspecified Asthma, Uncomplicated.

MMP highly recommends an early start with ICD-10-CM/PCS training. There is no doubt the transition will be challenging. Any type of procrastination is sure to bring on stress with increased complexity and costs. Early planning and preparation will be the key to a smooth and successful transition. For timely updates and informative articles, Continue to follow MMP through their weekly newsletter Wednesday@One Part 2 of Chapter 10 – Diseases of the Respiratory System will post March 12, 2014.

Illustration: Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].

 

Were you anxiously awaiting its release? Did you lie awake at night thinking about what old and new features might be included? When it was released, did you drop everything and rush to check it out? No, we are not talking about the latest version of some Smart Phone, a movie sequel, or a new video game. We are talking about the 2014 OIG Work Plan which was finally released at the end of January.

I want to point out a few of the issues, especially billing and payment issues that are most relevant to the types of issues with which we at MMP normally deal. For other issues addressed in the OIG Work Plan that might be of interest to hospitals, see the list at the end of this article.

First, let’s look at some of the issues that are not new to this year’s work plan.

• Compliance reviews of acute care hospitals to determine compliance with selected inpatient and outpatient billing requirements. These types of reviews have been ongoing for several years and address a number of different billing issues, including but not limited to medical necessity of inpatient admissions, inpatient DRG coding, outpatient CPT/HCPCS codes, discharge status, device credits, and units of service.
• One of the most notable aspects of these reviews is that in four of the 87 compliance reviews to date, the OIG has extrapolated the overpayment amount causing an overpayment of hundreds of thousands of dollars to become millions of dollars.
• Inpatient claims for mechanical ventilation to determine if the hospitals’ DRG assignments and payments are appropriate. For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Past OIG reviews have revealed overpayments when one of these DRGs was assigned, but the patient did not receive 96 or more hours of mechanical ventilation.
• Outpatient dental claims have also been previously identified at risk for overpayments. Generally dental services are excluded from Medicare coverage with only a few exceptions. Examples of covered dental services would be if teeth have to be removed in order to perform another covered procedure, such as excision of a tumor or to prepare for radiation treatments.

New OIG activities for 2014 include:

• Determining the impact of new inpatient admission criteria on hospital billing, Medicare payments, and beneficiary payments. The new admission criteria of a two-midnight expectation are substantially different than the previous admission criteria. Previous OIG reviews found overpayments, inconsistencies, and inappropriate billing under the old rules. It will be interesting to see if the new rules result in improved consistency or not.
• Review of Medicare outpatient payments to hospitals for clinic visits billed at the new patient rate. Prior to this year clinic visits were billed with Evaluation and Management (E&M) codes including both new and established patient codes. The higher paying “new patient” codes were only to be used if the patient had been registered as an inpatient or outpatient at the hospital within the past three years. With the changes to clinic visit reporting for 2014, hospitals no longer have to differentiate new vs. established patients or different levels of service intensity for clinic visits.
• Review of cardiac catheterizations and heart biopsies. Right heart catheterizations performed during the same operative session are included in the heart biopsy procedure and should not be billed separately unless a separate medical necessity for the right heart catheterization can be established eg: evaluate for rejection; failed previous heart procedure; compromised pulmonary status, etc.
• The OIG will review Medicare payments made to hospitals for claims that include a diagnosis of Kwashiorkor to determine whether the diagnosis is adequately supported by documentation in the medical record. Kwashiorkor is a severe form of protein malnutrition that is usually not found in the United States. Coding malnutrition as Kwashiorkor results in a larger payment from Medicare that is not appropriate if the patient really does not have this type of malnutrition.
• Although this is listed as a new issue, the OIG has already released three audit reports addressing this topic from January and February 2014. The reports note that Medicare paid hospitals $711 million for claims that include a diagnosis of Kwashiorkor. The audits have found no claims where the diagnosis of Kwashiorkor was appropriate. Removing the Kwashiorkor diagnosis has changed the DRG in about 18% of the claims reviewed, resulting in total overpayments for the three reviews exceeding $310,000.

 

Other Topics in the Work Plan include:

Hospitals; Policies and Practices:

Reconciliation of outlier payments
Medicare costs associated with defective medical devices (new)
Analysis of salaries included in hospital cost reports (new)
Impact of provider-based status on Medicare billing
Comparison of provider-based and free-standing clinics (new)
Critical Access Hospitals - Payment policy for swing-bed services
Critical Access Hospitals - Beneficiary costs for outpatient services
Long Term Care Hospitals - Billing patterns associated with interrupted stays

Hospitals: Billing and Payments:

Duplicate graduate medical education payments
Bone marrow or stem cell transplants (new)
Indirect medical education payments (new)

Hospitals: Quality of Care and Safety:

Participation in projects with quality improvement organizations
Emergency preparedness and response - Hurricane Sandy (new)
Oversight of pharmaceutical compounding (new)
Oversight of hospital privileging (new)
Adverse events in inpatient rehabilitation facilities

Nursing Homes:

Questionable billing patterns for Part B services during nursing home stays

Other Providers: Billing and Payments

Diagnostic radiology – medical necessity of high-cost tests
Electrodiagnostic testing – questionable billing
Laboratory tests – billing characteristics and questionable billing
Partial hospitalization programs
High utilization of sleep-testing procedures

Q:

When we perform a self-audit after a patient has been discharged and the documentation does not support a 2-Midnight expectation do we have to notify the beneficiary of the change from a Part A claim to a Part B claim?

A:

This question was addressed on pages 50913 – 50914 of the 2014 IPPS Final Rule.

Commenters asked that CMS clarify whether or not they were “proposing a self-audit process that would have to conform to the utilization review rules under the CoPs, notably physician concurrence, beneficiary notification, and other aspects related to continuation of an inpatient stay.”

CMS’s response was that “we did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self audit determination that does not conform to the requirements for utilization review under the CoPs. We do not agree with the commenters that beneficiaries need not be notified of a hospital’s determination that the inpatient admission was not reasonable and necessary. Part B billing pursuant to such a determination may result in an increase in financial liability for some beneficiaries which hospitals may not be able to ‘‘waive’’ or forego attempting to collect (we refer readers to sections XI.B.5 and B.6. of the preamble of this final rule). We believe that the CoP rules for beneficiary notification and physician involvement in hospital utilization review decisions are important for maintaining beneficiary rights, consistent with 42 CFR 482.13.”

 

§482.30 Condition of participation: Utilization Review

This CoP instructs that if after review the Utilization Review Committee determines that a stay was not medically necessary, written notification must be provided to the hospital, patient and MD responsible for the patient’s care, within 2 days of the decision being made.

With the major changes to Medicare’s inpatient admission requirements, trying to keep up with all the nuances of the rules and education efforts is like trying to juggle bowling balls. The Probe and Educate Review Process is replacing most previous Medicare Administrative Contractor (MAC) reviews, so this article addresses some questions concerning this process. If you have other questions, please refer to the resources listed at the end of this article or send me an email.

What is the purpose of the Probe and Educate Review Process?

The Probe and Educate Review Process is a focused prepayment medical review strategy for MACs designed to ensure provider understanding of the new two-midnight benchmark for determining the necessity of an inpatient admission (42 CFR 412.3) and to provide responsive provider-specific education, as necessary, to correct improper payments.

How long will the Probe and Educate Review Process last?

At the end of January, CMS decided to extend the Probe and Educate Review Process through September 30, 2014.

Will the MAC actually deny inpatient claims for not meeting the new inpatient criteria (2 midnight benchmark) during the Probe and Educate program?

Yes, claims that do not meet the two-midnight benchmark for an appropriate inpatient admission will be denied. Because the probe reviews will be conducted on a prepayment basis, hospitals can rebill for medically reasonable and necessary Part B inpatient services provided during denied Part A inpatient hospital stays provided the denial is on the basis that the inpatient admission was not reasonable and necessary. Hospitals may rebill for Part B inpatient services in accordance with Medicare Part B payment rules and regulations.

Will other Medicare review contractors be allowed to audit records for the medical necessity of inpatient admission?

No, Recovery Auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014.  

What types of inpatient claims will be selected for review by the MACs under the Probe and Educate Review Process?

MACs will select Medicare Part A inpatient claims spanning 0 to 1 midnight after formal inpatient admission.

Will claims containing inpatient-only procedures with stays less than 2 midnights be included in the Probe and Educate reviews?

No. However, CMS indicated on the last Special Open Door Forum concerning the new 2-midnight rule, that the contractors are not able to easily identify inpatient only procedure admissions up front. These claims may be initially selected for review, but will be released for payment when the MAC determines it was an inpatient–only procedure.

How many claims can a hospital expect to be selected for review?

MACs will initially select 10-25 records per hospital (25 for large hospitals, although “large” has not been defined). If a hospital has more than 1 error in a 10 record sample or more than 2 errors in a 25 record sample, after a three month education period, a repeat Probe & Educate sample of 10-25 records will be selected. Continuing problems of major concerns (7/10 or 14/25 errors) after a second three month education period could result in a third sample of 100-250 records for that hospital.

How will I be notified of the request for records for the Probe and Educate Review Process?

Providers will receive additional development requests (ADR) through the normal process. Providers that have claims selected for prepayment review may receive an ADR letter through the mail or will receive an ADR notice via the Fiscal Intermediary Standard System (FISS). Providers should monitor the Fiscal Intermediary Standard System (FISS) for claim status instead of seeking hard copy request for ADRs.

The MACs have published announcements on the Probe and Educate program; some include specific information on the ADR edits; for example Cahaba GBA 2-midnight ADR information, Novitas Probe and Educate information, and Palmetto Probe Reviews.

What elements will the MAC be looking for in the inpatient record for the Probe and Educate Review Process?

MACs will assess the hospital’s compliance with three things:

1. the admission order requirements,
2. the certification requirements, and
3. the 2-midnight benchmark

Will I be notified of the results of the reviews and if so, how?

Yes. MACs will send detailed results letters to providers for both denials and reviews with no findings.

Can the MAC and other Medicare Review Contractors audit inpatient claims for issues other than the medical necessity of the inpatient admission?

Yes. Medicare review contractors may review claims to ensure the services provided during the inpatient stay were reasonable and necessary in the treatment of the beneficiary, to ensure accurate coding and documentation, and may conduct other reviews as dictated by CMS and/or another authoritative governmental agency.

CMS will also monitor provider billing trends for variances indicative of abuse, gaming, or systematic delays in the submission of claims, for the purpose of avoiding the MAC prepayment probe audits during this initial probe and educate period.  Any evidence of systematic gaming, abuse or delays in the provision of care in an attempt to receive the 2-midnight presumption could warrant medical review.

Where can I obtain additional information about the Probe and Educate Review Process?

• Inpatient Hospital Reviews webpage
• See the following downloads at the bottom of this page:
• Questions and Answers Relating to Patient Status Reviews
• Selecting Hospital Claims for Patient Status Reviews
• Reviewing Hospital Claims for Patient Status
• MLN Matters Article SE1403
• Also check your local MAC’s website

 

For the I-10 Corner this week, we are discussing a few of the specific coding differences for cardiac diagnoses and conditions in ICD-9-CM and ICD-10-CM.

Angina Pectoris with Atherosclerotic Heart Disease (ASHD):

I-9

Angina, Unspecified (413.9)

ASHD, Unspecified (414.00)

I-10

Angina with ASHD, Unspecified—see Arteriosclerosis, Coronary (artery), Unspecified (I20.9)

NOTE FROM AUTHOR
Attention: Two codes in I-9 vs. one code in I-10

Atrial Fibrillation:

I-9

Atrial Fibrillation (established) (paroxysmal) (427.31)

I-10

Atrial Fibrillation or Auricular (established) (I48.91)

Chronic (I48.2)

Paroxysmal (I48.0)

Permanent (I48.2)

Persistent (I48.1)

Atrial Flutter:

I-9

Atrial Flutter or Auricular (427.32)

I-10

Atrial Flutter or Auricular (I48.92)

Atypical (I48.4)

Type I (I48.3)

Type II(48.4)

Typical (I48.3)

 

NOTE FROM AUTHOR
Attention: There are specific descriptions for Atrial Fibrillation and Atrial Flutter in I-10. In addition, there are no specific codes for Postoperative Fibrillation or Postoperative Flutter in the alpha index.

Heart Failure:

I-9

Congestive Heart Failure (compensated) (decompensated) (428.0)

Diastolic (428.30)

Acute (428.31)

Acute on Chronic (428.33)

Chronic (428.32)

Systolic (428.20)

Acute (428.21)

Acute on Chronic (428.23)

Chronic (428.22)

I-10

Congestive Heart Failure (compensated) (decompensated) (I50.9)

Diastolic (congestive) (I50.30)

Acute (congestive) (I50.31)

            and (on) chronic (congestive) (I50.33)

Chronic (congestive) (I50.32)

            and (on) acute (congestive) (I50.33)

Combined with Systolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Systolic (congestive) (I50.20)

Acute (congestive) (I50.21)

            and (on) chronic (congestive) (I50.23)

Chronic (congestive) (I50.22)

            and (on) acute (congestive) (I50.23)

Combined with Diastolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Myocardial Infarction (MI):

I-9

Infarct, Myocardial (acute or with a stated duration of 8 weeks or less) (with Hypertension) (410.9x)

NOTE FROM MANUAL
Note—Use the following fifth-digit subclassification with category 410:

0 - episode unspecified

1 - initial episode

2 - subsequent episode without recurrence

 

I-10

Infarct, Myocardial (acute) (with stated duration of 4 weeks or less) (I21.3)

NOTE FROM AUTHOR
Attention:

• For the episode of care in I-10, MIs are identified as either Acute (I21.xx) or Subsequent (I22.xx).
• The timeframe (stated duration of the MI) has decreased in I-10 to 4 weeks from 8 weeks in I-9.

           

Most MIs are considered to be ST-Elevation (STEMI) unless stated as Non-ST Elevation (NSTEMI) or Subendocardial.

STEMI

Anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) (I21.09)

Inferior (I21.09) (diaphragmatic) (inferolateral) (inferoposterior) (wall) NEC (I21.19)

Inferoposterior Transmural (Q wave) (I21.11)

Lateral (I21.29) (apical-lateral) (basal-lateral) (high) (I21.29)

Posterior (I21.29) (posterobasal) (posterolateral) (posteroseptal) (true) I21.29)

Septal (I21.29)

Specified NEC (I21.29)

NSTEMI

Subendocardial (I21.4)

Non-Q wave NOS (I21.4)

Nontransmural NOS (I21.4)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

NOTE FROM AUTHOR
For Acute MIs, we can now identify the specific coronary artery impacted. For example, per the alpha index:

Infarct, Myocardial, Involving

Coronary artery of anterior wall NEC (I21.09)

Coronary artery of inferior wall NEC (I21.19)

Diagonal coronary artery (I21.02)

Left anterior descending coronary artery (I21.02)

Left circumflex coronary artery (I21.21)

Left main coronary artery (I21.01)

Oblique marginal coronary artery (I21.21)

Right coronary artery (I21.11)

Please refer to the our article, ICD-10-CM Diseases of the Circulatory System, describing specific coding guidelines for cardiac diagnoses and conditions.

I hope this article has been beneficial in helping you become more familiar with cardiac diagnoses and conditions in ICD-10-CM.           

Is your hospital continuing to struggle to comply with Final Rule CMS-1599-F that went into effect on October 1, 2013? Are you still seeking any and all of the additional information that you can find to help comply with the new rules? If the answer is yes, you are not alone.

In the past couple of weeks CMS has been busy providing additional guidance. First, was the release of MLN Matters® Number: MM8586. This article provides guidance for the new use of Occurrence Span Code 72 to identify outpatient time associated with an inpatient hospital admission. Next, they posted updated guidance regarding the Hospital Inpatient Admission Order and Certification and an updated Reviewing Hospital Claims for Patient Status download to their Inpatient Hospital Review webpage. They also held yet another “Special Open Door Forum” (ODF) to discuss the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on February 4th.

As the question and answer portion of the ODF became more of a question being asked and CMS requesting that you submit that question to IPPSAdmissions@cms.hhs.gov, it became apparent that no big “aha” moments were going to be happening. It was at this point that all I could think about was the chorus to the Sonny and Cher 1967 hit song The Beat Goes On. For those old enough to remember this one sing along:

“The beat goes on, the beat goes on

Drums keep pounding

A rhythm to the brain

La de da de de, la de da de da.”

Now that this song is firmly stuck in your head, let’s take a look at the new and updated guidance from CMS.

Occurrence Span Code 72; Identification of Outpatient Time Associated with an Inpatient Hospital Admission and Inpatient Claim Payment:MLN Matters(R) Number: MM8586

Effective Date: December 1, 2013

Implementation Date: February 24, 2014

Why is this being implemented?

• “The redefinition of occurrence span code 72 allows providers to voluntarily identify those claims in which the 2-midnight benchmark was met because the beneficiary was treated as an outpatient in the hospital prior to the formal inpatient admission order. In other words, it permits providers and subsequently review contractors to identify the “contiguous outpatient hospital services (midnights) that preceded the inpatient admission,” as well as the total number of midnights after formal inpatient order and admission, on the face of the claim.”

Hospital Inpatient Admission Order and Certification (January 30, 2014)

CMS’s attempt to clarify the September 5th Guidance fell a little short. However, there were a few key pieces of information to point out to you.

• If you have a Medicare beneficiary waiting on a skilled nursing facility (SNF) bed, CMS indicates that “a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis.”
• Residents, non-physician practitioners and ED physicians who do not have admitting privileges can make the initial admission decision. “In countersigning the order, the ordering practitioner approves and accepts responsibility for the admission decision.” This counter-signature would “satisfy the order part of the physician certification, as long as the ordering practitioner also meets the requirements for a certifying physician.”
• “If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered an inpatient. The hospital stay may be billed to Part A as a hospital outpatient encounter.”

The entire update can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf

Highlights from the February 4, 2014 Special Open Door Forum

• CMS has extended the MAC Probe and Educate Period through September 30, 2014. CMS verified (at a caller’s request) that they have not cancelled or delayed the implementation of the new rule.
• In response to a question about whether or not there had to be a statement indicating the expected length of stay in the record, CMS indicated that there are no “magical words” that need to appear saying the physician certifies the stay. CMS would expect to find “regular good documentation” in the record, not a separate “I certify” statement.
• Another caller asked if the MD does not sign a verbal admit order until after the patient is discharged can we bill for anything? CMS responded that as far as the letter of the law you need the order to submit a Part A claim. If the order was not co-signed then you could submit a Part B Outpatient claim (a 13x type of bill).
• One hospital indicated that they were under the impression that they would receive a letter from their MAC after their records had been reviewed under the Probe & Educate program. CMS indicated that they had asked MACs to hold on letters until additional guidance was released regarding the Inpatient Admission Order and Certification. They went on to indicate that this information was released last week and the MACs should no longer be holding letters.

Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Last Updated: 01/31/14)

There were two specific clarifications made to this Guidance that I would like to point out to you. Prior to this update CMS had indicated that “it is not necessary for a beneficiary to meet an inpatient “level of care,” as may be defined by a commercial screening tool, in order for Part A payment to be appropriate.” In this updated version they further indicate that “In addition, meeting an inpatient “level of care,” as may be defined by a commercial screening tool, does not make Part A payment appropriate in the absence of an expected length of stay of 2 or more midnights.” Once again, CMS is making the point that good physician documentation supportive of a 2 or more midnight admission is the key to the decision to admit a patient as an inpatient.

The other clarification is about the documentation that the MACs would expect to find to support the 2-midnight expectation. CMS indicates that “physicians need not include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

National Provider Call: 2-Midnight Benchmark: Discussion of the Hospital Inpatient Admission Order and Certification

CMS is already planning additional education through a National Provider Call on Thursday February 27, 2014 from 2:30 PM – 4:00 PM Eastern Time. The target audience for this call includes hospitals, physicians and non-physician practitioners, case managers, medical and specialty societies, and other healthcare professionals. Topics to be covered in this call are the order and certification guidance with case examples, transfers and a question and answer session.

Registration is open and those interested in participating can sign up at the CMS MLN Connects Upcoming Callsregistration website.

It appears that the truism that best applies with the new regulations and guidance is that “The only constant is change.” MMP continues to be on the lookout for updated guidance and education opportunities to pass along to you so, stay tuned.

 

One of the most significant changes to the Hospital Outpatient Prospective Payment System (OPPS) for 2014 was the packaging of clinical laboratory services. Prior to this year, clinical diagnostic laboratory tests were separately paid under OPPS at the Clinical Laboratory Fee Schedule (CLFS) payment rates. In 2014, most laboratory tests will be packaged under OPPS.

There are some limited exceptions where hospitals may receive separate payment for otherwise packaged lab services. Does your hospital understand these exceptions and do you know how to bill to receive payment in these circumstances?

The January OPPS Update MLN Matters Article and associated transmittal explain the details of when and how to appropriately receive separate payment for packaged laboratory services.

Packaged laboratory services are separately payable in three situations:

• When a specimen is submitted for analysis to a hospital and the patient is not physically present at the hospital. These are commonly referred to as non-patient services, outreach lab services or reference lab tests.
• When laboratory tests are the hospital outpatient services that a patient receives during an outpatient encounter. For example, patients that are referred from a physician’s office or clinic to a hospital outpatient laboratory for laboratory testing only and no other outpatient services.
• When laboratory tests are clinically unrelated to other outpatient services the patient receives during an outpatient encounter and the lab tests are ordered by a different practitioner than the one who ordered the other (non-lab) outpatient services.

For 2014, the packaged laboratory tests have a status indicator (SI) of “N” (packaged) – so how are hospitals to receive separate payment?

CMS is allowing hospitals to bill laboratory tests provided in any of the above listed exceptions on a 14X type of bill (TOB). Prior to this year, only non-patient services were required to be billed on a 14x TOB. Most outpatient laboratory services were generally billed on a 13x TOB. For 2014, in order to receive separate reimbursement for packaged laboratory services a hospital must submit the lab charges on a 14x claim. It is the hospital’s responsibility to determine which lab services meet the criteria for separate payment and therefore are appropriate for a 14x claim.

There are some exceptions to packaging of laboratory services:

• CMS did not package molecular pathology test codes since they are recently added laboratory codes. Since molecular pathology laboratory tests are not packaged under OPPS they should be billed on a 13x claim.
• Pathology, cytology and blood bank services are not packaged because they have a SI of “X” and are paid under OPPS, not under the CLFS.
• The status indicator for some other clinical lab tests remained “A” instead of being changed to the packaged status indicator “N” (for example new codes, screening services, and drug screening codes) so these will also still be separately paid under OPPS.

Hospitals should develop processes to ensure that lab tests that meet the criteria are submitted on a 14x claim while lab services that do not meet the criteria continue to be billed on a 13x TOB. These process changes may affect your outpatient laboratory, registration, and billing departments.

 

Every year, there are a number of Medicare provisions that expire on a particular date. For the requirements of these provisions to continue past the expiration date, Congress must take action through a new law. Such was the case for several rehabilitative therapy provisions set to expire at the end of 2013. The Pathway for SGR Reform Act of 2013, signed into law on December 26, 2013 extended the following provisions related to payments for Medicare outpatient therapy services through March 31, 2014.

Application of therapy caps and therapy threshold to therapy services furnished in a hospital outpatient department -

Therapy caps are a financial limitation on the amount Medicare allows for outpatient therapy services for a single Medicare patient in a given calendar year. The therapy cap amount for each patient starts over each January 1st. For 2014, the therapy cap is $1,920 for physical therapy (PT) and speech language pathology (SLP) services combined; and a separate $1,920 for occupational therapy (OT) services.

Exceptions process for outpatient therapy caps -

When providers of therapy services furnish medically necessary therapy services beyond the therapy cap, they may request an exception by appending the KX modifier to the appropriate therapy services on the claim. Additional information about the exception process for therapy services may be found in the http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf">Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

Manual medical review of outpatient therapy services exceeding the threshold amount -

Medicare mandates that a Medicare contractor perform a manual medical review of therapy services exceeding a $3,700 threshold for PT and SLP services combined and a $3,700 threshold for OT services. Currently this review function is being handled by Medicare Recovery Auditor contractors.

Critical Access Hospitals will also want to study MLN Matters Article MM8426 concerning the application of therapy caps, the exceptions process, and manual medical review to outpatient therapy services provided in the CAH setting.

So we are all set for … well, three months. If this year follows the pattern of previous years, another law will likely extend these provisions through the remainder of 2014. But, we will just have to wait and see.