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Social Determinants of Health (SDOH) ICD-10-CM Z Codes
Published on Jan 19, 2022
20220119
 | Billing 
 | Coding 

“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”

Source: 18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.


Over the past thirteen years, part of my job has been to review medical records. When thinking about Social Determinants of Health (SDOHs), I distinctly remember one project where I reviewed three separate admissions for the same patient. Digging into the charts, I noted the patient’s discharge status was consistently to “tent city.” Unfortunately, tent cities are not a phenomenon limited to the Southeastern United States. Also unfortunately, this is a perfect example of a SDOH that can negatively impact an individual’s health outcomes.

Did You Know?

Social Determinants of Health (SDOHs) and Z Codes

Z codes first became available with the implementation of ICD-10-CM codes on October 1, 2015. Z code categories Z55 – Z65 are related to SDOHs. Eleven new codes became effective on October 1, 2021, bringing the list to a total of 109 codes.

New FY 2022 SDOH Z codes

  • Z55.5 – Less than a high school diploma,
  • Z58.6 – Inadequate drinking-water supply,
  • Z59.00 – Homelessness unspecified,
  • Z59.01 – Sheltered homelessness,
  • Z59.02 – Unsheltered homelessness,
  • Z59.41 – Food insecurity,
  • Z59.48 – Other specified lack of food,
  • Z59.811 – Housing instability, housed, with risk of homelessness,
  • Z59.812 – Housing instability, housed, homelessness in past 12 months,
  • Z59.819 – Housing instability, housed unspecified, and
  • Z59.89 – Other problems related to housing and economic circumstances.

In January 2020, the CMS published an initial Data Highlight focused on the utilization of Z codes among Medicare Fee-for-Service Beneficiaries in 2017 (link). The authors suggested that “reducing reliance on clinicians to capture SDOH, improving provider and medical coder education, and filling gaps in codes, among other policy-based interventions, would likely improve the reporting of SDOH coding across care settings.”

In September 2021, the CMS published a follow-up Data Highlight titled, Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries, 2019 (link).

September 2021 Data Highlight Key Findings

Barriers to increasing documentation of Z codes
  • Z code claims are not generally used for payment purposes,
  • There are a limited number of Z codes and sub-codes meaning some social, economic, and environmental determinants may not be captured,
  • While there are providers who may have had training regarding SDOH and recognize challenges some of their patient’s face, “they may feel limited in what they can do and/or may require guidance on how best to assist patients in addressing their non-medical needs.”
Data Highlight Authors Conclusions
  • “More widely adopted and consistent documentation of them is needed to comprehensively identify non-medical factors affecting health and to track progress toward addressing them; doing so could aid in work toward achieving health equity and ensuring highest quality and best-value care for all beneficiaries.”
  • “It will be critically important to carefully analyze data from 2020 and 2021 to understand whether and to what extent the public health emergency (PHE) may have had an impact on social, economic, and environmental determinants, and/or the rate of documentation of those determinants via Z codes.”
  • “All members of the US health system: payers, patient-centered medical homes, hospitals, national organizations, governments at the local, State, and Federal level, communities, providers, patients, as well as other stakeholders all have an important role to play in identifying social, economic, and environmental determinants, and ultimately improving health outcomes.”

RealTime Medicare Data CY 2020 Z Code Analytics

Analysis of CY 2020 Medicare Fee-for-Service paid claims data provided by our sister company, RealTime Medicare Data (RTMD), reinforced the current underuse of SDOH Z codes. For instance,

  • Less than 1% of claims include a SDOH Z code for the Inpatient Hospitals, Outpatient Hospital and Part B places of service,
  • Ninety-four percent of the claims were Hospital Outpatient claims, and
  • Z59.0 (Homelessness) was the top Z code used in all three places of service.

MMP has compiled a high-level summary of the data analysis that can be downloaded here (link).

Using Z codes to Advance Health Equity

The American Hospital Association has been advocating for utilization of SDOH Z codes and publishing education for Providers since 2015 and have recently updated their ICD-10-CM Coding for Social Determinants of Health Fact Sheet (link).

In the January 13, 2022 edition of MLN Connects (link), the CMS promotes awareness of January being National Poverty in America Awareness Month noting that “37.2 million Americans living in poverty have an increased risk of chronic conditions, lower life expectancy, and barriers to quality health care; and racial and ethnic minorities have poverty rates more than twice that of white Americans. The COVID-19 pandemic has significantly affected these populations and low-income families.”

CMS is also promoting the use of Z codes to help advance health equity for all Americans by identifying poverty, unemployment, homelessness, and other social determinants.

Moving Forward

Ensure that key stakeholders in your facility (i.e., Physicians, Nurses, Social Workers, Case Managers, CDI Specialists, Registered Dieticians) receive education about SDOH and coding ICD-10-CM Z codes. A good place to start is with the guidance found in the ICD-10-CM Official Guidelines for Coding and Report FY 2022 (link). Additional resources available for your education efforts includes:

  • CMS’ Using Z Codes infographic: (link)
  • Office of Disease Prevention and Health Promotion – SDOH webpage: (link)
  • CDC’s SDOH webpage: (link)
  • AHA’s SDOH webpage: (link)

    Beth Cobb

    National Thyroid Awareness Month
    Published on Jan 19, 2022
    20220119
     | Coding 
     | Billing 
    Did You Know?

    January is Thyroid Awareness Month.

    Why Should You Care?

    As a health care consumer, it is important to understand what the thyroid gland does, what thyroid hormone impacts and what can happen when your thyroid gland is not functioning properly. According to the CDC (link)

    • The thyroid gland, located in the front of the neck just below the Adam’s apple, takes iodine from your diet and makes thyroid hormone. Thyroid hormone affects your physical energy, temperature, weight, and mood.
    • In general, there are two broad groups of thyroid disorders: abnormal function and abnormal growth (nodules) in the gland.
    • Thyroid disorders are common, especially in older people and women. Most thyroid problems can be detected and treated.
    • Abnormal function is usually related to the gland producing too little thyroid hormone (hypothyroidism) or too much thyroid hormone (hyperthyroidism).
    • Benign nodules in the thyroid are common, usually do not cause serious health problems, can occasionally put pressure on the neck and cause trouble with swallowing, breathing, or speaking if too large.
    • Thyroid cancers are much less common than benign nodules and with treatment, the cure rate for thyroid cancer is more than 90 percent. You can learn more about Thyroid Cancer and the annual Medicare Treatment costs of Thyroid Cancer in a related RealTime Medicare Data (RTMD) infographic in this week’s newsletter.

    As a health care provider, it is important to be aware that MS-DRGs 625, 626, and 627 (Thyroid, Parathyroid & Thyroglossal Procedures with MCC, with CC, without CC/MCC respectively), have been under scrutiny by the Comprehensive Error Rate Testing (CERT) and Supplemental Medicare Review Contractor (SMRC).

    The 2018 CERT Medicare Fee-for-Service Improper Payment Rate Report noted an improper payment rate of 49.1% for this DRG group. Subsequently, in February 2020, CMS tasked Noridian, as the SMRC, to perform data analysis and DRG validation reviews of the same DRG group. Noridian published their review results in October 2021 (link) citing a 12% error rate.

    What Can You Do?

    As a healthcare consumer:

    • Have your doctor check for thyroid disease during a standard physical exam by palpation of the thyroid gland.
    • There are two standard blood tests that your doctor may recommend. One measures your thyroid hormone level (T4) and another measures thyrotropin (TSH) which is hormone secreted from the pituitary gland that controls how much thyroid hormone your thyroid makes.

    Treatment for thyroid disease will be specific to the type and severity of the thyroid disorder and the age and overall health of the patient.

    As a healthcare provider, one of the reasons cited by the SMRC for errors was providers not responding to requests for documentation within 45 calendar days of the additional documentation request (ADR). Noridian has a Documentation Requests webpage (link) which includes a link to an example ADR letter which provides guidance on how you can submit medical records.

    Beth Cobb

    New ICD-10-CM/PCS Codes in Response to COVID-19 Pandemic
    Published on Dec 08, 2021
    20211208
     | Billing 
     | Coding 

    In response to the ongoing COVID-10 public health emergency, CDC’s National Center for Health Statistics (NCHS) will be implementing new ICD-10 diagnosis and procedures codes. The three new ICD-10-CM diagnosis codes are for reporting an individual’s vaccination status.

    New Diagnosis Codes

    • Z28.310: Unvaccinated for COVID-19
    • Z28.311: Partially vaccinated for COVID-19
    • Z28.39: Other underimmunization status

    There are also seven new ICD-10-PCS procedure codes to describe the introduction or infusion or therapeutics, including vaccines for COVID-19 treatment. In the CMS announcement related to the procedure codes, providers are reminded that “for hospitalized patients, Medicare pays for the COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. As such, Medicare expects that the appropriate CPT codes will be used when a Medicare beneficiary is administered a vaccine while a hospital patient.”

    New Procedure Codes

    • XW013V7: Introduction of COVID-19 vaccine dose 3 into subcutaneous tissue, percutaneous approach, new technology group 7
    • XW013W7: Introduction of COVID-19 vaccine booster into subcutaneous tissue, percutaneous approach, new technology group 7
    • XW023V7: Introduction of COVID-19 Vaccine dose 3 into muscle, percutaneous approach, new technology group 7,
    • XW023W7: Introduction of COVID-19 Vaccine booster into muscle, percutaneous approach, new technology group 7,
    • XW0DXR7: Introduction of fostamatinib into mouth and pharynx, external approach, new technology group 7,
    • XW0G7R7: Introduction of fostamatinib into upper GI, via natural or artificial opening, new technology group 7, and
    • XW0H7R7: Introduction of fostamatinib into lower GI, via natural or artificial opening, new technology group 7.

    All ten new codes will become effective April 1, 2022.

    Resource: CMS’ MS-DRG Classifications and Software webpage (link), see ICD-10 MS-DRGs V39.1 Effective April 1, 2022 Zip file under “Latest News”

    Beth Cobb

    Cardiac Rehabilitation and Physician Supervision
    Published on Nov 17, 2021
    20211117
     | Coding 
     | Billing 
    Did You Know?

    In response to the COVID-19 Public Health Emergency, the CMS has published several Interim Final Rules with comment period (IFC). Included in the April 6, 2020 IFC, (https://www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-06990.pdf), with respect to pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, CMS adopted a change, “to specify that direct supervision for these services includes virtual presence through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider.”

    The CY 2021 OPPS Final Rule finalized maintaining this policy change being until the end of the PHE or December 31, 2021, whichever is later. The PHE was renewed on October 15, 2021, meaning this change will remain in place at least through January 13, 2022.

    CMS again references this policy change in the CY 2022 OPPS Final Rule (https://public-inspection.federalregister.gov/2021-24011.pdf), noting, “the required direct physician supervision can be provided through virtual presence using audio/video real-time communications technology (excluding audio-only) subject to the clinical judgment of the supervising practitioner.”

    Why This Matters?

    With the recent release of the CY 2022 OPPS/ASC final rule, MMP has had clients ask if CMS will make this option for audio/video real-time physician supervision for these rehabilitation services permanent. Specific to this question, I have listed a few comments by the CMS in the CY 2022 OPPS/ASC final rule:

    • Commentors are in favor of adoption of direct supervision via two-way, audio/video communication technology on a permanent basis, or if the decision is made to end this flexibility, they encourage CMS to maintain this policy for a period following the COIVD-19 PHE, such as the end of 2022.
    • Most commentors were in favor of developing a service-level modifier to allow CMS to track and collect data.
    • Based on public comments, and feedback since the policy was implemented, CMS is convinced “that we need more information on the issues involved with direct supervision through virtual presence before implementing this policy permanently.”

    Whether or not this policy becomes permanent, facilities providing cardiac rehabilitation services need to be aware of and compliant with coverage requirements for a couple of reasons. First, this continues to be an area of focus for Medicare review contractors. Second, given that according to the CDC ( https://www.cdc.gov/heartdisease/facts.htm), heart disease costs the United States about $363 billion each year from 2016 to 2017, cardiac rehabilitation is big business. You can read more about how cardiac rehabilitation can help heal your heart on the CDC website (https://www.cdc.gov/heartdisease/cardiac_rehabilitation.htm).

    So, just how big of a business is cardiac rehabilitation? To answer this question, I turned to RealTime Medicare Data (RTMD). Specifically, volume and paid claims data below represent Medicare Fee-for-Service outpatient hospital claims in the entire RTMD footprint for calendar years 2019 and 2020 for cardiac rehabilitation CPT codes 93798 (outpatient cardiac rehab with continuous ECG monitoring) and 93979 (outpatient cardiac rehab without continuous ECG monitoring).

    CY 2019 Procedure Volume % Of Procedure Volume Sum of Paid Claims
    CPT 93798 3,718,721 94.00% $307,007,481.00
    CPT 93797 239,673 6.00% $19,584,844.68
    Combined 3,958,394 100.00% $326,592,325.68

    CY 2019 Top 5 States by Procedure Volume

    • Florida (292,461)
    • Texas (287,575)
    • California (229,235)
    • Illinois (186,899), and
    • Pennsylvania (164,897)
    CY 2020 Procedure Volume % Of Procedure Volume Sum of Paid Claims
    CPT 93798 2,290,837 94.00% $178,236,580.99
    CPT 93797 150,097 6.00% $11,486,994.57
    Combined 2,440,934 100.00% $189,723,575.56

    CY 2020 Top 5 States by Procedure Volume

    • Florida (182,865),
    • Texas (180,179),
    • California (131,190),
    • Illinois (120,897), and
    • Pennsylvania (105,882)

    Even though the COVID-19 PHE had an impact on procedure volume and sum of paid claims, collectively across the country, Medicare payment for cardiac rehabilitation is big business.

    What Can You Do?
    • Be aware of documentation needed to support medical necessity of the services provided,
    • Submit medical record requests to the Medicare Contractor in a timely manner, and
    • Read a related article in this week’s newsletter to learn who is currently targeting Cardiac Rehabilitation and what coverage documents and education resources are available by CMS and Medicare Contractors.

    Beth Cobb

    CY 2022 OPPS and ASC Final Rule - Inpatient Only List & Medical Review of Certain Hospital Claims
    Published on Nov 10, 2021
    20211110
     | Coding 
     | Billing 

    The CMS released the Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule on November 2, 2021. This article focuses on changes to the Inpatient Only (IPO) List and medical review of claims. Click here for an article reviewing changes to the ASC covered procedure list and hospital price transparency civil monetary penalties.

    CMS reminds providers that “The removal of a service from the IPO list does not require the service to be performed only on an outpatient basis…we reiterate that services that are removed from the IPO list can be and are performed on individuals who are admitted as inpatients (as well as individuals who are registered hospital outpatients) when the patient’s condition warrants inpatient admission (65 FR 18456). It is a misinterpretation of CMS payment policy for providers to create policies or guidelines that establish the hospital outpatient setting as the baseline or default site of service for a procedure based on its removal from the IPO list. As stated in previous rulemaking, services that are no longer included on the IPO list are payable in either the inpatient or hospital outpatient setting subject to the general coverage rules requiring that any procedure be reasonable and necessary, and payment should be made pursuant to the otherwise applicable payment policies (84 FR 61354; 82 FR 59384; 81 FR 79697).”

    Criteria used prior to CY 2021 to assess for removal of a procedure from the Inpatient Only (IPO) list:

    • Most outpatient departments are equipped to provide the services to the Medicare population.
    • The simplest procedure described by the code may be furnished in most outpatient departments.
    • The procedure is related to codes that we have already removed from the IPO list.
    • A determination is made that the procedure is being furnished in numerous hospitals on an outpatient basis.
    • A determination is made that the procedure can be appropriately and safely furnished in an ASC and is on the list of approved ASC services or has been proposed by us for addition to the ASC list.

    In CY 2021, CMS removed 298 musculoskeletal-related services from the IPO List and finalized the elimination of the list over three years. For CY 2022, CMS has done a one-eighty and finalized the following changes:

    • The IPO list is not being eliminated,
    • A reference of phasing out the IPO list through a 3-year transition has been removed,
    • The five longstanding criteria for determining whether a service or procedure should be removed from the IPO list is being codified in regulation text, and
    • Most of the procedures removed from the IPO list in CY 2021 are being added back to the list.

    Commenters believed a few codes should not be added back to the IPO list and CMS agreed. CPT codes not being added back to the IPO list includes:

    • CPT 22630: Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar,
    • CPT 23472: Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (for example, total shoulder),
    • CPT 27702: Arthroplasty, ankle; with implant (total ankle) and corresponding anesthesia codes:
      • CPT 01638: Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement, and
      • CPT 01486: Anesthesia for open procedures on bones of lower leg, ankle, and foot; total ankle replacement

    AccuCinch Device: New Inpatient Only Procedure

    For the July 2021 update, the AMA’s CPT Editorial Panel established CPT code 0643T (Transcatheter left ventricular restoration device implantation including right and left heart catheterization and left ventriculography when performed, arterial approach) to describe the AccuCinch device implantation procedure.

    CMS proposed to assign this code to status indicator (SI) “E1” (Items, codes, and services not covered by any Medicare outpatient benefit category; statutorily excluded; not reasonable and necessary) to indicate the service is not covered by Medicare.

    A commenter requested the code be reassigned the inpatient-only SI “C,” believing “this is the more appropriate assignment for the ventricular restoration therapy based on the complex patient population enrolled in the US clinical trial. The commenter explained that the investigational device, the AccuCinch® Ventricular Restoration System, is currently under evaluation in the CORCINCH-HF pivotal trial (NCT04331769).”

    CMS noting that “Based on the interventional structural heart (SH) technique involved in the procedure, use of an experimental device, and close monitoring of the patient that is required during the intra- and post-op period consistent with the resources available in the hospital inpatient setting, we believe the AccuCinch procedure should be designated as an inpatient-only procedure. We note that the CORCINCH-HF pivotal trial (NCT04331769) was approved by Medicare and meet’s CMS’ standards for coverage as an Investigation Device Exemption (IDE) study effective November 11, 2020.”

    CMS finalized change the SI “E1” to “C” for CPT code 0643T.

    Information about this procedure is available on the Ancora Heart, Inc. website at https://www.ancoraheart.com/ and information about the clinical trial at https://clinicaltrials.gov/ct2/show/NCT04331769.

    Table 48 of the Final Rule lists changes made to the IPO list for CY 2022. Addendum E to this Final Rule includes all inpatient only procedure codes for CY 2022.

    Medical Review of Certain Inpatient Hospital Admissions

    For CY 2021, CMS finalized “that procedures removed from the IPO list after January 1, 2021, were indefinitely exempted from site-of-service claims denials under Medicare Part A, eligibility for BFCC-QIO referrals to RACs for noncompliance with the 2-Midnight rule, and RAC reviews for “patient status” (that is, site-of-service).” This exemption was to remain in place until Medicare claims data showed a procedure was performed more than 50 percent of the time in the outpatient setting.

    For CY 2022, CMS finalized the proposal to “rescind the indefinite exemption and instead apply a 2-year exemption from two midnight medical review activities for services removed from the IPO list on or after January 1, 2021.”

    As a provider, keep in mind this exemption is specific to site-of-service claim denials and does not include exemption from medical necessity reviews of services based on a National or Local Coverage Determinations (NCDs and LCDs) when applicable. Once a surgical procedure has been removed from the IPO List, documentation in the record must support the need for the inpatient admission.

    Resources

    CY 2022 OPPS Final Rule

    Beth Cobb

    CY 2022 OPPS and ASC Final Rule - ASC Covered Procedure List and Hospital Price Transparency Civil Monetary Penalties
    Published on Nov 10, 2021
    20211110
     | Coding 
     | Billing 

    The CMS released the Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule on November 2, 2021. In a related Fact Sheet (link), they note that this Final Rule “includes policies that align with several key goals of the Administration, including addressing the health equity gap, fighting the COVID-19 Public Health Emergency (PHE), encouraging transparency in the health system, and promoting safe, effective, and patient-centered care.”

    CMS estimates “that the OPPS expenditures, including beneficiary cost-sharing, for CY 2022 would be approximately $82.1 billion, which is approximately $5.9 billion higher than estimated OPPS expenditures in CY 2021.”

    Changes to the Ambulatory Surgical Center (ASC) Covered Procedure List (CPL)

    In the CY 2022 OPPS Proposed Rule, CMS also did an about face for the ASC CPL. Of the 267 procedures added to the list in CY 2021, CMS proposed to remove 258 procedures as they do not believe they meet the proposed revisions to the CY 2022 ASC CPL criteria.

    CMS noted in the Proposed Rule, “Based on our internal review of preliminary claims submitted to Medicare, we do not believe that ASCs have been furnishing the majority of the 267 procedures finalized in 2021. Because of this, we believe it is unlikely that ASCs have made practice changes in reliance on the policy we adopted in CY 2021. Therefore, we do not anticipate that ASCs would be significantly affected by the removal of these 258 procedures from the ASC CPL.”

    After reviewing recommendations made by commentors, CMS finalized the removal of 255 of the 258 codes proposed from the ASC CPL. Table 62 in the Final Rule includes the complete list of 255 procedures.

    Revisions to the CY 2022 ASC CPL Criteria

    In CY 2021, CMS revised their policy for adding surgical procedures to the ASC CPL. For CY 2022, they have finalized their proposal to revise the requirements for covered surgical procedures to reinstate the general standards and exclusion criteria established prior to CY 2021.

    Inpatient, outpatient or ASC, documentation is crucial to accurately reflect the complexity of the patient, support the medical necessity for services provided and support the setting in which services are performed.

    Hospital Price Transparency Increase in Civil Monetary Penalties

    CMS noted in the Proposed Rule from initial months of experience with enforcing the hospital price transparency requirements that they expressed “concern by what appears to be a trend towards a high rate of hospital noncompliance identified by CMS through sampling and reviews to date.” One approach to address this trend was their proposal to impose potentially higher penalties and “to scale the CMP to ensure the penalty amount would be more relevant to the characteristics of the noncompliant hospital.”

    CMS agrees with commenters in the Final Rule “that application of a scaling approach using bed count would be an effective way to ensure compliance, consistency and fairness in application of penalties across noncompliant hospitals” and finalized their proposal as follows:

    • Hospitals with a bed count ≤ 30 will have a minimum Civil Monetary Penalty (CMP) of $300 per day or $109,500 for a full CY of noncompliance,
    • Hospitals with at least thirty-one beds up to and including 550 beds will have a penalty of $10 per bed per day or a range from $113,150 to $2,007,500 penalty for a full CY of noncompliance depending on bed size, and
    • Hospitals with greater than 550 beds will have a daily dollar penalty of $5,500 or $2,007,500 for a full CY of noncompliance.

    Learn about changes to the Inpatient Only (IPO) by clicking here.

    Resource

    CY 2022 OPPS Final Rule CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-oppsasc-final-rule-increases-price-transparency-patient-safety-and-access-quality-care

    Beth Cobb

    Medicare Targeted Probe & Educate, Short Stay & Higher Weighted DRG Reviews to Resume
    Published on Aug 25, 2021
    20210825

    CMS Resumes Targeted Probe & Educate Program

    In response to the COVID-19 Public Health Emergency (PHE), CMS suspended medical review activities on March 30, 2020. In August 2020, Recovery Auditors, Comprehensive Error Rate Testing Program, and Medicare Administrative Contractor post-payment reviews were resumed. At that time, the Targeted Probe and Educate (TPE) program remained on hold.

    On May 8, 2019, CMS put a temporary hold on SSRs and HWDRG reviews as they planned to procure a new contractor to review both types of reviews on a national basis. The expectation was to award the contract by the 3rd quarter of calendar year 2019.

    According to a CMS TPE Q&A document (link), when performing medical review as a part of this program, Medicare Administrative Contractors (MACs):

    • Focus on specific providers/suppliers who, through data analysis, have been identified as varying significantly from their peers,
    • Typically review 20-40 claims per provider/supplier, per item or service (round),
    • Provide individualized education based on review results after a round, and
    • Perform up to three rounds of reviews per item or service.

    The CMS announced in the Thursday August 12, 2021, edition of MLN Connects (link) that the TPE Program is restarting “to help educate providers and reduce future denials and appeals.”

    Livanta to Begin Short Stay Reviews and Higher Weighted DRG Reviews

    Kepro and Livanta are the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) that serve all regions across the nation. The BFCC-QIO scope of work, among other things includes performing certain types of medical record reviews. Two specific reviews are Short Stay Reviews (SSRs) and Higher Weight Diagnosis-Related Group (HWDRG) review.

    It wasn’t until April of 2021, that Livanta announced they had been awarded this contract. On August 11, 2021, Livanta released a Provider Bulletin (link) to announce the official start of claims reviews. The bulletin includes information on the following topics:

    • What Hospitals Can Expect,
    • Hospital Inpatient Claim Review Types,
    • HWDRG Review Process,
    • SSR Process, and
    • Questions and Education.

    The review process for each type of medical review includes the timing of when they will begin requesting records. For HWDRG reviews, they expected to send the first medical record request the week of August 16th. For SSRs, Livanta anticipated sending the first individual medical record requests on or about the week of September 20, 2021. Note, record requests will be sent to your Medical Record point of contact via fax when possible or U.S. mail if fax is not possible. A hospital sample will consist of 30 claims reviewed within a rolling 3-month period and records must be submitted electronically.

    I encourage you to visit Livanta’s webpage (link), read the Provider Bulletin and share this information with appropriate staff at your facility.

    Beth Cobb

    IPPS FY 2022 Final Rule: New Technology Add-On Payments (NTAPs)
    Published on Aug 11, 2021
    20210811
    “The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”
    - Source: Appendix A: Economic Analysis of FY 2022 IPPS Final Rule

    CMS released the display copy of the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS) Final Rule (CMS-1752-F) on Monday August 2, 2021. This article focuses on New Technology Add-On Payments (NTAP) for FY 2022.

    New Technology Add-On Payment Pathways

    There are now several pathways for a new services or technology to be approved for New Technology Add-On Payments (NTAPs) including:

    • Traditional Pathway: To meet this pathway, the medical service or technology must be new, must be costly such that the DRG rate otherwise applicable to discharges involving the NTAP is inadequate, and must demonstrate a substantial clinical improvement over existing services or technologies.
    • Certain Antimicrobial Products Alternative Pathway: In FY 2021 the alternative pathway for Qualified Infectious Disease Products (QIDPs) was expanded to include products approved under the Limited Population for Antibacterial and Antifungal Drugs (LPAD) pathway. In the Final Rule, CMS finalized policy to refer more broadly to “certain antimicrobial products” rather than specifying FDA programs for antimicrobials (i.e., QIDPs and LPADs). Products approved through this pathway will be considered new and not substantially similar to an existing technology and will not need to demonstrate that it meets the substantial clinical improvement criterion. However, the technology will need to meet the cost criterion.
    • Certain Transformative New Devices Alternative Pathway: Beginning in FY 2021, “if a medical device is part of FDA’s Breakthrough Devices Program and received FDA marketing authorization, it will be considered new and not substantially similar to an existing technology for purposes of the new technology add-on payment under the IPPS.” However, the new device must meet the cost criterion and must receive marketing authorization for the indication covered by the Breakthrough Device Program designation.

    For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS will review the application based on the information provided under by the applicant under the alternative pathway specified by the applicant. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”

    Additional Payment for NTAP’s

    Payment for an NTAP is based on the cost to hospitals for the new medical service or technology. As set forth in § 412.88(b)(2), unless the discharge qualifies for an outlier payment, the additional Medicare payment will be limited to the following:

    • For “Traditional Pathway” and “Certain Transformative New Devices”, Medicare will make an add-on payment equal to the lesser of: (1) 65 percent of the costs of the new medical service or technology; or (2) 65 percent of the amount by which the costs of the case exceed the standard DRG payment.
    • For Certain Antimicrobial NTAPs (QIDPs and LPADs), Medicare will make an add-on payment equal to the lesser of: (1) 75 percent of the costs of the new medical service or technology; or (2) 75 percent of the amount by which the costs of the case exceed the standard DRG payment.

    Coding NTAPs

    Section X is the New Technology section that was added to ICD-10-PCS effective October 1, 2015. CMS has indicated that Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures. The public had opposed many requests to add new codes to the existing ICD-10-PCS sections for the use of specific drugs, devices, or supplies in an inpatient setting, even when the code related to an application for New Technology add-on payments.

    NTAPs for FY 2022 by the Numbers

    NTAPs are not budget neutral and generally this add-on payment is limited to the 2-to-3-year period after the date a technology becomes available. Due to the COVID-19 Public Health Emergency (PHE) impacting hospital volumes, CMS finalized using FY 2019 data for rate setting. They also finalized a one-year extension of NTAPs for technologies that would have otherwise been discontinued beginning October 1, 2021.

    CMS estimates the payment amounts for new technology add-on payments in the Final Rule based on the applicant’s estimates. This amount and the estimated number of patients is highlighted in Appendix A of the Final Rule. Appendix A begins on page 2,174 of the display version of the Final Rule.

    • A total of 42 services or technologies have been approved for NTAPs,
    • The estimated total amount to be paid to hospitals is $1,424,341,317.63, and
    • The estimated number of patients is 468,206.
    • The estimated number one NTAP by volume and payment is Veklury® (remdesivir) with an estimated 174,996 cases and estimated total payment of $354,891,888.00. This drug is used in the treatment of COVID-19 patients.

    NTAPs FY Trend: Number of Services or Technologies Approved for NTAP

    • FY 2020: 18
    • FY 2021: 24
    • FY 2022: 40

    NTAPs FY Trend: Estimated Number of Patients to Receive a New Technology during an Inpatient Stay

    • FY 2020: 71,659
    • FY 2021: 259,201
    • FY 2022: 468,206

    New COVID-19 Treatment Add-on Payments (NCTAPs)

    As new therapies were approved in response to the COVID-19 PHE, New COVID-19 Treatments Add-on Payment (NCTAP) were created. CMS finalized the following related to NCTAPs in the FY 2022 IPPS Final Rule:

    • The NCTAP for eligible COVID-19 products will extend through the end of the fiscal year in which the PHE ends, and
    • A hospital will be eligible to receive the NCTAP and the traditional NTAP for qualifying patient stays, through the end of the fiscal year in which the PHE ends, with the NTAP reducing the amount of the NCTAP.

    You can learn more about NCTAP’s on the related CMS COVID-19 NCTAP specific webpage (link).

    Moving Forward

    Identifying and coding new technologies is an opportunity not to be missed for those hospitals providing these services. That said, some questions come to mind for you to think about:

    • Is your hospital providing any of these medical services or technology?
    • Who needs to be aware of what the new technologies are? (i.e. Physicians, Pharmacy, Coding Professionals, Clinical Documentation Integrity Specialists, Case Managers)
    • What process do you have in place to alert your Coding Staff of the need to code the new technologies?

    Resources:

    CMS August 2, 2021, Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2022-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-0

    FY 2022 IPPS CMS webpage: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page

    Beth Cobb

    FAQ: Ambulatory Surgery Center (ASC) Covered Procedure List
    Published on Aug 04, 2021
    20210804
     | Billing 
     | Coding 
    Question

    In last week’s article about the OPPS and ASC Proposed Rule you indicated that CMS has proposed to remove 258 procedures that were added to the ASC covered procedure list in CY 2021. What procedures are remaining on the ASC list?

    Answer

    In the CY 2021 Final Rule, the finalized additions to the ASC Covered Procedure List were separated into two tables:

    • Table 59 listed procedures added under the standard review process, and
    • Table 60 listed procedures added under the second alternative proposal considered for CY 2021.

    The procedures proposed for removal from the ASC list for CY 2022 are from Table 60. The procedures listed in Table 59 were not proposed for removal from the ASC list and includes the following CPT/HCPCS codes:

    • 0266T: Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed),
    • 0268T: Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed),
    • 0404T: Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency,
    • 21365: Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches,
    • 27130: Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft,
    • 27412: Autologous chondrocyte implantation, knee,
    • 57282: Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus),
    • 57283: Colpopexy, vaginal; intra-peritoneal approach (uteroscacral, levator myorrhaphy),
    • 57425: Laparoscopy, surgical, colpopexy (suspension of vaginal apex),
    • C9764: Revascularization, endovascular, open or percutaneous, and vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed, and
    • C9766: Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed.

    Resources:

    Beth Cobb

    Four FY 2022 CMS Final Rules Christmas in July
    Published on Aug 04, 2021
    20210804
     | Coding 
     | Billing 

    In general, my day-to-day focus as it relates to Medicare Fee-for-Service guidance, is the acute hospital inpatient and outpatient setting. Last week, CMS issued Christmas in July gifts, in the form of 4 final FY 2022 payment rules. While not my day-to-day focus, highlights, and links to information about the final rules are important enough to share with you, our readers, who may be impacted.

    FY 2022 Skilled Nursing Facility (SNF) Prospective Payment System (CMS-1746-F)

    Major provisions in this final rule are highlighted in a related CMS Fact Sheet (link) and includes:

    • FY 2022 Updates to the SNF Payment Rates,
    • Methodology for Recalibrating the Patient Driven Patient Model (PDPM) Parity Adjustment,
    • Rebase and Revise the SNF Market Basket by using the 2018-based SNF market basket to update the PPS payment rates, instead of the 2014-based SNF market basket,
    • Section 134 of the Consolidated Appropriations Act, 2021 – New Blood Clotting Factor Exclusion from SNF Consolidated Billing,
    • Changes in the PDPM ICD-10 Code Mappings,
    • SNF Quality Reporting Program (SNF QRP) update, and
    • SNF Value-Based Purchasing (SNF VBP) Program.

    FY 2022 Hospice Payment Rate Update Final Rule (CMS-1745-F)

    Major provisions highlighted in a related CMS Fact Sheet (link) includes:

    • FY 2022 Routine Annual Rate Setting Changes,
    • Other Medicare Hospice Payment Policies,
    • Changes to the Hospice Conditions of Participation (CoPs) in response to the COVID-19 Public Health Emergency (PHE),
    • Hospice Quality Reporting Program, and
    • Home Health Quality Reporting Program.

    FY 2022 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Final Rule (CMS-1748-F)

    Major provisions in this final rule in a related CMS Fact Sheet (link) includes:

    • Updates to IRF Payment Rates,
    • IRF Quality Reporting Program (IRF QRP) Updates, and
    • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Policy Issues.

    FY 2022 Inpatient Psychiatric Facility (IPF) Prospective Payment System Final Rule (CMS-1750-F)

    Major provisions highlighted in a related CMS Fact Sheet (link) includes:

    • FY 2022 Updates to the IPF Payment Rates,
    • Updates to the IPF Teaching Policy, and
    • IPF Quality Reporting Program (IPF QRP) Updates.

    Beth Cobb

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