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FY 2023 IPPS Final Rule: Finding the Codes
Published on Aug 10, 2022
20220810
 | Coding 
 | Billing 

When first employed at MMP, there were two big challenges for me, identifying what I did not know but needed to know and knowing where to find the information. To that end, following are key resources you will need to prepare for the start of the new CMS Fiscal Year 2023 on October 1, 2022.

FY 2023 IPPS Final Rule Home Page

(link)

On this webpage you will find a links to:

  • The FY 2023 IPPS Final Rule,
  • FY 2023 Final Rule Tables
    • Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
    • Table 6: New Diagnosis Codes,
    • Table 6B: New Procedure Codes
    • Table 6I: Complete MCC List,
    • Table 6I.1: Additions to the MCC List,
    • Table 6I.2: Deletions to the MCC List,
    • Table 6J: Complete CC list,
    • Table 6J.1: Additions to the CC list,
    • Table 6J.2: Deletions to the CC list
  • FY 2023 MAC Implementation Files
    • MAC Implementation File 7: FY 2023 MS-DRGs Subject to the Replaced Devices Policy,
    • MAC Implementation File 8: FY 2023 New Technology Add-on Payment

2023 ICD-10-CM Files

(link)

Downloads available on this webpage includes:

  • 2023 POA Exempt Codes,
  • 2023 Conversion Table,
  • 2023 Code Description in Tabular Order,
  • 2023 Addendum,
  • 2023 Code Tables, Tabular and Index, and
  • FY 2023 ICD-10-CM Coding Guidelines.

The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (link).

2023 ICD-10-PCS Files

(link)

Downloads available on this webpage includes:

  • 2023 ICD-10-PCS Order File,
  • 2023 Official ICD-10-PCS Coding Guidelines,
  • 2023 Version Update Summary,
  • 2023 ICD-10-PCS Codes File,
  • 2023 ICD-10-PCS Conversion table, 2023 ICD-10-PCS Code Tables and Index, and
  • 2023 ICD-10-PCS Addendum.

MS-DRG Definitions Manual and Software

The ICD-10 MS-DRG Version 40 (V40) Grouper Software, ICD-10 MS-DRG Definitions Manual, and the Definitions of Medicare Code Edits V 40 files are publicly available on the CMS MS-DRG Classifications and Software webpage (link).

In addition to finding the codes, here are additional resources highlighting key facts from the FY 2023 Final Rule.

MLN Connects

CMS Newsroom

Beth Cobb

New COVID-19 Vaccine: Novavax COVID-19, Adjuvanted Vaccine Vaccine Differs from mRNA COVID-19 Vaccines
Published on Aug 10, 2022
20220810
 | COVID-19 
 | Coding 
 | Billing 

Did You Know?

Novavax COVID-19 Vaccine, Adjuvanted (NVX-CoV2373) is a new COVID-19 vaccination that the FDA has approved for Emergency Use Authorization (PHE) for individuals 18 years or older (link).

Why is Matters?

This is the first protein-based COVID-19 vaccine to receive Emergency Use Authorization and CDC endorsement (link) in the United States. This vaccine is to be administered as a series of two doses given three weeks apart. It is not authorized for use as a booster dose.

According to an HHS Press Release (link), “The Novavax COVID-19 vaccine is designed and manufactured differently than the mRNA COVID-19 vaccines. The Novavax COVID-19 vaccine contains SARS-CoV-2 recombinant spike protein, which is also known as an “antigen” of the SARS-CoV-2 virus, in combination with an adjuvant, which enhances the immune system response to the spike protein.

FDA-approved protein-based vaccines have been used widely for decades; examples of more recently approved vaccines that contain a purified protein combined with an adjuvant include vaccines to prevent hepatitis B and shingles. The Novavax COVID-19 vaccine offers an option to individuals who may be allergic to a component in the mRNA vaccines, or who have a personal preference for receiving a vaccine other than an mRNA-based vaccine.”

What Can You Do?

As a health care professional review the CDC’s overview and safety information about this vaccine (link), and become familiar with how to code and bill for this newly vaccine.

Coding and Billing

CMS issued new codes for this vaccine, effective July 13.

  • Vaccine code: 91304,
  • Administration codes: 0041A and 0042A,

Beth Cobb

CY 2023 OPPS and ASC Proposed Rule
Published on Jul 27, 2022
20220727
 | Coding 
 | Billing 

CMS recently released the Calendar Year (CY) Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. In last week’s newsletter (link) we reviewed proposed changes to the Inpatient Only (IPO) List. This week’s focus is on the Ambulatory Surgery Center Covered Procedure List (CPL) and the Hospital Outpatient Prior Authorization Program proposals.

Ambulatory Surgery Center (ASC) Covered Procedure List (CPL)

The CMS evaluates the ASC CPL yearly to determine whether to add or remove specific procedures from the list. Covered surgical procedures performed on or after January 1, 2022, are:

  • Procedures specified by the Secretary and published in the Federal Register,
  • Separately paid under the OPPS,
  • Would not be expected to post a significant safety risk to a Medicare beneficiary when performed in an ASC, and
  • Standard medical practice dictates the expectation that the beneficiary would not typically require active medical monitoring and care at midnight following the procedure.

For CY 2023, CMS proposed to add one procedure to the ASC CPL:

  • CPT 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)).

RTMD Data Analysis

I turned to our sister company, RealTime Medicare Data (RTMD) to help estimate the potential impact to hospital outpatients if this procedure can also occur in an ASC setting. The claims data represents Medicare Fee-for-Service paid claims in calendar year 2021 for CPT 38531 for all states in the RTMD footprint. Currently, this includes all states except Kentucky and Ohio.

  • Overall Claims Volume: 4,606
  • CPT Payment: $13,088,298.18
  • Top 5 States
    • California had 411 claims with a payment of $1,468,801.23,
    • Florida had 338 claims with a payment of $939,648.34,
    • Texas had 253 claims with a payment of $705,682.74,
    • Pennsylvania had 245 claims with a payment of $721,419.95, and
    • New York has 229 claims with a payment of $651,816.93.

      CMS ends this section of the proposed rule by noting they “believe that any additions to the CPL should be added in a carefully calibrated fashion to ensure that the procedure is safe to be performed in the ASC setting for a typical Medicare beneficiary. We expect to continue to gradually expand the ASC CPL, as medical practice and technology continue to evolve and advance in future years. We encourage stakeholders to submit procedure recommendations to be added to the ASC CPL, particularly if there is evidence that these procedures meet our criteria and can be safely performed on the typical Medicare beneficiary in the ASC setting.”

      Hospital Outpatient Prior Authorization Program

      The Prior Authorization for Certain Hospital Outpatient Department (OPD) Services initiative became effective on July 1,2020 and made a prior authorization request (PAR) a condition of payment for specific service categories. Service categories effective July 1, 2020, included:

      • Blepharoplasty,
      • Botulinum toxin injections,
      • Panniculectomy,
      • Rhinoplasty, and
      • Vein ablation.

      Effective July 1, 2021, CMS added cervical fusion with disc removal and implanted neurostimulators as new service categories.

      You can learn more about this initiative on the CMS Hospital OPD Services initiative webpage (link).

      CMS has proposed to add Facet Joint Interventions as a new service category and would include facet joint injections, medial branch blocks and facet joint nerve destruction CPT codes. This list of applicable CPT codes is in Table 79 of the proposed rule. If finalized, this would be effective for dates of services on or after March 1, 2023.

      CMS Data Analysis

      CMS performed data analysis of CPT codes 64490-64495 (Facet Injections and Medical Branch Blocks) and CPT Codes 64633-64636 (Nerve destruction services). Analysis revealed facet joint intervention claims volume increased by 47 percent between 2012 and 2021. This reflected a 4 percent average annual increase which is higher than the 0.6 percent annual increase for all outpatient department services.

      Contractor Scrutiny

      As part of the discussion for adding facet joint interventions to this initiative, CMS includes discussion of prior audits performed by the OIG and Department of Justice.

      • OIG Report Medicare Improperly Paid Physicians for More Than Five Spinal Facet-Joint Injections Sessions During a Rolling 12-Month Period (A-09-20-03003) published October 2020 (link): The OIG found that MACs in the 11 jurisdictions with a coverage limitations made improper payments of $748,555.
      • OIG Report Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions (A-09-21-03002) published December 2021 (link): The OIG found that Medicare improperly paid physicians $9.5 million.

      In addition to past reports, there are two active OIG Work Plan items related to facet joint procedures.

      • In the Department of Justice case reference in the proposed rule, the DOJ reported on a $250 million health care fraud scheme where “to obtain prescriptions, the evidence showed that the patients had to submit to expensive, unnecessary and sometimes painful back injections, known as facet joint injections.”

      CMS notes, “both our data analysis and research show that the increases in volume for these procedures are unnecessary, and further program integrity action is warranted.”

      RTMD Data Analysis

      I once again turned to RTMD to help estimate the potential impact of adding Facet Joint Interventions to the prior authorization initiative. Keep in mind that data volume includes all procedures and there may be claims that could include multiple facet procedures in the same encounter.

      Facet Injections and Medical Branch Blocks (CPT 64490-64495)

      • Overall Claims Volume: 391,410
      • CPT Payment: $141,144,372.81
      • Top 5 States
        • Texas had 40,472 claims with a payment of $13,102,475.35
        • California had 24,109 claims with a payment of $11,433,125.41,
        • Massachusetts had 23,738 claims with a payment of $9,892,874.58,
        • New York had 18,901 claims with a payment of $6,922,608.02, and
        • Pennsylvania had 18,624 claims with a payment of $6,764,696.64.

      Facet Joint Nerve Destruction (CPT codes 64633-64636)

      • Overall Claims Volume: 185,564
      • Sum CPT Paid: $124,386,756.18
      • Top 5 States
        • Texas had 19,051 claims with a payment of $12,335,211.47,
        • California had 11,620 claims with a payment of $10,144,086.72,
        • Florida had 8,641 claims with a payment of $4,970,708.01,
        • Illinois had 8,023 claims with a payment of $4,782,664.98, and
        • Pennsylvania had 7,711 claims with a payment of $5,205,371.13.

Beth Cobb

CY 2023 OPPS and ASC Proposed Rule
Published on Jul 20, 2022
20220720
 | Coding 
 | Billing 

True to form, the CMS announced the release of the Calendar Year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule late last Friday July 16th. This week we review the proposed changes to the Inpatient Only (IPO) list.

CMS once again reminds providers in this proposed rule that “Designation of a service as inpatient only does not preclude the service from being furnished in a hospital outpatient setting but means that Medicare will not make payment for the service if it is furnished to a Medicare beneficiary in the hospital outpatient setting (65 FR 18443). Conversely, the absence of a procedure from the list should not be interpreted as identifying that procedure as appropriately performed only in the hospital outpatient setting (70 FR 68696).”

Before reviewing proposals, here is a quick look back at the “flip flopping” of CMS over the past two calendar years. In CY 2021, CMS removed 298 musculoskeletal-related services from the IPO List and finalized the elimination of the list over three years. In CY 2022, CMS did an about face and finalized the following changes:

  • The IPO list will not be eliminated over three years,
  • Most procedures removed from the IPO list in CY 2021 were added back to the list for CY 2022, and
  • The five longstanding criteria for determining whether a service or procedure should be removed from the IPO list was codified in regulation text.

Calendar Year 2023 Proposed Procedures for Removal from the IPO List

CMS is proposing to remove ten procedures from the IPO list.

CPT code 16036 (Escharotomy; each additional incision (list separately in addition to code for primary procedure)). This code is an add-on code typically billed with primary procedure CPT 10635 (escharotomy; initial incision) which was removed from the IPO list in CY 2007.

CPT code 22632 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (list separately in addition to code for primary procedure)). This code is an add-on code typically billed with primary procedure CPT 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar), which was removed from the IPO list in CY 2021. Note, this code was removed from the IPO list in CY 2021 and replaced back on the list for CY 2022.

The remaining eight procedures proposed for removal from the IPO list are all maxillofacial procedures removed from the IPO list in CY 2021 and replaced back on the list for CY 2022:

  • CPT code 21141 (Reconstruction midface, lefort I; single piece, segment movement in any direction (e.g., for long face syndrome), without bone graft).
  • CPT code 21142 (Reconstruction midface, lefort I; 2 pieces, segment movement in any direction, without bone graft).
  • CPT code 21143 (Reconstruction midface, lefort I; 3 or more pieces, segment movement in any direction, without bone graft).
  • CPT code 21194 (Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)).
  • CPT code 21196 (Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation).
  • CPT code 21347 (Open treatment of nasomaxillary complex fracture (lefort II type); requiring multiple open approaches).
  • CPT code 21366 (Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft)); and
  • CPT code 21422 (Open treatment of palatal or maxillary fracture (lefort I type);).

Calendar Year 2023 Proposed Additions to the IPO List

CMS has proposed the addition of eight newly created codes by the AMA CPT Editorial Panel to the IPO list for CY 2023:

  • 157X1 (Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (i.e., external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma,
  • 228XX (Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure),
  • 49X06 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, incarcerated or strangulated),
  • 49X10 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated),
  • 49X11 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible,
  • 49X12 (Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), recurrent, including placement of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, Incarcerated or strangulated,
  • 49X13, (Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including placement of mesh or other prosthesis, when performed; reducible), and
  • 49X14 (Repair of parastomal hernia, any approach (i.e., open, laparoscopic, robotic), initial or recurrent, including placement of mesh or other prosthesis, when performed; incarcerated or strangulated).

All proposed changes to the IPO list, including the CPT code, longer descriptor, proposed action (deletion or addition), proposed status indicator and for proposed deletions the proposed APC assignment are listed in Table 46 of the proposed rule.

CMS is accepting comments on the proposed rule through September 13, 2022.

Resources

CY 2023 OPPS Proposed Rule

Beth Cobb

Using the Correct Discharge Status Code
Published on Mar 23, 2022
20220323
Did You Know?

It has been over eight years since new discharge status codes (81 through 95) were finalized in the 2014 IPPS Final Rule (link).

The new codes were added to the GROUPER logic for MS-DRGs 280, 281, and 282 to identify those patients diagnosed with an acute myocardial infarction (AMI) who were discharged/transferred to another facility with a planned acute care hospital inpatient readmission alive. Following are pertinent comments from the 2014 final rule regarding these codes:

“The new discharge status codes related to a planned acute care hospital inpatient readmission were developed and approved by the National Uniform Billing Committee (NUBC) in response to a request by the provider community. The purpose of the new codes is to allow providers to track these types of situations when they occur. According to meeting notes from the NUBC, there is not a designated timeframe (or limitation) in reporting these new codes.”

“The planned readmission discharge status codes can also be reported for other MS-DRGs.”

“These new discharge status codes are not related in any way to the Hospital Readmission Reduction Program and will not be taken into account in the readmission measures for that program.”

You will find the discussion about the new codes on pages 50533 and 50534 of the 2014 IPPS Final Rule.

With these codes having been in place since October 1, 2013, I wanted to know if hospitals are using them? To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Here is what the data revealed:

  • In FY 2021, in the RTMD database, there were 7,898,214 Medicare Fee-for-Service acute inpatient hospital paid claims.
  • Of those claims, 12,146 included one of the discharge status codes that includes a planned readmission.
  • The top five discharge status codes with a planned readmission by volume were:
    • 2,307 claims included discharge status code 81 (Discharged to home or self-care with a planned acute care hospital inpatient readmission),
    • 2,185 claims included discharge status code 83 (Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission,
    • 1,873 claims included discharge status code 90 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission,
    • 1,602 claims included discharge status code 86 (Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission), and
    • 1,437 claims included discharge status code 82 (Discharged/transferred to a short-term general hospital with a planned acute care hospital inpatient readmission.
    • Top five states using discharge status codes with a planned readmission:
      • Florida – 1,281 claims
      • Texas – 1,140 claims
      • Pennsylvania – 918 claims
      • New York - 884 claims
      • California – 760 claims
    • Bottom five states using discharge status codes with a planned readmission:
      • Arkansas – 13 claims
      • Ohio – 7 claims
      • Vermont – 5 claims
      • Hawaii – 3 claims
      • Hawaii – 3 claims
Why It Matters?

Assigning the correct discharge status code is important and can be costly if not correct.

The Comprehensive Error Rate Testing (CERT) A/B Medicare Administrative Contractor (MAC) Outreach & Education Task Force has published an education resource titled Patient Discharge Status Codes Matter (link). In this document, the CERT contractor notes they have issued errors related to the incorrect use of Discharge Status Codes that may result in an overpayment or underpayment of Medicare claims.

Incorrect discharge status codes can also cause an admitting facility to not be able to be paid due to the incorrect billing of the acute inpatient hospital.

What Can You Do?

A patient’s discharge disposition can change after the patient has already discharged from your hospital. The CERT contractor encourages hospitals “to follow-up with the patient after discharge and prior to submitting the claim to Medicare to ensure the patient went to the planned facility that was recorded in the medical record. This will prevent incorrect billing of the Discharge Status Code and avoid unnecessary adjustments to claims when the incorrect code is used.”

I encourage you to read the CERT Task Force document as well as the listed resources on this document to help prevent improper payments due to incorrect billing of discharge status codes.

Additional Resource:

MLN SE21001 Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services & Other Information on Patient Discharge Status Codes (link)

Beth Cobb

Happy Social Work Month 2022
Published on Mar 23, 2022
20220323

March is National Professional Social Work Month. This year’s the National Association of Social Workers (NASW) is celebrating with the theme “The time is right for social work.” The NASW notes that “The time is always right for social work. However more people are entering the field because the life-affirming services that social workers provide are needed more than ever. This is especially true as our nation continues to grapple with the COVID-19 pandemic, systemic racism, economic inequality, global warming, and other crises.”

A few of the resources available on NASW’s website for your 2022 Social Work Campaign (link) include:

  • A Social Work Month 2022 video.
  • A quiz to assess how much you know about social work; and
  • A document highlighting the theme and rationale for this year’s Social Work Month.

I want to acknowledge and thank all the wonderful social workers that I have worked with or who have been an invaluable resource in my own life when family members have been hospitalized.

The transition of care from a hospital to a post-acute setting can be a very stressful time. As MMP has done in years past, we are providing an updated list of resources to assist with discharge planning.

Resources for You:

  • Medicare Costs at Glance for 2022 (link)
  • MLN Booklet: Medicare and Medicaid Basics (link)
  • MLN Educational Tool: Medicare Payment Systems (link)
  • CMS National Training Program Module: 2021/2022 Getting Started with Medicare (link)

Resources for your patients

  • Taking Care of Myself: A Guide for When I Leave the Hospital (link)
  • Discharge Planning Protects You (link)
  • Your Discharge Planning Checklist: For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting (link)
  • Your Guide to Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (link)
  • Your Medicare Benefits (link)
  • Medicare Hospice Benefits (link)
  • Medicare Appeals (link)

From all of us at MMP, Happy Social Work Month!

Beth Cobb

2021 CERT Annual Report
Published on Feb 02, 2022
20220202
 | Billing 
 | Coding 

Fiscal Year 2021 Estimated Improper Payment Rates

In mid-November 2021, the Comprehensive Error Rate Testing (CERT) program published the Fiscal Year (FY) 2021 Annual CERT Report. A related Press Release, (link) noted that “CMS’ aggressive corrective actions led to an estimated $20.72 billion in reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.”

While CMS cites an impressive reduction in improper payments over seven years, there was only a slight change from 2020 to 2021.

  • Improper Payment Rate
    • o FY 2020: 6.27%
    • o FY 2021: 6.26%
  • Improper Payment Amount
    • o FY 2020: $25.74 billion
    • o FY 2021: $25.03 billion

As I have noted in past articles, CMS noted in the Press Release that “while fraud and abuse may lead to improper payments, it is important to note that the vast majority of improper payments do not constitute fraud, and improper payment estimates are not fraud rate estimates.”

Fiscal Year 2021 Supplemental Improper Payment Data

The 2021 Supplemental Improper Payment Data Report (link) was published on December 12, 2021. This report highlights common causes of improper payments and includes tables allowing you to drill down into the review findings.

COVID-19 Impact
  • From March 27, 2020, until August 10, 2020, CERT program activities were suspended,
  • CMS reduced the claim sample size for FY 2021 (claims submitted July 1, 2019, through June 30, 2020), and
  • Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities.
“0 or 1 day” Length of Stay Claims

Since implementation of the Two-Midnight Rule, the supplemental data report has included a table comparing improper payments rates for Part A hospital claims by length of stay (LOS). The improper payment rate for “0 or 1 Day” stay claims was highest in 2014 at 37.18% and in 2021 hit an all-time low of 16.8%. However, with the project improper payment rate being $1.5 billion, it is not surprising that Two-Midnight Stays are currently on the OIG Work Plan (link) and Livanta as the National Medicare Claim Review Contractor (link), is focusing their review efforts solely on Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews.

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories:

  • No documentation,
  • Insufficient documentation,
  • Medical Necessity,
  • Incorrect Coding, and
  • Other.

Overall, 58.9% of the errors in this table were due to the error category medical necessity. The CERT places a claim into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. One hundred percent of the errors for the following four DRG Types was attributed to medical necessity:

  • DRG 069: Transient Ischemia,
  • DRGs 308, 309, 310: Cardiac Arrhythmia & Conduction Disorders,
  • DRG 312: Syncope, and
  • DRG 313: Chest Pain.

Moving Forward

For the Septicemia DRGs 871 and 872, 37.2% of the errors was attributed to “no documentation.” Unfortunately, denied claims due to no documentation is also a frequent issue reported by the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor (SMRC).

Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:

  • Visit the CERT Provider Website (link) to find information about the CERT, how to submit records, sample request letters and much more.
  • Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of specific services. For example, DRGs 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity) had the highest projected improper payment in Table D4 at $724,055,597. The CERT attributed 19.5% of the error to insufficient documentation and 80.3% to medical necessity. CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (link) that provides guidance on what to document to avoid denied claims.
  • Become familiar with and utilize your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER).
  • And finally, take the time to review the CERT’s Supplemental Improper Payment Data report annually.

Beth Cobb

CERT Program: What is it?
Published on Feb 02, 2022
20220202
 | Billing 
 | Coding 

A related article in this week’s newsletter (link), provides detail from the 2021 Comprehensive Error Rate Testing (CERT) program annual report and annual supplement data to the report. This article provides key facts about the CERT.

About the CERT

  • The objective of the CERT program is to monitor and report the accuracy of claims payment in the Medicare Fee-for-Service program.
  • CMS uses the CERT error rate to evaluate the performance of the Medicare Administrative Contractors (MACs).
  • There are two CERT contractors:
    • The CERT Review Contractor (CERT RC), and
    • CERT Statistical Contractor (CERT SC).
  • The CERT claim selection includes a stratified random sample of approximately 50,000 claims that are chosen by claim type (Part A, Part B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and includes paid and denied claims by the MAC.
  • The CERT process is a federally mandated program and not responding to documentation requests will result in a denial of all services billed on the claim.
  • CERT request letters are mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS).
  • You can submit requested documentation to the CERT via postal mail, fax, Electronic Submissions of Medical Documentation (esMD), via CD or via email attachment(s).
  • For short (less than 24 – 48 hours stay) inpatient hospital stay, a discharge summary is not required when a beneficiary is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
  • The billing provider is responsible for obtaining medical records from the third-party to substantiate the claim that was billed.
  • The CERT makes every effort to obtain the request documentation. Providers have 45 days to respond to the first letter requesting documentation. When the CERT does not receive the requested documentation by the 75th day, a claim is counted as a non-response error and is subject to overpayment recovery by the MAC.
  • Claims reviews by the CERT includes program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and provision in the CMS instructional manuals.
  • Denied claims as well as overpayments and underpayments are all considered to be an improper payment by the CERT program.
  • Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
  • The improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements.
  • Providers that wish to appeal a CERT contractor’s determination can follow the normal redetermination process to appeal all CERT denials.
  • The CERT A/B MAC Outreach & Education Task Force has a goal to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force webpage (link) includes education resources for providers.

Resources:

  • CERT C3Hub: https://c3hub.certrc.cms.gov/
  • CMS.gov CERT webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT
  • Beth Cobb

    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

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