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Having undergone back surgery at the age of twenty-seven, I would tell you that yes I needed that back surgery. Whether or not my chart demonstrated that need or not, who knows. That was then and this is now and in the current Medical Review Contractor environment, if the documentation in a medical record does not support the medical necessity of the procedure, claims submitted by hospitals and in some instances the surgeon can and are being denied.

There are countless types of back surgeries but for this article the focus is on documentation required to support the medical necessity of lumbar spinal fusions that code to DRGs 459 (Spinal Fusion Except Cervical with Major Co-morbidity or Complication) and DRG 460 (Spinal Fusion Except Cervical without Major Co-Morbidity or Complication).

Who is Looking?

The CMS Inpatient Hospital Reviews webpage indicates that despite the current Medicare Administrative Contractor (MAC) Probe & Educate Program, “MACs, Recovery Auditors and the Supplemental Medical Review Contractors will continue other types of inpatient hospital reviews” including “reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary.”

MACs

Jurisdiction-N (J-N): First Coast Services Options, Inc.

First Coast is the MAC for Florida and in the absence of a National Coverage Determination (NCD) they were the first and to date the only MAC to have a Local Coverage Determination (LCD) for Spinal Fusions. LCD L32074: Lumber Spinal Fusion for Instability and Degenerative Disc Conditions had an original effective date for services performed on or after October 16, 2011.

Key LCD Guidance

• It is “when conservative therapy (non-surgical medical management) is unsuccessful after at least 3 to 12 months, depending on the diagnosis, lumbar spinal fusion may be considered for certain conditions.”
• “The hospital records are the primary source of information for the audit of hospital/procedure services. Therefore, any historical data supporting the medical necessity of the fusion (for example, duration and outcome of physiotherapy, injection therapy, anatomic factors influencing the decision for surgery, etc.) must be included in the inpatient medical record as noted in the history and physical examination, operative note and/or copies of office notes. For example, fusion of iatrogenic instability (i.e., surgical resection of facet as essential portion of the required decompression rendering an unstable segment) should be documented in a pre-operative note and/or an operative note.”
• “To meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) can be denied.”
• Physician documentation must support the need for surgery and “must include the following:
• Office notes/hospital record, including history and physical by the attending/treating physician
• Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management) when applicable. Failure of non-surgical medical management can be historical and does not have to be under the direction of the operating surgeon.
• Interpretation and reports for X-rays, MRI’s, CT’s, etc.,
• Medical clearance reports (as applicable)
• Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted (if applicable)
• Complete operative report outlining operative approach used and all the components of the spine surgery

Medical record documentation must be made available to Medicare upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.”

Jurisdiction-11 (J-11) Palmetto GBA

Palmetto, the MAC for North Carolina, South Carolina, Virginia and West Virginia posted the YouTube Presentation Clinical Updates: DRG 459, 406earlier this year on August 11th. The most common reason cited by Palmetto for denials was a lack of information in the medical record about the conservative care provided prior to the surgical intervention.

Palmetto goes on to list documentation examples of conservative treatment that when clearly documented may help support payment for spinal fusion-related hospital care. Physical therapy, joint injections, neurologic deficits and upper and lower extremity strength are just a few of the examples provided.

Cahaba GBA, the MAC for Alabama, Georgia and Tennessee, has on more than one occasion indicated that simply documenting “failed outpatient therapy” for a total joint replacement is not sufficient to support the surgery. Similarly, Palmetto notes in this presentation that “failed outpatient therapy, admit for spinal fusion” is not sufficient evidence of Medical Necessity for a spinal fusion.

Supplemental Medicare Review Contractor (SMRC)

Transmittal 508 had an Effective and Implementation date of April 8, 2014 and added the Supplemental Medicare Review Contractor (SMRC) to the already long list of “Review Contractors” (MACs, CERT, RAC, PSCs, and ZPICs) performing medical review activities.

Strategic Health Solutions, LLC was awarded the SMRC Contract and they have been busy this year fulfilling one of their primary tasks of “conducting medical review based on the analysis of national claims data versus data that is limited to a specific jurisdiction as performed by Medicare Administrative Contractors (MACs).”

One such Project was a review of Medicare Part A Inpatient Services for Spinal Fusions. As part of the Project Background they noted that “analysis of Medicare claims data for calendar years 2012 and 2013 indicated a significant increase in billing and payment in Inpatient Hospitals Stays of Diagnosis-Related Group (DRG) Codes 459 (Spinal Fusion, except cervical spine, with major complications or comorbidities) and 460 (Spinal Fusion, except cervical spine, without major complications or comorbidities).”

The purpose of this project was to determine if claims had been appropriately adjudicated according to Medicare regulations and guidelines. At the end of the project 986 claims had been reviewed. Of those claims 589 were denied due to no response from the hospital and 374 claims were denied after review with a resultant overall Error Rate of 49%.

Project findings also included Specific Denial Reasons and Ways to Prevent Denials.

Denial Reasons

• Providers not responding to Additional Documentation Request (ADR) within the 45 day time frame
• Lack of documentation supporting the medical necessity of the procedure.
• Lack of documentation showing that conservative treatment was done prior to the surgical intervention.

Ways to Prevent Denials

• “Responding timely to SMRC ADR letters,
• Submit all documentation related to the services billed which support the medical necessity of services billed.”

Moving forward, hospitals need to be aware of NCD and LCD requirements to ensure records support the medical necessity of a procedure, be mindful of all of the Review Contractors that could be requesting records and submit requested information within the allowed time frame.

“The ABC’s of …” refers to the basic facts of a topic. This article looks at the basic facts of the rehabilitative therapy updates for 2015, which involve C’s (caps and codes), D’s (documentation), E’s (exceptions and extensions), and F’s (functional reporting). So the ABC’s of the CDEF’s of therapy are…

There are not a lot of changes for rehabilitative therapy for 2015 like there have been the past few years. But all of the changes from previous years remain in place, at least for now. So let’s look at what is new and review some of the ongoing requirements for therapy services.

Therapy Caps

• The 2015 therapy cap for physical therapy and speech-language pathology combined is $1,940
• The cap for occupational therapy is $1,940 for 2015
• There is an exception process for therapy services beyond the cap limit if services are reasonable and necessary
• Use KX modifier on therapy services to request exception to therapy caps
• KX modifier - therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary’s medical record
• See MLN Matters Article MM8970

Therapy Code List

• Two new codes created to describe negative pressure wound therapy with the use of a disposable system
• CPT Code 97607 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are less than or equal to 50 square cm
• CPT Code 97608 – Negative pressure wound therapy utilizing disposable, non-durable medical equipment …, total wound(s) surface are greater than 50 square cm
• CPT codes 97607 and 97608 designated as “Sometimes Therapy”
• Negative pressure wound therapy CPT codes 97605 and 97606 revised to specify the use of durable medical equipment
• G-codes (G0456 and G0457) that described negative pressure wound therapy using disposable device are being deleted
• See MLN Matters Article MM8985

Extension of Therapy Provisions

The Protecting Access to Medicare Act of 2014 (PAMA) extended the following provisions through March 31, 2015:

• The exceptions process for outpatient therapy caps
• The manual medical review process for therapy services exceeding threshold of $3,700 (one threshold for PT/SLP combined; one for OT)
• The application of the therapy caps and related provisions to services furnished in hospital outpatient departments
• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.

Functional Limitation Reporting

Reporting of the functional limitation G-codes and severity modifiers is now a requirement for rehabilitative therapy claims to allow Medicare to gather data on therapy usage and outcomes to assist in reforming the Medicare payment system for outpatient therapy services. From therapy reviews performed by Medical Management Plus, it appears providers are generally reporting these correctly. The one issue that needs improvement is the documentation of the rationale for selection of the severity modifiers. The Medicare manual states – “Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.”

Documentation should clearly indicate the measures and reasons the therapist selected a particular degree of impairment. Some examples of documentation that meets these requirements are:

• The patient’s performance on the Berg Balance Scale (score 46 out of 56) indicates that she is a low fall risk according to the interpretive guidance provided. However, the patient is a moderate fall risk due to the added contribution of lower extremity muscle weakness and reduced vision. The patient classifies as between 20%-40% impaired (CJ). Due to ongoing visual impairment, the patient is expected to obtain a goal of 1-20% impairment (CI) with the recommended therapy plan of care.
  (Paraphrased from APTA Functional Limitation Reporting Toolkit at the following link: http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/)

• Patient’s goal for PT is to be able to walk in her house and around the community (G8978) with minimal to no assist. Her current impairment is 80% (CM) based on her OPITMAL, Berg Balance, and 10 meter walk scores. She is expected to be able to walk with minimal assistance with around 30% (G8979 CJ) impairment after 6 weeks of therapy.

Therapists definitely need to know their alphabet for billing, coding and documentation.

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout “by encouraging smokers to use the date to make a plan to quit, or to plan in advance and quit smoking that day.” We at MMP would also like to use this date to encourage our readers to make a plan and be prepared for the documentation changes for smoking in ICD-10.

In record reviews I have seen doctors note a patient has never smoked, is a smoker, is a reformed smoker, patient has cut back to 2-3 cigarettes a day. While all of this is interesting, currently in ICD-9 physicians simply need to document when a patient smokes or uses tobacco.

However, in ICD-10, physicians will need to provide more detailed documentation. Physicians will need to document the following additional information for the coder to most accurately report a patient’s tobacco use:

• The physician should document the type of tobacco a person uses (e.g. cigarettes, chewing tobacco, pipe, and/or gum).

• To further specify the type of tobacco dependence that a patient has, the physician will need to document the frequency of use.
• The patient uses nicotine, or
• The patient abuses nicotine, or
• The patient has a nicotine dependence or
• The patient is in remission from nicotine.

• Also, when it is applicable, the physician should document the type of second hand smoke experienced by the patient (e.g. from parent, at work, perinatal, etc.).

Take a look at what your physicians are currently documenting about tobacco use and begin to educate your physicians on what needs to be documented for the accurate reporting of tobacco use.

Everyone knows that in medical record documentation you have to be sure to “say what you did.” But don’t forget that it also has to be authenticated, dated, legible, timely, and include documentation to not only support the service provided, but the clinical indications for why it was provided. Sort of an extended version of “who, what, when, where, and why…”

Our focus this month is the medical review of claims containing CPT code 33249 (Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber). There has been a lot of concern about appropriate billing of AICDs; in fact over the last few years the Department of Justice has investigated these claims to determine if they meet the requirements of the National Coverage Determination (NCD). All of this attention on AICDs is due to high-dollar reimbursement and a long and complex NCD. The Medicare Quarterly Compliance Newsletter for October 2014 discusses the findings of a special study of CPT 33249 by the Comprehensive Error Rate Testing (CERT) program. The CERT review found that many improper payments were made due to insufficient documentation and medical necessity errors.

I will not address all of the requirements for AICDs in this article, but will concentrate on the deficiencies sighted in the Compliance newsletter. For complete information on AICD coverage, please see the NCD for Implantable Automatic Defibrillators (20.4).

The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, meaning the required information was missing from the medical record or was inadequate to support payment. Services that were not medically necessary, based on Medicare coverage policies, accounted for approximately 12% of the improper payments.

Signature Issues:

• The procedure note was not signed by the physician.
• There was not a signature log or attestation for cases in which the physician’s signature was illegible.
• There was a lack of policies for electronic signature process in electronic health records, when applicable.
• Clinical records supporting the patient’s history of heart disease were not authenticated.
• A second copy of a previously unsigned post-operative history and physical examination note was submitted to which a signature had been added without a signature date. Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process.

Date of Service:

• There was a lack of records for the specified date of service.
• An operative report showed that the patient had an AICD implanted; however, the date on the report did not match the billed date of service. Medicare payment rules do not allow reviewers to accept documents with dates that are significantly different from the billed date of service.

Clinical Indication:

• Documentation did not support the clinical indication for the procedure.
• Clinical documentation did not support a previous Myocardial Infarction (MI). MIs must be documented and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Clinical Trial:

• There was a lack of records to support the patient was enrolled in a clinical trial/study. Patients receiving defibrillator implantation for primary prevention must be enrolled in either:
• A Food and Drug Administration (FDA) approved category B investigational Device Exemption (IDE) clinical trial;
• A trial under the CMS Clinical Trial Policy; or
• A qualifying data collection system including approved clinical trials and registries.
• Documentation of enrollment in a clinical trial/study is required to support the use of the Q0 (Q zero) modifier.

 

Lack of Medical Necessity:

• For all AICDs, the beneficiary must not have irreversible brain damage from preexisting cerebral disease.
• For primary prevention of sudden cardiac death, criteria include that the beneficiary must not have:
• Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm;
• Had a Cardiopulmonary Artery Bypass Graft (CABG) surgery or Percutaneous Transluminal Coronary Angioplasty (PTCA) within the past 3 months;
• Had an acute Myocardial Infarction (MI) within the past 40 days;
• Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
• Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year.

Amendments, Corrections and Delayed Entries:

• Medical record amendments, corrections and delayed entries must comply with the widely accepted Recordkeeping Principles described in the Medicare Program Integrity Manual, Chapter 3 (Section 3.3.2.5 (Amendments, Corrections and Delayed Entries in Medical Documentation), Section B (Recordkeeping Principles) to be considered for review determinations.
• Medicare Reviewers do not consider any entries that do not comply with the principles listed in Section B, even if such exclusion would lead to a claim denial.
• For example, undated or unsigned entries handwritten in the margin of a document are excluded from consideration.

So be sure your medical records contain sufficient information to support your Medicare billing. But be especially mindful of those AICD records – that’s a lot of money!!

One other note about Medicare Administrative Contractor (MAC) medical reviews – CMS now requires that MACs post their review topics to their public websites (see Transmittal 527). This requirement was effective September 5, 2014. You will notice on this month’s MAC Review table that First Coast (Jurisdiction N MAC) has added numerous current review topics. These may have been noted on their website previously, but this is the first time I have been able to locate this information.  

In billing Medicare, the details are important. And the details are complicated! Is the status inpatient or outpatient? Is there additional reimbursement? Are the services provided on or off campus? And with an inpatient only list, packaging of services, and provider-based vs. satellite vs. remote locations, how is a provider to figure it out? It takes lots of reading, interpreting, head-banging and gnashing of teeth. And as if the sheer complexity isn’t enough, the rules change constantly or at least once a year - as is the case with the 2015 Outpatient Prospective Payment System Final Rule (OPPS FR).

The other two articles in this week’s Wednesday@One address some of the major changes from the 2015 OPPS FR, specifically the new packaging rules including Comprehensive APCs and the changes to the physician certification requirements for inpatient admissions. In keeping with the theme, this article will address some of the other outpatient changes found in the final rule.

Inpatient Only Procedures

CMS did not make a lot of changes to the Inpatient Only list for this year but some of the changes were significant in terms of hospital operation.

They added an Osteotomy code –

• CPT code 22222 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic)

They removed two codes for additional spinal levels of laminotomy –

• CPT code 63044 (Laminotomy … each additional lumbar interspace)
• CPT code 63043 (Laminotomy … each additional cervical interspace)

The removal of these codes seems extremely reasonable since the primary codes (CPT 63040 and 63042) representing the first and single interspace for these additional-level procedures were already not listed as inpatient only procedures. Since these are add-on codes, there will not be additional reimbursement for the additional levels, but at least these can now be performed as outpatient services.

Payment for Drugs and Biologicals

Medicare is continuing to pay for both pass-through drugs and separately payable drugs, biologicals, and therapeutic radiopharmaceuticals without pass-through status at ASP + 6%. The packaging threshold for separately payable drugs for CY2015 increased to $95. The packaging threshold (average per day cost) began at $50 in 2005 and has steadily increased from year to year; for example it was $90 for 2014. Drugs with a per day cost equal to or below this threshold (by Medicare calculations) are not separately paid, but are packaged into other services.

Off-campus Provider-Based Departments

Medicare and other governmental agencies have recently expressed concerns about the trend of hospitals acquiring physician practices. Outpatient hospital services are paid at a higher reimbursement rate than services provided in a physician’s office or free-standing clinic. In order to collect data on the amount and types of services being provided in hospital off-campus provider-based departments (PBDs), CMS will be requiring the addition of a modifier to services furnished in an off-campus provider-based department on facility claims and a new place of service (POS) code on the physician claims. This proposal was finalized in the 2015 OPPS Final Rule with the following details:

• The addition of the modifier for hospital services in an off-campus provider-based department is not required until 2016. The modifier may be voluntarily added beginning in 2015.
• The new HCPCS modifier is “PO” (Services, procedures and/or surgeries furnished at off-campus provider-based outpatient departments) and is to be appended on the hospital claim to all services furnished in the off-campus PBD.
• CMS defines “campus” as the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.
• The modifier is not to be reported for services furnished in:
• Remote locations of a hospital as defined at 42 CFR 412.65,
• Satellite facilities of a hospital as defined at 42 CFR 412.22(h), or
• Services furnished in an emergency department.
• CMS will be deleting POS code 22 (outpatient hospital department) and replacing it with two new codes, one of which will identify services furnished in a hospital off-campus PBD for physician reporting.

CMS indicates that additional instructions and provider education will be forthcoming in sub-regulatory guidance.

These are some more of the most recent changes – until the next changes come along. Hospitals need to adjust their processes to address the above new regulations and watch for any clarifying guidance. Don’t bang your head too hard!

The 2014 IPPS Final Rule placed a significant burden on hospitals by requiring that a Physician Certification be completed on ALL Medicare inpatient admissions. In their effort to achieve “policy goals with the minimum administrative requirement necessary,” CMS finalized the 2015 OPPS proposed changes to the physician certification process that only requires physician certification for long-stay and outlier cases.

Implications for Hospitals:

• The physician certification change does not change the fact that there must be a signed inpatient order prior to a beneficiary being discharged as a hospital Condition of Participation (CoP) & a requirement for payment for Medicare Part A Services.
• Physician documentation in the medical record (e.g., History & Physical, MD Progress Notes and Physician Orders) still must support the medical necessity for hospital care that is expected to span at least two midnights.

• For Medicare beneficiaries that reach a 20 day length of stay it will be important to make sure that the “physician certifies or recertifies the following:

1. (1)The reasons for either –
2. (i)Continued hospitalization of the patient for medical treatment or medically required diagnostic study; or
3. (ii)Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F or part 412 of this chapter).
4. (2)The estimated time the patient will need to remain in the hospital.
5. (3)The plans for posthospital care, if appropriate.’

• The physician certification continues to be a requirement until January 1, 2015 and must include the following:
• Authentication of the Practitioner order prior to the beneficiary being discharged,
• The reason for inpatient services,
• The estimated time that the patient will require as an inpatient; and
• The plans for hospital care.

Final Rule Comments and Responses

• Comment: CMS indicates that several commenters “continued to disagree that CMS has the statutory authority to require signed admission orders for all inpatient cases.”
  
  Commenters further “argued that the continued requirement for admission orders is essentially the same as the certification requirement and stated that section 1814(a)(2) of the Act is explicit in requiring physician certification only for services “furnished over a period of time” and not for all services.”
  
  Response: Not surprising, CMS disagrees noting that, “While the inpatient admission order was a required component of the physician certification under our previous policy, the order and the physician certification do not serve identical policy goals under our proposal, which we are now finalizing. For all cases, a properly authorized and documented admission order is necessary because the admission order is integral to a clear regulatory definition of when and how a beneficiary becomes an inpatient.”

• Comment: There were also several commenters that requested that the timing of a signed admission order be by the time of billing as is permitted for Critical Access Hospitals (CAHs).
  
  Response: Again, not surprising, CMS disagrees and indicates that “we believe that, in most cases, matters relating to the determination of patient status should be resolved before discharge, due to the consequences that flow from such a determination. For example, whether services are billed under Medicare Part A or Part B can have a significant impact on a beneficiary’s financial liability. Therefore, we do not believe it is appropriate to change our existing policy which requires that inpatient orders be signed prior to discharge by a practitioner familiar with the case and authorized by the hospital to admit inpatients.”

• Comment: Several commenters also requested additional guidance around the required content and format of the physician certification statement.
  
  Response: CMS reiterates in the Final Rule that “the physician certification requirements at § 424.13 generally may be satisfied by elements routinely found in a patient’s medical record, such as progress notes. CMS does not require that a physician certification comply with a specific standard or format--only that it ensures that the conditions at § 424.13(a) were met. If the medical record adequately describes the reasons for continued hospitalization, the estimated time the patient is expected to require inpatient care, and discharge planning (where appropriate), and the medical record is signed by a physician involved with and responsible for the patient’s care, this would satisfy certification requirements.”

Final Rule

“We are finalizing the policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases”

“We are also are finalizing our proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

For those interested, the Revision of the Requirements for Physician Certification of Hospital Inpatient Services Other Than Psychiatric Inpatient Services can be found on pages 901-912 of the Display Copy of the Final Rule.

Link to the Display Copy of the Final Rule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1613-FC.html?DLPage=1&DLSort=2&DLSortDir=descending

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:
What does Medicare expect from providers concerning limiting drug wastage? For example, if a chemo drug comes in two sizes of single-dose vials, 100 mg and 160 mg and the patient’s dose is 237 mg, could we use three 100mg vials with a wastage of 63 mg, or must we use one 100mg and one 160mg vial for the least amount of wastage (23mg)? 

A:

The Medicare Claims Processing Manual, Chapter 17, section 40 states, “The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.”

Medicare is generally not concerned if you have to jump through extra hoops in order to comply with their guidelines.

Since…

• This drug is separately reimbursed by Medicare
• Medicare has done targeted reviews of some of the other chemo drugs specific to waste issues
• Medicare has instructed hospitals how to report drug waste

 ……MMP recommends you try to minimize waste, even if it involves extra steps.

If you have only the 100 MG dose vials available, then you use what you have. In this case, you are allowed to bill the waste as long as there is not another patient getting the same drug for which the unused portion could have been used.

If you are reviewed by a Medicare reviewer, and they question your billing, you might have to provide invoices, or other documentation proving why you billed as you did.  

 

I enjoy what I do. For some weird reason, I like to read and do my best to interpret the Medicare regulations. I hope my efforts make it easier for hospitals to receive the appropriate reimbursement for the healthcare services they provide by helping them to follow Medicare’s documentation, coding and billing requirements. But unfortunately, the news I share is not always the best news or even fun. So before I get into the “not so fun” part of this article, I want to acknowledge National Radiologic Technology Week.

As in many areas of healthcare, radiology includes many different types of services, such as plain x-rays, computed tomography (CT), magnetic imaging resonance (MRI), ultrasound, nuclear medicine, interventional radiology, radiation oncology, and others. Radiologic technologists provide a valuable contribution to healthcare. How many times over the past year have you, your family or friends received radiologic services? How would your care have been affected without this technology? Within my own circle of family and friends – an x-ray for a broken wrist, annual mammogram, Dexa scan, MRI for spinal stenosis, and CT to rule out a pulmonary embolism. So thanks to all our radiology friends!

A few weeks ago an article reviewed some of the National Correct Coding Initiative (NCCI) guidance for respiratory services for their recognition week. Continuing that theme for National Radiology Week, let’s look at some of the NCCI instructions that apply to Medicare coding and billing for radiology services.

A recent NCCI edit (July 2014) bundled spinal myelography procedures (72240-72270) into procedures for CT neck, chest and lumbar studies (72125-72133). The code pairs may be reported together with the appropriate modifier when warranted. If both tests are medically necessary, distinctly ordered, and there is a separate interpretation for each procedure, then it is appropriate to append modifier 59 to the CT of the spine with contrast code to identify that it is a separate and distinct procedure. (CPT Assistant September 2014)

The following are selected excerpts from the Radiology chapter of the NCCI manual. For complete information regarding these topics and other radiologic issues, please see Chapter IX of the NCCI Policy Manual found in the downloads section of the Medicare NCCI Website.

• CPT code descriptors that specify a minimum number of views include additional views if there is no more comprehensive code specifically including the additional views.
• CPT Manual instructions state that in the presence of a clinical history suggesting urinary tract pathology complete ultrasound evaluation of the kidneys and urinary bladder constitutes a complete retroperitoneal ultrasound study (CPT code 76770). A limited retroperitoneal ultrasound (CPT code 76775) plus limited pelvic ultrasound (CPT code 76857) should not be reported in lieu of the complete retroperitoneal ultrasound (CPT code 76770).
• When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. Similarly when an emergency endotracheal intubation procedure (CPT code 31500), chest tube insertion procedure (e.g., CPT codes 32550, 32551, 32554, 32555), or insertion of a central flow directed catheter procedure (e.g., Swan Ganz)(CPT code 93503) is performed, a chest radiologic examination is usually performed to confirm the location and proper positioning of the tube or catheter. The chest radiologic examination is integral to the procedures, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.
• CPT code 75635 describes computed tomographic angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. This code includes the services described by CPT codes 73706 (computed tomographic angiography, lower extremity...) and 74175 (computed tomographic angiography, abdomen...). CPT codes 73706 and 74175 should not be reported with CPT code 75635 for the same patient encounter. CPT code 73706 plus CPT code 74175 should not be reported in lieu of CPT code 75635.
• Diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59.
• Fluoroscopy reported as CPT codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.
• Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.
• If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281,19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
• CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
• The code descriptor for CPT code 77417 states “Therapeutic radiology port film(s)”. The MUE value for this code is one (1) since it includes all port films.
• An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit (CPT codes 70540-70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed.

There are more rules on coding and reporting radiology services on a claim than there are slices of a CT scan. And that is not so fun!

Coding Kwashiorkor has been and continues to be a hot topic for contractors (e.g., Recovery Auditors and the Office of Inspector General (OIG)). In fact, auditing claims including a diagnosis of Kwashiorkor to determine if the record adequately supports the diagnosis was a new scope of work in the FY 2014 OIG Work Plan and is a continued scope of work in the FY 2015 OIG Work Plan. In the Work Plan the OIG indicates that “a diagnosis of Kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare.”

What is Kwashiorkor?

According to the National Institutes of Health, “Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet. Kwashiorkor is most common in areas where there is:

• Famine
• Limited food supply
• Low levels of education (when people do not understand how to eat a proper diet)
• Dates of service of records reviewed ranged from 2010 – 2013 with most records being prior to 2013.

This disease is more common in very poor countries. It often occurs during a drought or other natural disaster, or during political unrest.”

“Kwashiorkor is very rare in children in the United States. There are only isolated cases. However, one government estimate suggests that as many as 50% of elderly people in nursing homes in the United States do not get enough protein in their diet.

When Kwashiorkor does occur in the United States, it is usually a sign of child abuse and severe neglect.”

Kwashiorkor and the OIG Work Plan

In fulfillment of the Work Plan, the OIG has completed several hospital audits that found that hospitals had incorrectly billed Medicare inpatient claims with Kwashiorkor.

In the audit reports, the OIG indicates that Kwashiorkor generally affects children and the Medicare program is primarily provided to people age 65 or older. Yet, “for calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis for Kwashiorkor. Therefore, we are conducting a series of reviews of hospitals with claims that include this diagnosis code.”

Key Takeaways from 2014 OIG Reports:

• Consistent in the findings for all of the hospitals was that almost all claims reviewed did not comply with Medicare requirements for billing Kwashiorkor in that they used code 260 but should have used codes for other forms of malnutrition. In several instances removing code 260 did not result in a DRG change. When it did result in a DRG change it resulted in overpayments being made to the hospital.
• The combined overpayment by Medicare was $2,074,341. This is staggering when you consider that this amount is overpayment for one single secondary diagnosis code at only twelve hospitals.
• The reasons for coding errors sited by the hospitals included:
• Lack of clarity in the coding guidelines,
• Issues with the medical coding software program used to code the diagnosis; and
• Incorrect guidance from a third party consultant.

What Guidance is Available to Hospitals?

To answer the “lack of clarity in coding guidelines” for coding Kwashiorkor here are two resources that hospitals can look to for malnutrition coding guidance.

Coding Clinic

Volume 3, Issue 1 , page 3 of the October 2012 Medicare Quarterly Compliance Newsletter, provides an example of a Recovery Auditor findings where Kwashiorkor had been coded as a secondary major comorbidity incorrectly and refers the reader to Coding Clinic, Third Quarter 2009.

Specifically, Coding Clinic, Third Quarter 2009, p. 6 advises hospitals to only code 263.0 for moderate protein malnutrition as this category also includes protein-calorie malnutrition. Coding Clinic further advises that unless the physician specifically documents Kwashiorkor Code 260 should not be used.

Consensus Statement

The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) published a Consensus Statement in the May 2012 Journal of the Academy of Nutrition and Dietetics.

This article acknowledges that “the diagnosis of malnutrition in a patient is an undeniably complicating condition that in many cases significantly increased resource utilization in the acute care setting beyond that experienced by the patient in nutritional health.”

While hospitals have historically looked to serum albumin and prealbumin levels as an indicator of malnutrition, the Academy’s Evidence Analysis Library (EAL) analysis found that “acute-phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.”

This article also notes that “CMS has also questioned the use of acute-phase serum proteins as primary diagnostic criteria for malnutrition since studies increasingly suggest limited correlation of these proteins with nutritional status.”

The Academy and Aspen state that two of the following six characteristics should be identified in a patient when diagnosing malnutrition:

• Weight loss;
• Loss of muscle mass;
• Loss of subcutaneous fat;
• Localized or generalized fluid accumulation that sometimes mask weight loss; and
• Diminished functional status as measure by hand grip strength
• Insufficient energy intake;

It is advised that these characteristics be assessed at the time of the hospital admission and “at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.”

The article goes on to site a study by Fry and colleagues that “showed that preexisting “malnutrition and/or weight loss” was a positive predictive variable for all eight major surgery-associated “never events” (inexcusable outcomes in a health care setting.”

Assessment, diagnosis and treatment of malnutrition are critical for the wellbeing of our patients. Equally important is identifying the characteristics that need to be assessed in formulating the correct type of malnutrition (e.g. moderate or severe) diagnosis. This article contains a table with detailed clinical criteria to assist in determining the severity levels of malnutrition and I strongly encourage you to read this article.

It pains me to admit that my nursing school days are now decades in the past. With that said, there are still key mnemonics that helped me survive the information overload. One particular example is the five stages of coping or D.A.B.D.A. (Denial, Anger, Bargaining, Depression and Acceptance). As I began writing this article it struck me that the stages of coping must be similar to the stages hospital Appeals Coordinators are dealing with in regards to Medicare’s five stages of appeals.

Level 1: Redetermination by a Medicare Administrative Contractor (MAC) a.k.a. Denial

Once a claim has been denied by your MAC, and on internal review you can’t believe that the hospitalization was denied you would request a Redetermination. It is at this level that the MAC will perform a document review of the initial claim determination.

Level 2: Reconsideration a.k.a. Anger

At this point you can become both frustrated and irritated that the same MAC has denied what you believe to be a medically necessary hospitalization twice so you press on to the Reconsideration level. At this level a Quality Independent Contractor (QIC) will perform a document review of the Redetermination and a hospital may still submit any evidence not previously present to support the medical necessity for the admission.  

Level 3: Administrative Law Judge (ALJ) Hearing a.k.a. Bargaining

It is at this level that we will spend the most time on today.

This past July, Nancy J. Griswold, the Chief Administrative Law Judge for the Office of Medicare Hearings and Appeals (OMHA) made a statement before the United States House Committee on Oversight & Government Reform. Ms. Griswold reported that the OMHA adjudication capacity is approximately 72,000 appeals a year. However, “weekly appeal levels have ranged between 10,000 and 16,000 throughout FY 2014. As a result, OMHA had over 800,000 appeals pending on July 1, 2014. At current receipt and adjudication capacity levels, OMHA’s Central Operations, which is the focal point for all incoming appeals, is receiving one year’s worth of appeals every four to six weeks.”

So, what exactly does this translate into at the individual hospital level? According to the OMHA web page, “the average processing time for appeals decided in fiscal year 2014 is 414.8 days.” However, as you continue to look through their web page, by September of this year the average appeals processing time was 514.5 days.

Added to this delay is the recent release of Transmittal 543 where CMS asserts that “significant time and effort is spent by CMS and its contractors to ensure that review staff are making quality decisions. It is important for contractors to support and defend their medical review decisions throughout the appeals process, including at Administrative Law Judge (ALJ) hearings.” In line with this assertion this Transmittal instructs Medicare Administrative Contractors (MACs) “to support their medical review decisions through the ALJ level of appeal.”

Key Guidance in Transmittal 543 Effective October 27, 2014:

• For claim determinations made by the MAC they “shall assign a physician to participate or take party status “ at ALJ hearings,
• The Physician “is generally the primary individual overseeing and/or taking party/participant status, a contractor may elect to have an attorney or clinician take party or participant status, or another qualified individual if approved by the COR.”
• MACs shall determine a process to identify cases that they will participate in at the ALJ level of appeal. “Factors to be examined should include, but not be limited to policy implications, dollars at issue, source of the denial, program integrity matters, and the extent to which a particular issue is, or has been, a recurring issue at the ALJ level of appeal.”
• “MACs shall coordinate with the QIC to ensure timely notification of all ALJ hearings.”
• “For extrapolation cases, the MAC shall be prepared to discuss the background on how the provider/supplier was selected for review, results of the sample case adjudications, as well as matters related to the extrapolation process.”

Why include the MACs now? In part, this could be in response to the 2012 OIG report where the OIG found that improvements are needed at the ALJ Medicare Appeals level, that in FY 2010 the ALJ reversed the decisions of the QICs in favor of the appellants 56 percent of the time, and one recommendation made in this report was to “continue to increase CMS participation in the ALJ appeals.”

This is where the bargaining comes into play. As a hospital, should we stay the course with the appeal even though it may be more than a year before it goes before the ALJ, or should we consider one of the options currently being offered by CMS (Statistical Sampling Initiative, Settlement Conference Facilitation Pilot, or the Medicare Appeals Settlement Offer)?

Level 4: Medicare Appeals Council Review a.k.a. Depression

CMS instructs that “if you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review.”

It is also at this level that it would be easy for depression to set in due to the fact that even though you continue to believe in the medical necessity of the case you are appealing you also realize that by now you have spent countless hours and more than likely at least two years or more championing your appeal.

Level 5: Judicial Review a.k.a. Acceptance

Escalation to this level can happen when “you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed.” At this level, win or lose, you should be prepared that this is the end of the line for the case you have been defending.

Resources:

Transmittal 543: Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R543PI.pdf

Link to OIG November 2012 Report – Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals: http://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf

Link to Statement of Nancy J. Griswold, Chief Administrative Law Judge to the United States House Committee on Oversight & Government Reform: http://oversight.house.gov/wp-content/uploads/2014/07/CMS-Griswold-OMHA-Final.pdf

Link to Medicare Learning Network’s Medicare Appeals Process Fact Sheet (ICN 006562 August 2014): http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf

Link to Statistical Sampling Initiative: http://www.hhs.gov/omha/statistical_sampling_initiative.html

Link to Settlement Conference Facilitation Pilot: http://www.hhs.gov/omha/settlement_conference_facilitation_pilot.html

Medicare Appeals Settlement: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html