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Medical Review Updates from SMRC, RAC, and MACs

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Tuesday, March 19, 2019

My co-worker and I, as part of our duties at MMP, monitor Medicare’s medical review activities. We are often amused that the same old issues seem to come around again and again and again. I guess there are certain Medicare services that are harder to perform, document, code, and/or bill appropriately. And despite the repeated reviews and ongoing education, providers still struggle to get it right. Therefore, Medicare contractors often review the same issues again and again and again. This month is no different; this article contains some new “old” updates of medical review activity.

Dental Services

The new Supplemental Medical Review Contractor (SMRC), Noridian Healthcare Solutions, added several new current projects this month, but the one affecting acute-care hospitals is the medical review of hospital outpatient dental services. As is often the case with SMRC reviews, this one is based on the findings of an Office of Inspector General (OIG) audit. As a reminder, Medicare generally does not cover dental services such as tooth extraction except in very limited circumstances.

From the OIG report, “Under the general exclusion provisions of the Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures) are not covered (§ 1862(a)(12)). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

For hospital outpatient dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare. For example, Medicare covers extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw, but a tooth extraction performed because of tooth decay is not covered.”

The OIG found that 542 of 600 dental services (90.3%) did not comply with Medicare’s requirements resulting in overpayments for the six Medicare contractors reviewed of $9,783,023 for a three-year time frame. No wonder this topic keeps being reviewed.

Cardiac and Pulmonary Rehabilitation

The Recovery Auditors (RACs) recently announced newly approved reviews of cardiac and pulmonary rehabilitation services.

Cardiac and pulmonary rehab are Medicare-covered physician-supervised programs that provide exercise, education, and assessments for specific cardiac and pulmonary conditions to improve patients’ physical and social function. Medicare has specific guidelines for the covered conditions eligible for each program, the required components that must be included in each program, and other requirements such as physician supervision and program duration. The Medicare requirements for cardiac and pulmonary rehab can be found in Chapter 15 of the Medicare Benefit Policy Manual, sections 232 and 231 respectively. The required components for both services include:

  • Physician-prescribed exercise
  • Education or training (in the form of cardiac risk factor modification for cardiac rehab)
  • Psychosocial assessment
  • Outcomes assessment
  • Individualized treatment plan

For the RAC reviews, “Medical Documentation will be reviewed to determine if pulmonary or cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.” Some recommendations on how your documentation could meet the Medicare requirements are discussed in this prior Wednesday@One article about Cardiac Rehab, but also can apply to Pulmonary Rehab documentation.

At the time of the writing of this article, all RAC regions had posted an approved audit issue for cardiac rehab and all but one RAC (Performant Region 1) had posted an approved audit issue for pulmonary rehab.

Facility ED Levels of Care

WPS, the Medicare contractor for Jurisdictions 5 and 8, had previously posted a Targeted Probe and Educate (TPE) review of CPT Codes 99281-99285 Emergency Department Visits. That topic temporarily disappeared from the listing of TPE topics for both J5 and J8 but now it is back. There have not been many, if any, other reviews of facility ED levels by Medicare reviewers, although some commercial insurers have attempted to curb high-level ER payments through review. This is a tricky subject because there are no national guidelines for assigning facility levels of care for Emergency Department services. Each hospital is instructed to develop their own level definitions based on the following guidance from the 2008 OPPS Final Rule.

  • The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate to the intensity of hospital resources to the different levels of effort represented by the code.
  • The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
  • The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
  • The coding guidelines should meet the HIPAA requirements.
  • The coding guidelines should only require documentation that is clinically necessary for patient care.
  • The coding guidelines should not facilitate up-coding or gaming.
  • The coding guidelines should be written or recorded, well-documented and provided the basis for selection of a specific code.
  • The coding guidelines should be applied consistently across patients in the Clinic or emergency department to which they apply.
  • The coding guidelines should not change with great frequency. CMS would not generally expect hospitals to adjust guidelines less frequently than every few months, but would be reasonable to adjust annually.
  • The coding guidelines should be readily available for fiscal intermediary or MAC review.
  • The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

WPS’s checklist for the audit recommends submitting documentation of:

  • The number and type of interventions under the facility charge,
  • The visit record showing the signs/symptoms that support the medical necessity for the interventions, and
  • The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines).

If a hospital’s codes meet their own definitions, who is to say if that is right or wrong. It does make me cringe to see a Facility ED Level graph that is significantly skewed one way or the other. Medicare has been clear that an individual hospital does not have to have a perfect bell curve, but hospitals should still consider a reasonable distribution of levels for their patient population.

It is likely this topic will not go away. As reported by various healthcare newsletter, MedPAC (the Medicare Payment Advisory Commission) addressed the topic of national guidelines for coding hospital emergency department visits in a recent meeting. This call for guidelines appears to be in response to a commission report showing hospitals are reporting increased volumes of the higher ED levels.  If the recommendation passes in the April MedPAC meeting, it would likely require CMS to revisit national guidelines by 2022 which would result in CMS having a foundation for assessing and auditing coding behavior.

DRG Validation Reviews

One other interesting item to note is an announcement by HMS, the RAC for Region 4, clarifying that MS-DRG reviews are comprehensive coding reviews and are not limited to only code changes that impact the DRG code billed and paid. You can find the March 8, 2019 provider update here.

The good news about reviewing the same topics is that, as a provider, it gives you specific risk areas on which to concentrate. You may find your internal audits, like those of outside contractors, reviewing the same issues again and again and again.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

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.