Knowledge Base Category -

Compliance Education

March 9, 2023: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier – Revised

In the March 9^th edition of MLN Connects CMS encouraged readers to learn about the requirement to include a modifier on claims for separately payable Part B drugs and biologicals acquired under the 340B Program. Along with the announcement, CMS provided links to an updated MLN Fact Sheet and Updated FAQs. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc

March 27, 2023: The Livanta Claims Review Advisor: Short Stay Review (SSR) – Review Findings from Year One

In Livanta’s March 2023 edition of their Claims Review Advisor newsletter, they report findings from the first year of reviews, noting that Medicare short stay reviews were paused in May 2019 and resumed in October 2021. Of the 18,672 claims reviewed, 2,663 (14%) were admission denials. The first common reason cited by Livanta for denials was insufficient documentation to support a two-midnight expectation at the time of the admission order. You can find past issues of the Livanta Claims Review Advisor as well as the full Review Findings from Year One report on Livanta’s website at https://www.livantaqio.com/en/ClaimReview/Provider/provider_education.html.

COVID-19 Updates

February 27, 2023: CMS PHE Fact Sheet: What Do I Need to Know? Waivers, Flexibilities, and the Transition Forward

CMS published a fact sheet covering COVID-19 vaccines, testing, and treatments; telehealth services; continuing flexibilities for health care professionals; and inpatient hospital care at home when the PHE expires at the end of the day on May 11, 2023. https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

March 10, 2023: OIG’s COVID-19 PHE Flexibilities End May 11, 2023

The OIG published a notice to describe the flexibilities they had implemented in response to the COVID-19 PHE (i.e., their March 17, 2020 Telehealth Policy Statement), and to remind the health care community said flexibilities will end on May 11, 2023.  https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp

 March 13, 2023: FDA’s Guidance Documents related to COVID-19

The FDA published this notice in the Federal Register “to provide clarity to stakeholders with respect to the guidance documents that will no longer be effective with the expiration of the PHE declaration and the guidance’s that FDA is revising to continue in effect after the expiration of the PHE declaration.” Specifically, there are 72 COVID-19 related guidance documents currently in effect addressed in this notice. Twenty-two will expire at the end of the COVID-19 PHE, another twenty-two will continued for 180 days after the PHE ends, twenty-four will remain in effect with plans to revise (i.e., guidance related to emergency use authorization for vaccines to prevent COVID-19), and the remaining four will also remain in effect. https://www.federalregister.gov/documents/2023/03/13/2023-05094/guidance-documents-related-to-coronavirus-disease-2019-covid-19

March 16, 2023: MLN Connects: Do not Report CR Modifier & DR Condition Code After Public Health Emergency

CMS included the following in the March 13^th edition of MLN Connects: “The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.” https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-16-mlnc#_Toc129789600

Other Updates

February 28, 2023: New Region 2 Recovery Auditor

On February 28^th, Performant posted a general program update alerting providers that on February 7, 2023, CMS approved Performant to begin performing on their new Region 2 contract. Coming soon to their website will be Provider Outreach and education plans. https://performantrac.com/cms-rac/cms-rac-resources/cms-rac-provider-resources/default.aspx

March 9, 2023: MLN Connects: New Inflation Reduction Act Resources

This addition of MLN Connects includes information about the Inflation Reduction Act (IRA), including a recently issues social media toolkit that stakeholders can use to educate people with Medicare about the new insulin benefit and additional vaccines available at no cost and additional resources to provide to your patients that need it. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc

The fourth quarter FY 2022 Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released last week. At the same time, the 36^th Edition of the related PEPPER User’s Guide is now posted on the PEPPER Resources website.

About the PEPPER

As part of a hospital’s Compliance Program, regular chart audits should be completed to confirm guidance with Medicare coverage, coding, and billing requirements. The PEPPER is a free resource that provides a compare of a hospital to its state, MAC region, and the nation for specific Target Areas. This comparison enables a hospital to identify whether it is an outlier as compared to other short-term acute care hospitals.

In general, there are two types of Target Areas, targets related to DRG coding and admission necessity focused target areas. The “PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify areas of potential concern:

• Significant changes in billing practices
• Possible over- or under – coding, and
• Changes in lengths of stay.”

When CMS approves a Target Area it is because it has been identified as prone to improper Medicare payments. Historically, target areas have been the focus of past Office of Inspector (OIG) or Recovery Auditor audits.

35^th Edition PEPPER User’s Guide, What’s New?

Three target areas have been removed from the report including Excisional Debridement, Emergency Department Evaluation and Management Visits, and Chronic Obstructive Pulmonary Disease.

In keeping with the trend that MMP has noticed where services are moving away from the inpatient hospital setting, the existing Spinal Fusion target area has been modified to now include hospital outpatient spinal fusion claims.

The last change is to the existing Percutaneous Cardiovascular Procedures target area. This has been modified to remove reference to the following two outpatient codes in the denominator:

• Current Procedural Terminology® (CPT®) code 92942, and
• Healthcare Common Procedure Coding System (HCPCS) code C9606.

Moving Forward

Also included in the PEPPER User’s Guide are suggested interventions for when a hospital is a high or low outlier for each of the review targets.

DRG Coding Focused Target Area Example: Unrelated OR Procedure

• Suggested Interventions for High Outliers: “This could indicate that there are coding or billing errors related to over-coding of DRGs 981, 982, 987, 988, or 989. A sample of medical records for these DRGs should be reviewed to determine whether the principal diagnosis and principal procedure are correct.
• Suggested Intervention for Low Outlier: “This could indicate that the principal diagnosis is being billed with the related procedures No intervention is necessary.”

Admission Necessity Focused Target Area Example: Spinal Fusion

• Suggested Interventions for High Outlier: “This could indicate that unnecessary spinal fusion procedures may have been performed. A sample of medical records for spinal fusion cases, including both the inpatient and outpatient setting, should be reviewed to validate the medical necessity of the procedure. Medical record documentation of 1) previous non-surgical treatment, 2) physical examination clearly documenting the progression of neurological deficits, extremity strength, activity modification, and pain levels, 3) diagnostic test results and interpretation, and 4) adequate history of the presenting illness, may help substantiate the necessity of the procedure.”
• Suggested interventions for Low Outlier: “Not applicable, as this is an admission-necessity focused target area.”

Of note, more than half of the target areas in the 36^th Edition User’s Guide are admission-necessity focused. Moving forward, I encourage you to review your hospital’s latest PEPPER and take advantage of suggested interventions available in the User’s Guide, paying close attention to documentation that may help substantiate the inpatient admission.

Reference

PEPPER Resources: https://pepper.cbrpepper.org/

COVID-19 Updates

January 24, 2023 CDC Call: Updates to COVID-19 Testing and Treatment for the Current SARS-CoV-2 Variants: This CDC call included an overview of COVID-19 epidemiology and the current variant landscape, addressed current CDC testing guidance and the National Institutes of Health and Infectious Disease Society of America COVID-19 treatment guidelines, and discussed risk assessment and considerations for treatment options. You can access a recording of this session and slides on the CDC website.

 

February 9, 2023: Letter to U.S. Governors from HHS Secretary Xavier Becerra: HHS Secretary Xavier Becerra published a letter to Governors (https://www.hhs.gov/about/news/2023/02/09/letter-us-governors-hhs-secretary-xavier-becerra-renewing-covid-19-public-health-emergency.html), informing them “that effective February 11, 2023, I am renewing for 90 days the COVID-19 Public Health Emergency (PHE)…the U.S. Department of Health and Human Services is planning for this to be the final renewal and for the COVID-19 PHE to end on May 11, 2023. Rather than 60 days’ notice, I am providing 90 days’ notice before the COVID-19 PHE ends to give you and your communities ample time to transition.” HHS also published the Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap (https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html).

 

February 23, 2023: PHE 1135 Waivers: Updated Guidance for Providers: CMS published an MLN Connects (https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-02-23-oce), letting providers know the COVID-19 PHE Provider-specific fact sheets have been updated and in the coming weeks they will be hosting stakeholder calls and office hours to provide additional information.

 

February 27, 2023: What Do I Need to Know? CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 PHE: CMS released a new overview fact sheet providing clarity on several topics including: COVID-19 vaccines, testing and treatments, telehealth services, and healthcare access (https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf).

Other Updates

January 23, 2023: The MOON and IM/DND Receive OMB Approval: A January 23, 2023, update on the Beneficiary Notices Initiative webpage (https://www.cms.gov/medicare/medicare-general-information/bni) alerted providers that the Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IM), and Detailed Notice of Discharge (DND) have received OMB approval and the updated versions are now available. The new versions must be used no later than April 27, 2023.

 

January 26, 2023: Guidance for Newest Medicare Provider Type – Rural Emergency Hospitals (REH): This memorandum (https://www.cms.gov/files/document/qso-23-07-reh.pdf) provides guidance regarding the REH enrollment and conversion process for eligible facilities, FAQs, and a newly developed State Operations Manual Appendix (Appendix O) with survey procedures and Conditions of Participation (CoP) regulatory text. CMS notes the interpretive guidance is pending and will be provided in a future release. You can learn more about REHs in an October 2022 MLN Fact Sheet (https://www.cms.gov/files/document/mln2259384-rural-emergency-hospitals.pdf).

 

CY 2023 Therapy Services Threshold Amounts: The February 2, 2023 edition of MLN Connects included the CY 2023 per-beneficiary threshold amounts for therapy services. Claims must include the KX modifier to confirm services were medically necessary and justified by appropriate documentation. Threshold Amounts for CY 2023 are:

• $2,230 for Physical Therapy (PT) and Speech-Language Therapy (SLT) combined, and
• $2,230 for Occupational Therapy (OT) services.

To learn more about therapy services, visit the CMS Therapy Services webpage (https://www.cms.gov/medicare/billing/therapyservices).

We are fast approaching the ten-year anniversary of the Two-Midnight Rule that went into effect on October 1, 2013. Following the start date of this rule, CMS provided sub-regulatory guidance. Specific to claims reviews, CMS directed Medicare review contractors to apply the Two-Midnight presumption that “directs medical reviewers to select Part A claims for review under a presumption that the occurrence of 2 midnights after formal inpatient hospital admission pursuant to a physician order indicates an appropriate inpatient status for a reasonable and necessary Part A claim.”

Initially, Medicare Administrative Review Contractors (MACs) were tasked with auditing short stay claims. Next, this task was turned over to the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) KEPRO and Livanta. In 2019, reviews were halted as CMS began the process of selecting one contractor to perform Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews nationally.

In April 2021, Livanta announced they had been awarded the contract to be the National Medicare Claim Review Contractor. Livanta notes on their website that “claim review services represent an important activity of advancing Medicare’s triple aim of better health, better care, and lower costs.”

In October 2021, Livanta began requesting records monthly and they have recently posted their First Year Review Findings for SSRs and HWDRG reviews.

First Year Review Findings for Short Stay Reviews

Livanta notes in this report that SSRs focus on appropriate application of the Two-Midnight Rule, they are not incentivized to find errors, providers may provide supplementation documentation for initially denied claims, and a hospital may request education sessions at any point in the review process.

Livanta developed a review strategy, approved by CMS, to score each eligible paid claim to account for the influences of volume, cost, and clinical risk of improper payment. This score also scores a claim by length of stay (LOS) with a 0-day LOS scoring higher than a 1-day LOS.

 

Year 1 Report Highlights

• Livanta reviewed 18,672 short stay claims,
• 2,663 (14%) reviews were denied,
• The 0-Day LOS error rate was eighteen percent,
• The 1-Day LOS error rate was thirteen percent,
• The highest volume of claims denied were circulatory system claims, and
• The principal diagnosis with the highest number of denials was I480 (Paroxysmal atrial fibrillation).

  Higher Weighted DRG Reviews

  A HWDRG review occurs when a claim is resubmitted by a hospital with a higher weighted DRG as a correction to an original claim. The focus of this type of review is “on medical necessity of the inpatient admission and DRG validation.” Further, “this review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the record.” Similar to SSRs, each claim is scored to account for the influences of volume, cost, and clinical risk.

  Year 1 Report Highlights

• Livanta completed 54,251 reviews.
• A Livanta physician identified 4,804 clinical coding errors due to lack of evidence to support the diagnosis code.
• >There were 6,480 technical coding errors that involved inappropriate application of ICD-10-CM/PCS coding guidelines.

Top Three Reasons for a Denial

1. The principal diagnosis was not supported by the medical record and coding guidelines.
2. Submission of a major complication or comorbidity (MCC) or CC not supported by documentation in the medical record. Common diagnoses cited in the report were sepsis, encephalopathy, and malnutrition.
3. Inappropriate query submissions and unsupported responses.

Moving Forward

Share this information with your Coding and Clinical Documentation Integrity professionals. I also encourage you to review information available to Providers on Livanta’s website and sign up for their monthly newsletter, The Livanta Claims Review Advisor.

Resources

• FAQs - CMS 2 Midnight Inpatient Admission Guidance & Patient Status Reviews for Admissions on or after October 1, 2013: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/2MidnightInpatientAdmissionGuidanceandPatientStatusReviewsforA-.pdf
• Livanta National Medicare Claims Review Contractor website: https://www.livantaqio.com/en/ClaimReview/index.html
• Livanta Claim Review Services First Year Review Findings for Short Stay Reviews (SSR): https://www.livantaqio.com/en/ClaimReview/files/Claim-Review-Services-Year1-Findings-SSR_012423.pdf
• Livanta Claim Review Services First Year Review Findings for Higher Weighted Diagnosis Related Group (HWDRG) Reviews: https://www.livantaqio.com/en/ClaimReview/files/Claim-Review-Services-Year1-Findings-HWDRG_012423.pdf

In an August 18, 2022 special edition of MLN connects, CMS sounded the call for providers to begin to prepare hospitals for operations after the COVID-19 Public Health Emergency (PHE) comes to an end.

Some five months later, On January 30, 2023, the Biden administration communicated their intent to end the COVID-19 national emergency and public health emergency (PHE) on May 11, 2023, noting that “This wind-down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE.”

CMS was quick to follow-up on this announcement and on February 1, 2023, they posted an update to the coronavirus waivers & flexibilities CMS webpage:   

• “Update: On Thursday, December 29, 2022, President Biden signed into law H.R. 2716, the Consolidated Appropriations Act (CAA) for Fiscal Year 2023. This legislation provides more than $1.7 trillion to fund various aspects of the federal government, including an extension of the major telehealth waivers and the Acute Hospital Care at Home (AHCaH) individual waiver that were initiated during the federal public health emergency (PHE).

• Additionally, on January 30, 2023, the Biden Administration announced its intent to end the national emergency and public health emergency declarations on May 11, 2023, related to the COVID-19 pandemic.
• CMS is committed to updating supporting resources and providing updates as soon as possible. Please continue to use the provider-specific fact sheets for information about COVID-19 Public Health Emergency (PHE) waivers and flexibilities.” Note, all provider-specific fact sheets were recently updated on February 1, 2023 and include information about the status of waivers when the PHE ends, for example:  

 

Fact Sheet: Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19

• Medicare Telehealth: The Consolidated Appropriations Act of 2023 provides for an extension for some of the flexibilities through December 31, 2024. However, when the PHE ends Clinicians must once again have an established relationship with the patient prior to providing remote patient monitoring (RPM).
• Reducing Administrative Burden: “Stark Law” waivers: When the PHE ends, all Stark Law waivers will terminate, and physicians and entities must immediately comply with all provisions of the Stark Law.
• National Coverage Determinations (NCDs) for Percutaneous Left Atrial Appendage Closure, Transcatheter Aortic Valve Replacement, Transcatheter Mitral Valve Replacement and Ventricular Assist Devices: CMS has not enforced the procedural volume requirements contained in these four NCDs for facilities and providers that, prior to the public health emergency for COVID-19, met the volume requirements. This enforcement discretion ensures that beneficiaries continue to have access to the services that are covered under these NCDs. This waiver will end at the conclusion of the PHE. 

 

Fact Sheet: Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs: CMS Flexibilities to Fight COVID-19

• Enhanced Medicare Payments for New COVID-19 Treatments: Hospital Inpatient Stays: Immediately following the end of the PHE, effective for discharges occurring on or after November 2, 2020, and through the end of the FY in which the COVID-19 PHE ends, the Medicare program has provided an enhanced payment for eligible inpatient cases that involve use of certain new products authorized or approved to treat COVID-19 (86 FR 45162). The enhanced payment is equal to the lesser of 1) 65% of the operating outlier threshold for the claim; or 2) 65% of the costs of the case beyond the operating Medicare payment (including the 20% add-on payment under section 3710 of the CARES Act) for eligible cases.
• Separate Medicare Payment for New COVID-19 Treatments: Hospital Outpatient Departments: CMS has excluded FDA-authorized or approved drugs and biologicals (including blood products) authorized or approved to treat COVID-19 (and for which the FDA authorization or approval does not limit use to the inpatient setting) from being packaged into the Comprehensive Ambulatory Payment Classification (C-APC) payment when these treatments are billed on the same claim as a primary C-APC service. Instead, Medicare has been paying for these drugs and biologicals separately for the duration of the PHE. After the PHE, payment for these treatments will be packaged into the payment for a C-APC when these services are billed on the same outpatient claim.
• Utilization Review: CMS has been waiving the entire Utilization Review Conditions of Participation (CoP) at §482.30 as “removing these administrative requirements allows hospitals to focus more resources on providing direct patient care.” This waiver will end at the conclusion of the PHE.

 

I have provided only a select few examples of what will happen when the PHE ends and encourage you to check for updates to the provider-specific fact sheets often as you develop a plan for your hospital beyond the end of the COVID-19 PHE.

 

Resources

• August 18, 2022 MLN Connects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-08-18-mlnc-se
• January 30, 2023 Office of Management and Budget Statement of Administration Policy: https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf
•  CMS Coronavirus waivers & flexibilities webpage: https://www.cms.gov/coronavirus-waivers 

Payment Integrity: Medicare FFS Hospital Outpatient

The FY 2022 HHS Agency Financial Report (https://www.hhs.gov/sites/default/files/fy-2022-hhs-agency-financial-report.pdf) was published in late 2022.  Section 3 of this document includes the Payment Integrity Report where HHS indicates “the actual overpayments identified by the Comprehensive Error Rate Testing program during the FY 2022 report period were $24,004,089.28. The MACs recovered the identified overpayments via standard payment recovery methods. As of the report publication date, MACs reported collecting $15,552,853.67 or 64.79 percent of the actual overpayment dollars.”

 

The improper payment estimate for hospital outpatient claims increased from 4.57 percent in RY 2021 to 5.43 percent in RY 2022. However, this increase was not statistically significant. The primary reason cited for hospital outpatient errors was “missing documentation to support the order, or the intent to order for certain services.   

 

Mitigation Strategies and Corrective Actions

HHS addresses improper payments through mitigation strategies and corrective actions believing that “targeted actions will prevent and reduce improper payments in these areas.” Strategies and corrective actions in the hospital outpatient setting cited in this report includes:  

 

Internal Policy Change: In 2020, HHS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services process. This initiative was once again expanded in the CY 2023 OPPS Final Rule to include Facet Joint interventions effective July 1, 2023.

 

Internal Process: Medical Review Strategies

Medical review strategies are developed “using improper payment data to target the areas of highest risk and exposure. HHS requires its Medicare review contractors to identify and prevent improper payments due to documentation errors in certain error-prone claim types,” including hospital outpatient claims.

 

Audits: Targeted Probe & Educate (TPE)

Medicare Administrative Contractors (MACs) perform the TPE process. In 2022, MACs continued to offer extensions as needed due to the continued impacts of COVID-19. Approximately 3,280 hospital outpatient providers were reviewed by the MACs in 2022.

 

Audits: Supplemental Medical Review Contractor (SMRC)

The SMRC conducts reviews on a post-payment basis at the direction of CMS. When the SMRC completes a review, the results are shared with the MACs for claim adjustments. Providers receive detailed review result letters and MAC demand letters for overpayment recovery. Letters include educational information regarding what was incorrect in the original billing of the claim. In 2022, the SMRC performed post-payment medical reviews for 26,777 hospital outpatient claims.

 

Audits: Recovery Audit Contractor (RAC) Reviews

In 2022, the largest share of Medicare FFS RAC collections (37.4 percent) were from hospital outpatient overpayments.

 

Moving Forward

• Prepare for the July 1, 2023 addition of Facet Joint interventions to the Prior Authorization for Certain OPD Services process.
• Identify active TPE, SMRC and RAC review targets to assess your compliance with related documentation, coding, and billing requirements.
• Respond to additional documentation requests in a timely manner.

Fiscal Year 2022 Supplemental Improper Payment Data

On December 8, 2022, the Comprehensive Error Rate Testing (CERT) published the 2022 Medicare Fee-for-Service Supplemental Improper Payment Data (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports).

This report supplements the FY 2022 HHS Agency Final Report for Fiscal Year 2022, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.

 

Estimated Improper Payment Rates

Calculation for the FY 2022 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2020 through June 30, 2021. As compared to FY 2020 and 2021, the improper payment rate is trending up:

 

Improper Payment Rate

• FY 2020: 6.27%
• FY 2021: 6.26%
• FY 2022: 7.46%

  Improper Payment Amount

• FY 2020: $25.74 billion
• FY 2021: $25.03 billion
• FY 2022: $31.46 billion.

   

  “It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).

  Similar to prior years, in FY 2022 “insufficient documentation” was the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.

  While the CERT data reports on improper payments in several settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.

   

   

  “0 or 1 day” Length of Stay Claims

  A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this report since the October 1, 2013 implementation of the Two-Midnight Rule:

   

• 2014: “0 or 1 Day” stay claims highest improper payment rate to date at 37.18%,
• 2021: “0 or 1 Day” stay claims lowest improper payment rate to date at 16.8%.
• 2022: The “0 or 1 Day” claims rate increased to 20.1% with projected improper payments of $1.5 billion.

 

In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who is actively requesting short stay claims across the nation on a monthly bases.  

 

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.

 

Overall, 44.4% of the errors in the top 20 service types were due to error category medical necessity. A claim is placed in this category when the CERT contractor reviewer receives 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 two DRG Types was attributed to medical necessity:

 

• DRG Group 252, 253, and 254: Other Vascular Procedures, and
• DRG Pair 551 and 552: Medical Back Problems.

   

  Top Root Causes of Improper Payments

  The 2022 report includes tables highlighting the top root cause of improper payments for the top three service types with the highest projected improper payments in the Part A (Hospital IPPS) setting.

   

   

  Moving Forward

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

• Visit the CERT Provider Website (https://c3hub.certrc.cms.gov/) 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, CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf) to provide guidance on what to document to avoid denied claims, and
• Take the time to review the CERT’s Supplemental Improper Payment Data report annually.

1. Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity (DRGs 469, 470) Top Root Cause: “Inpatient admission not medically necessary and the invasive procedure should have been billed as an outpatient procedure.”
2. Endovascular Cardiac Valve Replacement and Supplement Procedures (DRGs 266, 267) Top Root Cause: “Documentation to support medical necessity for the procedure – missing.”
3. Percutaneous Intracardiac Procedures (DRGs 273, 274) Top Root Cause: NCD requirement(s), other documentation required for payment – Missing.”

Did You Know?

On January 11, 2023 CMS updated their 2023 ICD-10-CM and PCS webpages to provide information about the new codes that will be effective April 1, 2023. You can read more about the codes in a related MMP article ( https://www.mmplusinc.com/kb-articles/new-icd-10-cm-and-icd-10-pcs-codes-effective-april-1-2023).

 

Why Should I Care?

In addition to new diagnosis codes, the FY 2023 ICD-10-CM Official Guidelines for Coding and Reporting has been updated to include new guidance regarding Social Determinants of Health (SDOH).

 

Specifically, new guidance clarifying when to assign a code for living alone, food insecurity and homelessness, has been added to guidelines for SDOHs in Chapter 21 of the Chapter-Specific Guidelines, Section b.17.  Following is a compare of the June 2022 guidance to the January 11, 2023 guidance.

 

Excerpt from June 2022 Official Guidelines for Coding and Reporting (https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2023/ICD-10-CM-Guidelines-FY2023.pdf)

 

Codes describing problems or risk factors related to social determinants of health (SDOH) should be assigned when this information is documented. Assign as many SDOH codes as are necessary to describe all of the problems or risk factors. These codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, not every individual living alone would be assigned code Z60.2, Problems related to living alone.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

 

Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.

 

Excerpt from January 2023 Official Guidelines for Coding and Reporting

(https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf)

 

Social determinants of health (SDOH) codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record. Assign as many SDOH codes as are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care. For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living.

When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2. Documentation by a clinician (or patient-reported information that is signed off by a clinician) that the patient expressed concerns with access and availability of food would support assignment of code Z59.41, Food insecurity. Similarly, medical record documentation indicating the patient is homeless would support assignment of a code from subcategory Z59.0-, Homelessness.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.

The files containing information on the ICD-10-CM updates effective with discharges on and after April 1, 2023 are available on the CMS ICD-10-CM webpage (https://www.cms.gov/medicare/icd-10/2023-icd-10-cm) and the CDC’s Comprehensive Listing ICD-10-CM Files webpage (https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm).

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., Coding Professionals, Clinical Documentation Improvement Specialists, and Case Management).

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

Did You Know?

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

Why It Matters?

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

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

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

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

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

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

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

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

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

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

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

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

What Can I Do?

If your hospital provides either of these services:

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

On November 22nd, CMS published the following announcement regarding new ICD-10 diagnosis and procedure codes that will become effective April 1, 2023:

In an effort to better enable the collection of health-related social needs (HRSNs), defined as individual-level, adverse social conditions that negatively impact a person’s health or healthcare, are significant risk factors associated with worse health outcomes as well as increased healthcare utilization, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing 42 new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting effective April 1, 2023.

Fourteen of the new diagnosis codes are identified as external cause of injury codes and as such there is no assigned severity level, MDC, or MS-DRG.

In addition, the Centers for Medicare & Medicaid Services (CMS) is implementing 34 new procedure codes into the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), effective April 1, 2023.

The ICD-10 MS-DRG V40.1 Grouper Software, Definitions Manual Table of Contents, and the Definitions of Medicare Code Edits V40.1 manual to accommodate these new diagnosis and procedure codes, effective for discharges on or after effective April 1, 2023 will be available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html.

The Code Tables, Index and related Addenda files for the 34 new procedure codes will be available at: https://www.cms.gov/medicare/icd-10/2023-icd-10-pcs.

The Index and Tabular Addenda for the new diagnosis codes will be made available via the CDC website at: https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm.