Knowledge Base Article

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on the Shared Decision-Making (SDM) requirement for Left Atrial Appendage Closure (LAAC) and Implantable Cardioverter Defibrillator procedures.

Did You Know?

The Agency for Healthcare Research and Quality (AHRQ) (link) defines Shared Decision-Making (SDM) as “a model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect their health,” and goes on to note that “the innovation of shared decision making is the use of evidence-based tools, known as patient decision aids, to inform patients and help them set their own goals and clarify their values.”

Why It Matters?

There are two National Coverage Determinations (NCDs) for a cardiac procedure in which an SDM encounter is listed as one of the nationally covered indications for coverage of the procedure.

• NCD 20.34: Left Atrial Appendage Closure (LAAC)
• NCD 20.4 Implantable Automatic Defibrillators

This matters because the Comprehensive Error Rate Testing (CERT) Contractor lists both procedures in Table D4 of the 2021 Comprehensive Error Rate Testing (CERT) supplemental improper payment data report. This table details the top 20 service types with the highest improper payments in the Part A hospital inpatient prospective payment system (IPPS) setting.

DRG pair 273 and 274 (Percutaneous Intracardiac Procedures) had the third highest projected improper payment at $160,504,177 and a 29.3% improper payment rate. LAAC procedures group to this DRG pair. Insufficient documentation accounted for 83% of the improper payment rate and 17% of the improper payment rate was attributed to medical necessity issues.

DRG pair 226 and 227 (Cardiac Defibrillator Implant without Cardiac Catheterization) had the fifth highest projected improper payment rate at $">link),790,870 and a 22.7% improper payment rate. Insufficient documentation accounted for 85.3% of the improper payment rate and 14.7% of the improper payment rate was attributed to medical necessity issues.

CMS recently provided the following guidance in the Thursday, December 1, 2022 edition of MLN Connects (link):

“Shared decision-making (SDM) is an important part of person-centered health care. You work with your patient to make decisions that meet their needs based on:

• Evidence-based information about available options
• Your knowledge and experience
• Patient's values and preferences

When you provide SDM for percutaneous left atrial appendage closure (LAAC) and implantable cardioverter defibrillators (ICDs):

• Document the SDM encounters correctly in medical records before you implant.
• Get preoperative documents from all providers before submitting medical records. While not mandatory, it speeds processing of your claims.

The Comprehensive Error Rate Testing (CERT) contractor reviews your claim documentation to determine if it meets SDM requirements. If it doesn’t, CMS will:

• Issue an error for overpaid claims for these procedure codes
• Recoup the overpayment”

What Can I Do?

If your hospital provides either of these services:

• Ensure documentation in your medical record meets the requirements detailed in the NCD. Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdiction J (Alabama, Georgia, and Tennessee) has published two resources to assist you:
• A Cardiac Procedure Checklist (link) for when a claim is selected for review by the CERT contractor, and
• A Left Atrial Appendage Closure education module (link). Palmetto notes, “This module provides an overview of what Palmetto GBA, and the Comprehensive Error Rate Contractor (CERT) requires in your documentation to support billing of these claims. Shared decision-making (SDM) encounters with the patient is a very intricate part of your documentation.”
• Share this information with your Physicians,
• Respond to Additional Documentation Requests (ADRs) in a timely manner, and
• Have a process in place to ensure that all documents needed to support the medical necessity of the services provided are included when responding to Additional Documentation Requests (ADRs) from Medicare Contractors (i.e., CERT, Recovery Auditor).