Knowledge Base Category -
MEDICARE TRANSMITTALS
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update
The April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment.
E/M Service Documentation Provided By Students (Manual Update)
Allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
New ADR limits for the Recovery Audit Program.
Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
Updates to diagnosis codes required in order to allow add-on payments under the Inpatient Prospective Payment System (IPPS) for blood clotting factor administered to hemophilia inpatients.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Changes in the April 2018 quarterly update to the Clinical Laboratory Fee Schedule (CLFS).
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services – REVISED
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits – REVISED
Revised to add HCPCS code G0475 as a code that is subject to CLIA edits effective, April 13, 2015.
Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System
Enables MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system.
Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of the International Classification of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
MEDICARE COVERAGE UPDATES
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
Effective May 25, 2017, new NCD to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).
Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Changes to the ICD NCD from the 2005 reconsideration.
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs
https://www.gpo.gov/fdsys/pkg/FR-2018-01-31/pdf/C1-2017-27949.pdf
Targeted Probe and Educate (TPE) Website Update
New resources available on the TPE website.
MEDICARE EDUCATIONAL RESOURCES
Transition to New Medicare Numbers and Cards FACTSHEET
DECISION
CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). CMS finalized what they describe as “minimal changes” to the ICD NCD from the 2005 reconsideration. After you have finished reading this article I will leave it to you to decide if you agree with their definition of “minimal changes.”
DECISION SUMMARY OF THE CHANGES
Patient Criteria
- Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
- Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
- Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
- Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
- Note: This includes all patient’s receiving an ICD for primary prevention.
Additional Patient Criteria
- Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)
Exceptions to Waiting Periods
- Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
- Add an exception for patients with an existing ICD and qualifying replacement
- End the data collection requirement
Evidence
When developing a National Coverage Determination (NCD), CMS in general “evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a findings that an item or service falling within a benefit category is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
The evidence review primarily focused “on randomized controlled trials that assess the clinical utility of defibrillators compared to optimal medical therapy, and relevant formal Technology Assessments and professional society guidelines. While reading through this part of the Decision Memo, some of the conclusions were reminiscent of statements made when Jack Handy shared “Deep Thoughts” on Saturday Night Live in the 1990’s. The following table highlights four of the studies.
PUBLIC COMMENTS
A significant portion of this Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses related to the “minimal changes” being made.
ANALYSIS
Patient Shared Decision Making
In addition to the example SDM tool for ICDs, CMS notes that a website was also developed “which leads patients step-by[step through some information on ICDs designed to increase patients’ knowledge of their medical condition, the risks and benefits of available treatments and to empower patients to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.
CONSIDERATIONS MOVING FORWARD
Shared Decision Making
There are now 6 covered indications listed in the NCD. All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.”
Questions to Consider:
- Who will be the healthcare provider to provide the SDM encounter?
- What tool will you utilize?
- When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
- Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?
Optimal Medical Therapy
Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement.
Questions to Consider:
- Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
- Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?
MMP strongly encourages key stakeholders take the time to read the entire Decision Memo.
Beth Cobb
It is that time of year when the winter season tries its best to hang on while spring makes faltering attempts to assert itself. The intermittent but increasing days of warmer weather are accompanied by spring rains, spring fever, spring breaks, and oh don’t forget taxes. If you have family or friends in the accounting business, you experience first hand that it is also the “busy season” for tax accountants. Income taxes are one of the prime examples of the government taking away. In the recent Bipartisan Budget Act (BBA) of 2018, an example of our government giving and taking relates to rehabilitative therapy services and the infamous therapy cap.
Since the Balanced Budget Act of 1997, there has been an annual limitation on the amount Medicare will pay for rehabilitative therapy services for a beneficiary. This is known as the therapy caps. There has been one therapy cap for outpatient occupational therapy (OT) services and another separate therapy cap for physical therapy (PT) and speech-language pathology (SLP) services combined. Finally, however, the therapy cap is gone. The BBA signed into law on February 9, 2018 repealed the therapy cap effective for claims on and after January 1, 2018.
There are a few catches to the repeal. Providers must continue to report the KX modifier for therapy services that exceed the dollar amount previously known as the therapy cap. That amount remains $2,010 for 2018 – one $2,010 limit for physical therapy and speech-language services combined and another $2,010 limit for occupational therapy. The KX modifier is attestation the services above this dollar amount are reasonable and necessary and that there is documentation of medical necessity for the services in the patient’s medical record. Since there is not technically a therapy cap, it is not yet known if therapy services exceeding the dollar amount reported without a KX modifier will be denied. Such details should be forthcoming from CMS in sub-regulatory guidance. All types of therapy providers, including those in a hospital outpatient setting, are affected by the new rules.
There will also continue to be targeted medical reviews of therapy services that exceed a threshold amount. The BBA lowered that threshold amount for 2018 through 2028 from $3,700 to $3,000 – again, one threshold for PT/Speech combined and a separate threshold for OT. Not all therapy services exceeding the new, lower threshold will be reviewed. Targeted reviews for therapy exceeding the threshold will be selected based on such factors as therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers. The Supplemental Medical Review Contractor (SMRC) currently performs these types of reviews for CMS.
The bad news (i.e. the taking away) for therapy providers from the Bipartisan Budget Act relates to payment rates for services provided by therapy assistants. The BBA mandates that for PT and OT services furnished on and after January 1, 2022, the payment rate will be 85% of the usual payment when the services are provided in whole or in part by a therapy assistant. A modifier will be created to be reported when therapy services are provided by a therapy assistant to trigger the reduced payment rate.
This requirement for reduced payment for therapy assistant services offsets the excitement of the therapy cap repeal. At least there are a few years prior to any reduction in payment for assistant services. A lot can happen between now and then – maybe even another incident of the “government giveth.” We can always hope.
Debbie Rubio
“If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.”
-George Bernard Shaw
Probe & Educate Target: Emergency Room Services
This past November, the Medicare Administrative Contractor (MAC) WPS announced that they would begin reviewing facilities billing emergency room services (CPT codes 99281-99285) as part of the Targeted Probe and Educate (TPE) review process.
The TPE process includes MACs utilizing data analysis to identify:
- Providers and suppliers who have high claim error rates or unusual billing practices, and
- Items or services that have high national error rates and are a financial risk to Medicare.
WPS provides the following guidance in the announcement for a successful review of emergency department visits for facility services (Type A Emergency Rooms):
- The number and type of interventions under the facility charge,
- The visit record showing the signs/symptoms that support 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.
WPS is currently the MAC for Jurisdiction 5 (IA, KS, MO, and NE Providers) and Jurisdiction 8 (IN, MI Providers). For those of you in a different MAC Jurisdiction, take note now as in general when one MAC targets a specific service it is not long before other MACs follow suit.
Are you an Outlier?
The question is, how do your E.R. levels codes compare to other facilities? Now, the Program for Evaluating Payment Patterns Electronic Report for short-term acute care hospitals (ST PEPPER) can assist you in analyzing your volume of emergency room services claims and comparing your data to your state, MAC jurisdiction and at the national level.
As of the 4th Quarter of the 2017 CMS IPPS Fiscal Year (July – September 2017), Emergency Department Evaluation and Management Visits (ED E&M) is a new PEPPER Target Area.
Target areas are approved by CMS because they have been identified as prone to improper payments. The Twenty-fourth Edition of the ST PEPPER User’s Guide notes that “concerns with overuse/misuse of higher level E&M codes have been prevalent for several years. The Office of Inspector General identified increasing trends of E&M coding for higher-level services (https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf ) as well as improper payments associated with E&M coding errors (https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf).”
PEPPER Recommendations for Outliers?
High Outliers could represent coding and billing errors related to over-coding of CPT code 99285. Appendix 5 of the User’s Guide notes attributes CPT 99285 as when “usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.” The ST PEPPER recommends reviewing a sample of claims coded to 99285 to validate the code is supported by documentation in the medical record.
Low Outliers could represent coding errors related to under-coding 99285. The ST PEPPER recommends reviewing a sample of claims coded to 99281, 99282, 99283 or 99284 should be reviewed to validate the code level is supported by documentation in the medical record.
Related article about the ST PEPPER: http://www.mmplusinc.com/news-articles/item/pepper-resources-guide-updates.
To learn more about the TPE Review Process visit the CMS TPE webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html
Beth Cobb
Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health! According to the American Heart Association website, cardiac rehab is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.
However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services. One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.
Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier. Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.” Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.
Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials). Diagnoses supporting coverage of cardiac rehabilitation services are:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant; or
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.
Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy. These include:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.
Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.
Debbie Rubio
“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,
Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.
Patients over Paperwork
On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”
CMS is keeping stakeholders informed through Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.
December 2017 Newsletter
In this inaugural edition, CMS noted that they have the following three aims for this initiative:
- Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
- Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
- Increase the proportion of tasks that CMS customers can do in a completely digital way.
CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.
January 2018 Newsletter
The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:
- Quality Measures,
- Quality Payment Program (QPP) (5522-FC),
- Appropriate Use Criteria for Advanced Diagnostic Imaging,
- Documentation Review,
- Quality and Safety Oversight,
- Promote Affordability for Consumers,
- States,
Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.
Clarified Signature Requirements
“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.
After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.
To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”
Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims
“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.
We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.
To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”
E/M Service Documentation Provided by Students (Manual Update)
Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)
While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.
Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.
Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.
Beth Cobb
“Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without applying this essential step.”
- Seema Verma, the Administrator of the Centers for Medicare and Medicaid Services speaking at the Health Care Payment Learning and Action Network Fall Summit, October 30, 2017
The American Hospital Association (AHA) published the report Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers to determine the impact of regulatory burden” on hospitals, health systems and post-acute care (PAC) facilities. The purpose of the report is twofold. First, inform policymakers, lawmakers and the public about the administrative impact federal regulatory requirements have on the ability to furnish high-quality patient care. Secondarily, this report seeks to offer a starting point for discussions on implementing meaningful regulatory reform.
The AHA approached this endeavor with a thorough review of the Federal Register and the U.S. Code of Federal Regulations for regulations impacting hospitals and PACs across the following nine domains:
- Quality Reporting,
- New Models of Care/Value-Based Payment (VBP) Models,
- Meaningful Use (MU) of Electronic Health Records (EHRs),
- Hospital Conditions of Participation (CoPs),
- Program Integrity,
- Fraud and Abuse,
- Privacy and Security,
- Post-Acute Care, and
- Billing and Coverage Verification Requirements.
The four agencies described by the AHA as being “the primary drivers of federal regulations impacting these providers” are the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG), the Office of Civil Rights (OCR) and the Office of the National Coordinator for Health Information Technology (ONC).
Report Findings by the Numbers
- 629 – The number of mandatory regulatory requirements in effect as of March 2017.
- 341 – The number of hospital related requirements.
- 288 – The number of PAC related requirements.
- $38.6 Billion – The national cost of administrative activities related to regulatory compliance across the 9 domains.
- 59 – The number of FTEs an average-sized hospital (161 beds) dedicates to regulatory compliance. PAC regulations require an additional 8.1 FTEs.
- 4.6 – The number of FTEs an average-sized hospital devotes to quality reporting requirements.
- $706,000 – The annual amount spent by an average-sized hospitals on administrative aspects of quality reporting.
- $760,000 – The annual amount spent by an average-sized hospital to meet Meaningful Use (MU) administrative requirements.
- 63% - The report found that over 63% of compliance costs are dedicated to compliance with documenting CoP adherence and billing and coverage verification processes.
AHA Recommends Immediate Actions
The report lists twelve immediate activities that should be taken by Congress and the Administration to “reduce regulatory burden and enhance care coordination, without negatively impacting patient care.”
Among the recommendations, two specific recommendations would definitely relieve regulatory burden for Hospital Case Managers.
- Modify Medicare CoP to allow hospitals to recommend post-acute care providers, and
- Remove the mandatory free-text field from the Medicare Outpatient Observation Notice (MOON) and eliminate the confusing Second Important Message from Medicare.
In keeping with the purpose to inform policymakers and lawmakers, all of the recommendations were provided by AHA in letters to President Trump, CMS and Congress.
The report ends by noting that regulations are needed to support the safe delivery of care. “However, the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
At MMP, we understand the regulatory burden our clients are faced with daily. This is why we publish our weekly e-newsletter and why our mission is Making Health Care Make Sense.
Beth Cobb
According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.
Expressed positively, a proper payment has four main attributes: right recipient, right amount, right reason, and right time. A violation of any one of any attributes may result as an “improper payment” if an agency cannot document those conditions. Furthermore, not all “improper payments” are the result of fraudulent actions or represent monetary loss to the government.”
The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2017 CERT Report.
CERT Program & Review Process
The CERT Program was implemented by CMS to measure improper payments in the Medicare Fee-for-Service (FFS) Program. For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs).
Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. This process includes the following steps:
- Claim selection,
- Medical Record Requests,
- Review of claims by medical review professionals to determine whether a claim was paid properly under Medicare coverage, coding and billing rules,
- Assignment of Improper Payment Categories (no documentation, insufficient documentation, medical necessity, incorrect coding and other), and
- Calculation of the Improper Payment Rate.
CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”
CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”
In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.
2017 CERT Report by the Numbers:
Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices. CMS published the 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report on January 8, 2018. This report includes a review of claims submitted from July 1, 2015 through June 30, 2016.
Overall Claims Volume
- 21,120 - The number of claims sampled.
- 14,500 - The number of claims reviewed.
Accuracy & Improper Payment Rates
- 5% - The Percent Accuracy Rate representing $344.68 billion in claims.
- 5% - The Improper Payment Rate representing $36.2 billion in claims.
Common Causes of Improper Payments
- 1% - Insufficient Documentation
- 5% - Medical Necessity
- 1% - Incorrect Coding
- 7% - No Documentation
- 6% - Other
“0 or 1 Day” LOS Claims Continued Outlier
The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.
“0 or 1 Day” Audit Focus
The FY 2016 Office of Inspector (OIG) Work Plan included the issue of Hospital’s use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020). In December 2016, the OIG released the report, Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy. This study was based on hospital claims and did not include a medical review. More specifically, the OIG considered inpatient claims lasting 2 midnights or longer as being “appropriate” and claims lasting less than 2 midnights to be “potentially inappropriate.”
One recommendation made to CMS by the OIG was to “conduct routine analysis of hospital billing and target for review the hospitals with high or increasing numbers of short inpatient stays that are potentially inappropriate under the 2-midnight policy.” CMS agreed and noted that its Quality Improvement Organizations are currently conducting short stay patient status reviews for the appropriateness of Part A payment.
Short Stays for Chest Pain: New LCD for Jurisdiction J
The OIG report identified chest pain as one of the most common reasons for a short inpatient stay to be “potentially inappropriate.”
Hopefully, you are aware that the MAC for Jurisdiction J Part A transitioned from Cahaba GBA to Palmetto GBA this past Monday January 29th. What you may not know is that Palmetto GBA has a One Day Stays for Chest Pain Local Coverage Determination (LCD L34551) that became active the same day. This guidance will be used by the BFCC-QIO (KEPRO) for Alabama, Georgia and Tennessee when reviewing short stay claims for chest pain.
Compliance with Short Stays
Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?
PEPPER
One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.
The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:
“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”
RealTime Medicare Data
Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.
To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.
Beth Cobb
Medicare Transmittals
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018
Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf
Medicare Special Edition Articles
Proper Use of Modifier 59 – REVISED
Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.
Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures
Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.
Medicare Coverage Updates
Proposed Decision Memo for Magnetic Resonance Imaging (MRI)
Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.
Rules and Regulations
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction
This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’
https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf
State Survey Memorandums
Texting of Patient Information among Healthcare Providers
Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Medicare Press Releases
New Payment Model
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).
Medicare Educational Resources
Medicare Quarterly Provider Compliance Newsletter – January 2018
Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners
Major Joint Replacement (Hip or Knee) MLN Booklet
Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
Over the past few months, several retail stores in my geographic area have closed. I really hate that as it leaves the people who worked there without jobs and the stores are no longer available for browsing. However, I must admit, I am one of the reasons retail stores are closing. I did all of my Christmas shopping last year on line. It is so quick and convenient and then the packages are delivered to your door. I like my delivered packages though I regret the unintended consequence of putting retail stores out of business. Medicare is also a big proponent of packages, although most of theirs is with intent. But with repetitive billing, there may unintended consequences of per claim packaging.
A recent Wednesday@One newsletter discussed how “CMS has taken numerous actions to move the OPPS more toward an actual prospective payment system as the name indicates. To this end, ‘the OPPS packages payments for multiple interrelated items and services into a single payment to create incentives for hospitals to furnish services most efficiently and to manage their resources with maximum flexibility.’ Specifically, over the past few years CMS has created and expanded comprehensive APCs which bundle payment for all adjunctive services into the payment for the primary service, packaged add-on codes, and conditionally packaged payment of ancillary services with a geometric mean cost of $100 or less.”
Another change over the past few years related to packaging of payments is the transition from packaging per date of service, to packaging per claim. Comprehensive APCs, which began in 2015, package payment for all adjunctive services on the claim (with only limited exceptions) into the payment of one primary procedure. Primary procedures are identified with a status indicator of “J1.” In 2016, CMS created a new status indicator of “Q4” for laboratory services to be conditionally packaged if reported on the same claim as other services. The conditional packaging of services with an SI of “Q1” and “Q2” remained per date of service for 2016, but transitioned to per claim packaging for CY 2017.
Providers need to understand the impact this “per claim” payment packaging may have on repetitive billing. When a repetitive claim spans multiple dates of service, the packaging rules apply to the entire claim. Medicare requires repetitive billing for some hospital services such as rehabilitative therapy and cardiac or pulmonary rehabilitation among others (see the Medicare Claims Processing Manual, Chapter 1, section 50.2.2). For other recurring services not defined as repetitive by Medicare, such as chemotherapy or radiation therapy, the hospital can choose to submit a separate claim for each date of service, or report charges for these recurring services on a single span bill.
Providers need to evaluate the packaging repercussions when submitting span bills. For example, a client reported recently submitting a span bill for radiation and chemotherapy services. The claim included charges for CPT 77371 (sterotactic radiosurgery - SRS) and chemotherapy charges for the drug Herceptin. CPT 77371 has a status indicator of “J1” (comprehensive APC), so only one total payment for the whole claim was made for the SRS. There was no separate payment for the high-cost drug Herceptin even though the infusion was on a different date of service from the SRS. Payment packaging for comprehensive APCs is on a per claim basis. This resulted in a significant loss of reimbursement for the hospital. There could also be an impact on reimbursement if SRS services provided on different days are billed together on one span claim.
Another example is the application of negative-pressure wound treatment (NPWT or wound vac) billed with other wound care services on a span bill. CPT codes 97605 and 97606 have status indicators of “Q1.” This means Medicare will pay separately for wound vac applications if they are the only service provided and billed on a claim. Wound vac applications submitted on a span bill with outpatient services with status indicators of “S,” “T,” “V,” or more than one “Q1” will package with the other services on the claim even when the wound vac was the only service provided on some days.
In both of these examples (SRS and wound vac applications performed by nurses or practitioners in a wound clinic), it would be more appropriate to submit one claim for each date of service to prevent inappropriate bundling. NPWT services performed by a physical or occupational therapist are required to be billed on a repetitive bill.
To avoid unintended consequences with recurring claims and per claim packaging, hospitals should consider carefully what combination of services performed on different days of service are included on a recurring span bill. Were the services actually adjunctive to the primary service on the claim or not? It is easy to see in these examples that Herceptin infusion is not adjunctive to the SRS procedure, or the wound vacs are not adjunctive to wound debridement unless performed on the same day or during a continuous encounter.
Debbie Rubio
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