Knowledge Base Category -

The 2019 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital Final Rule was released this past Thursday August 2nd. The display copy comes in at a mere 2,593 pages. So, if you are someone who likes to eat dessert before your meal or start a book by reading the ending, this article is for you. CMS finalized their “proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment.”  

Similar to there being so much more to a meal than dessert or a good story than the last page of a book, there is more you need to know and think about in relation to this finalized proposal. This article provides a look back at when this initially became a requirement, details an “almost apology” to hospitals from CMS, provides CMS’s expected outcomes from this rule change, a sampler, if you will, of some of the more notable comments to and responses from CMS and ends with an important list of items to keep in mind that did not change.

Background

In the 2014 IPPS Final Rule, CMS adopted the “2-Midnight” payment policy, codified “the longstanding policy that a beneficiary becomes a hospital inpatient if formally admitted pursuant to the order of a physician (or other qualified practitioner as provided in the regulations) in accordance with the hospital conditions of participation (CoPs), and made it a specific condition of Medicare Part A payment that a written inpatient admission order be present in the medical record.  

Commenters of the 2014 IPPS Proposed rule felt this requirement was “duplicative and burdensome on hospitals.” CMS’s response was that “The physician order reflects affirmation by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and the “order serves the unique purpose of initiating the inpatient admission and documenting the physicians (or other qualified practitioner as provided in the regulations) intent to admit the patient which impacts its required timing.”

They did “acknowledge that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”

Proposed Revision to the Policy, Why Now?

While the Final Rule does not include an apology to hospitals for making the status order a requirement of payment since October 1, 2013, CMS does note that, “it has come to our attention that some medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders.”

Common technical discrepancies cited by CMS include:

• Missing practitioner admission signatures,
• Missing co-signatures or authentication signatures, and
• Signature occurring after discharge.

They further share they “have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim…we have concluded that if the hospital is operating in accordance with the hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay. It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for medically reasonable and necessary inpatient stays, even if such denials occur infrequently.”

Anticipated Outcome of Policy Revision

Two key outcomes CMS hopes to achieve through this Policy Revision are:

• First, to reduce this unnecessary administrative burden on physicians and providers, and
• Second, to “properly adjust the focus of the medical review process towards determining whether an inpatient stay was medically reasonable and necessary and intended by the admitting physician rather than towards occasional inadvertent signature or documentation issues unrelated to the medical necessity of the inpatient stay or the intent of the physician.”

Comments & CMS Responses

As mentioned earlier in this article, here are some key comments received and CMS responses related to the admission order policy change.

Comment: Concern the proposal may render the inpatient admission order completely insignificant and not required for any purpose.

CMS Response: “Our proposal does not change the requirement that, for purposes of Part A payment, an individual becomes an inpatient when formally admitted as an inpatient under an order for inpatient admission. The physician order remains a significant requirement because it reflects a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and initiates the process for inpatient admission.”

Comment: Commenters referenced the January 2014 sub-regulatory guidance which explained that if a practitioner disagreed with the decision to admit a patient to inpatient status, the practitioner could simply refrain from authenticating the inpatient admission order and the patient would remain in outpatient status. There was a concern that if CMS no longer requires a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment, CMS would not be able to distinguish between orders that were simply defective and orders that were intentionally not signed.

CMS Response: “It should never have been the case that the only evidence in the medical record regarding this uncommon situation was the absence of the physician’s or other qualified practitioner’s signature. The medical record as a whole should reflect whether there was a decision by a physician or other qualified practitioner to admit the beneficiary as an inpatient or not.”

This fact is precisely why, under our current guidance, we acknowledged that in the extremely rare circumstance where the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors have discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record. We disagree with these commenters that reliance only on the absence of the signature in these uncommon situations reflected good medical documentation practice.”

Comment: Concerned the proposal would remove the requirement for an order altogether, affecting patient appeal rights, or increase financial liability.

CMS Response: “As stated earlier, the physician order remains a requirement for purposes of reflecting a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, initiating the inpatient admission. Additionally, regardless of this proposal and other physician order requirements described earlier, the hospital CoPs include the requirement that all Medicare inpatients must receive written information about their hospital discharge appeal rights.”

Commenters provided the example of a patient being in outpatient status receiving observation services but spent two medically necessary midnights and was discharged. The question being, can the stay be reviewed after discharge, a determination be made that the 2-midnight benchmark was met, and the hospital submit a claim for inpatient admission?

CMS responded by referring readers to the FY 2014 IPPS/LTCH PPS final Rule (78 FR 50942) where they stated that “The physician order cannot be effective retroactively. Inpatient status only applies prospectively, starting from the time the patient is formally admitted pursuant to a physician order for inpatient admission, in accordance with our current policy.”

Comment: Some commenters stated that the proposed policy change appears to suggest that the completion of admission orders would now be optional and other available documentation could be used to create retroactive orders.

CMS Response: “Regarding the comment about retroactive orders, it has been and continues to be longstanding Medicare policy to not permit retroactive orders. The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (for example, for a prescheduled surgery), but the inpatient admission does not occur until hospital services are provided to the beneficiary.”

Comment: Commenters inquired if the proposal would change the requirements regarding which practitioners are allowed to furnish inpatient admission orders.

Response: “The proposed revision relating to hospital inpatient admission order documentation requirements under Medicare Part A does not include revisions to the requirements regarding which practitioners are allowed to furnish inpatient admission orders.”

What was Not Proposed and Has Not Changed?

Hospitals have struggled with this requirement since it was finalized in the 2014 IPPS Final Rule. While I truly believe that this policy revision is a good thing for hospitals, it is vital to be mindful of what has not changed.

• Hospitals and physicians are still required to document relevant orders in the medical record to substantiate medical necessity requirements.
• The requirement remains that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.
• Nothing was proposed nor changed with respect to the “2 midnight” payment policy.
• Guidance from the Medicare benefits Policy Manual (MBPM), Chapter 1, Section 10.2 will not change. Specifically, “The order to admit may be missing or defective (that is, illegible, or incomplete, for example ‘inpatient’ is not specified), yet the intent, decision, and recommendation of the ordering practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record. In these situations, contractors have been provided with discretion to determine that this information provides acceptable evidence to support the hospital inpatient admission. However, there can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.”
• Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

One final reminder, this policy change will become effective with hospital discharges on or after October 1, 2018. So for now stay vigilant with making sure there is a valid inpatient order in your records prior to the beneficiary being discharged.

Be on the lookout for more articles about the Final Rule over the next few weeks. Until then, you can access a copy of the Final Rule on the CMS IPPS Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

MEDICARE TRANSMITTALS

Revisions to the Telehealth Billing Requirements for Distant Site Services - REVISED

Revised criteria that allows the GT modifier to be present on Method II CAH claim lines.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10583.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update - REVISED

The article is revised to show the Type of Service Code for CPT code 90739 remains as V.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10624.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.3, Effective October 1, 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10827.pdf

Medical Review of Evaluation and Management (E/M) Documentation

Provides direction to Medicare’s medical review contractors on how to review claims where a medical student documented the E/M service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10627.pdf

Medicare Special Edition Articles

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED

This article was revised on July 11, 2018, to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/SE18006.pdf

 

MEDICARE RULES

2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule

Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

 

MEDICARE EDUCATIONAL RESOURCES

Medicare Billing for Cardiac Device Credits

Learn about billing Medicare inpatient and outpatient cardiac devices and reducing overpayments.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/cardiacdevicecredits-ICN909368.pdf

Beneficiary Notices Initiative (BNI) webpage – updated

New look for Medicare’s Notices webpage.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html

Medicare Fee for Service Recovery Audit Program webpage – updated

New look for Medicare’s RAC webpage

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html

Transition to New Medicare Numbers and Cards Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Medicare Quarterly Provider Compliance Newsletter – July 2018

Addresses common billing errors and other erroneous activities and provides guidance to help health care professionals address and avoid the top issues of the particular quarter.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909378.pdf

 

MEDICARE FAST FACTS

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
• Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

 

OTHER MEDICARE UPDATES

Contract Award for A/B MAC Jurisdiction F

CMS awarded the Jurisdiction F contract to Noridian, the current incumbent contractor for JF.

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

Can I be honest?

I have type 2 diabetes and take a pill for it every day, but I don’t like diabetes coding. Diagnosis code assignment for diabetes and diabetes-related conditions has always been confusing to me. When looking at a chart of a patient with diabetes, I frequently go back to the ICD-10 diagnosis coding guidelines and Coding Clinic articles to validate my understanding.

Based on some of the coding proficiency reviews we’ve done over the past couple of years, I think other coders may share some of my confusion.  One of the most common diagnosis coding discrepancies we come across with diabetes coding is the scenario of a patient with Type 2 diabetes who is also taking an oral antidiabetic drug. We usually see the appropriate diagnosis code for Type 2 diabetes, but ICD-10 diagnosis code Z79.84 is not reported for long-term use of an antidiabetic drug when it’s applicable.

Z79.84 was introduced October 2016, and in addition to all the other diabetes-related coding rules we already had, this new code came with, yet, another rule to remember:  When E11- is reported for type 2 diabetes, use an additional code to identify control using an oral antidiabetic / hypoglycemic drug.

In talking with coders and coding supervisors, one of the problems in picking up Z79.84 is that coders may not know which drugs are classified as an antidiabetic. The good news is – we don’t have to know if the drug is a biguanide versus an alpha-glucosidase inhibitor versus SGLT 2 inhibitor, etc., we just need to know which oral medications are considered antidiabetic or hypoglycemic.

Below is a list of the more common oral antidiabetic drugs we see. Did you realize the different preparations of Metformin had so many other names? Keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.84 should be reported in addition to the E11- diabetes code. Click here to see a more comprehensive list on the Healthline.com website.

Metformin / Kazano

Metformin / Invokamet

Metformin / Xigduo XR

Metformin / Synjardy

Metformin / Glucovance

Metformin / Jentadueto

Metformin / Actoplus

Metformin / PrandiMet

Metformin / Avandamet

Metformin / Kombiglyze XR

Metformin / Janumet

Sitagliptin / Januvia

Sitagliptin-Metformin / Janumet

Canagliflozin / Invokana

Canagliflozin-Metformin / Invokamet

Empagliflozin / Jardiance

Glimepiride / Amaryl

Glipizide / Glucotrol

Chlorpropamide / Diabinese

Tolazamide / Tolinase

Tobbutamide / Orinase

MEDICARE TRANSMITTALS

July 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

CMS supplies MACs with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE). Also see related content at PalmettoGBA - “The drug pricing files contain the payment amounts used to reimburse for Part B covered drugs for the applicable quarter of 2018. The payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufactures (ASP X 1.06). The ASP rate must be adjusted before applying the 22.5 percent reduction (for 340B-acquired drugs).”

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10667.pdf

Claim Status Category and Claim Status Codes Update

HIPAA requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10777.pdf

July 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Changes and billing instructions for various payment policies implemented in the July 2018 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10781.pdf

July 2018 Integrated Outpatient Code Editor (I/OCE) Specification Version 19.2

The I/OCE is being updated for July 1, 2018. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10699.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

 

New Medicare Beneficiary Identifier (MBI) Get It, Use It

Explains ways you can get MBIs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf

 

REVISED MEDICARE TRANSMITTALS

 

Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients – REVISED

Revised to correct the code description for ICD-10-CM D68.32.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10474.pdf

 

MEDICARE EDUCATIONAL RESOURCES

 

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Vide: The Importance of Proper Documentation
• Bill Correctly for Device Replacement Procedures
• Billing for Stem Cell Transplants

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

 

FEDERAL REGISTRY CMS RULES

 

Medicare Program; Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR): Extreme and Uncontrollable Circumstances Policy for the CJR Model

Finalizes a policy that provides flexibility in the determination of episode spending for Comprehensive Care for Joint Replacement Payment Model (CJR) participant hospitals located in areas impacted by extreme and uncontrollable circumstances for performance years 3 through 5.

https://www.gpo.gov/fdsys/pkg/FR-2018-06-08/pdf/2018-12379.pdf

 

OTHER MEDICARE UPDATES

 

Hospital Appeals Settlement Process Update

May 8, 2018, CMS executed settlements with an additional 612 hospitals, representing approximately 72,000 claims.   

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Hospital-Appeals-Settlement-Process-2016.html

FY 2019 ICD-10-PCS Procedure Codes

FY 2019 ICD-10-PCS procedure code updates including a complete list of code titles are posted on the 2019 ICD-10-PCS webpage.

FY 2019 ICD-10-CM Codes

FY 2019 ICD-10-CM code updates have been posted on the CDC website at: https://www.cdc.gov/nchs/icd/icd10cm.htm.

Although the official start of summer is not until tomorrow at 5:07 AM Central Time, here in Alabama the oppressive humidity and heat activated thunderstorms have already begun. Additionally, and much to my delight, I am already seeing more lightening bugs in the night sky than in recent years. This brings to mind the oft made statement by Mark Twain, “the difference between the almost right word and the right word is really a large matter. ‘tis the difference between the lightening bug and the lightening.”

The same analogy can be made for documentation in a medical record. CMS posted the FY 2019 ICD-10-CM diagnosis code updates to the CMS website on June 11, 2018. Several of the updates revise or expand a code description. Professional Coders and Clinical Documentation Improvement Specialists should take on the challenge of a little summer reading to find out what is changing. In the meantime, here are a few highlights about what will change come October 1, 2018.

Code Changes by the Numbers:

The FY 2019 ICD-10-CM codes updates includes:

• 279 New Codes
• 143 Revised Titles
• 51 Deleted Codes
• 71,932 Total Codes for FY 2019. (Increase from 71,704 in FY 2018).

The following tables highlights some of the changes come October 1, 2018.

(*)Note, code Z62813 falls within the Z62 category “Problems Related to Upbringing.” This is one of the ICD-10-CM code categories that identifies patients with potential health hazards related to socioeconomic and psychosocial circumstances. Coding Clinic for ICD-10-CM/PCS, First Quarter 2018 advised that it would be acceptable to report these codes based on documentation from non-physician clinicians following the patient. You can read more about the Z55-Z65 code categories in a related MMP article about Social Determinants of Health.

Information about the FY 2019 ICD-10-CM code updates can also be found on the Centered for Disease Control and Prevention (CDC) website at: https://www.cdc.gov/nchs/icd/icd10cm.htm. Reminder, the code updates will be used for discharges occurring from October 1, 2018 through September 30, 2019.

The Office of Inspector General (OIG) has released the Spring 2018 Semiannual Report to Congress. This report summarizes work by the OIG for the reporting period covering October 1, 2017 to March 31, 2018. This Report describes work undertaken “to identify significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”

The Inspector General, Daniel R. Levinson, notes “over the 6-month reporting period OIG worked to enhance the integrity of HHS programs and operations, protect vulnerable populations, and drive value in health and human services…Looking forward, OIG will continue to leverage our staff expertise to inform Department-wide goals, including combating the opioid crises, bringing down the cost of prescription drugs, addressing the cost and availability of health insurance, and transforming our health care system to a value-based system.”

This article highlights OIG overall expected recoveries and statistics found in the report and provides examples of OIG Activities specific to the Centers for Medicare & Medicaid Services (CMS) from the first half of FY 2018.

“Fighting Fraud” by the Numbers

Highlights of Enforcement Accomplishments

• $1.46 billion is the expected investigative recoveries.
• 424 is the number of individuals or entities that engaged in crimes against HHS programs where criminal actions against them have been taken.
• 1,588 is the number of individuals and entities that have been excluded from Federal health care programs.
• 349 is the number of civil actions taken against individuals or entities.

Highlights of Accomplishments in Assessment of Mismanagement and Abuse in HHS Programs

• $187.5 million is the amount the OIG expects to recover.
• $1.5 billion is the amount of potential savings.
• $680 million is the amount of questioned costs during this time period.

Highlights from CMS Medicare Program Reports and Reviews

 

CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor (A-03-14-00010), November 2017

Report Highlights

• 2,145 inpatient claims at 25 providers were reviewed.
• The OIG determined that only 1 claim correctly included the diagnosis code for Kwashiorkor.
• Findings equated to overpayments in excess of $6 million.
• CMS agreed with OIGs recommendations.
• The 25 hospitals reviewed repaid $5.7 million in overpayments.

Note: In January of this year the OIG Announced the Active Work Plan Item: Hospitals Billing for Severe Malnutrition on Medicare Claims. The OIG indicated in the announcement that “this review will assess the accuracy of Medicare payments for the treatment of severe malnutrition. We will determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims.”

Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements (A-01-15-00515), February 2018

 Report Highlights

• Wisconsin Physicians Service (WPS) paid 73 providers for HBO therapy services that did not comply with Medicare requirements.
• OIG estimated WPS overpaid providers in Jurisdiction 5 $42.6 million.
• WPS “generally agreed” to the following OIG recommendations:
• Recover the “appropriate portion of the $300,789 in identified Medicare overpayments,
• Notify providers responsible for the 44,820 non-sampled claims with potential overpayments to investigate and return any identified overpayments, and
• To identify and recovery any improper payments after the audit and strengthen policies & procedures for making payments for HBO therapy.

Note: HBO Therapy Services is a current Targeted Probe & Educate Medical Review target for Palmetto JM. Palmetto’s May 15, 2018 Ask the Contractor Teleconference (ACT) focused on Hyperbaric Oxygen Therapy. You can find Answers to Pre-submitted Questions on Palmetto’s JM website.

While this is not an Active Medical Review for Palmetto JJ (Alabama, Georgia, Tennessee), for those providing HBO therapy services it would be worth your time to read this and ask the question, are we compliant with Medicare requirements?

 

Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Devices (A-05-16-00059), March 2018

 Report Highlights

• All 296 payments reviewed did not comply with Medicare requirements.
• Medicare contractors incorrectly paid hospitals $7.7 million rather than the $3.3 million they should have been paid.
• CMS agreed with the recommendation to “consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits.”

Note: In the Thursday, June 7, 2018 edition of the MLNConnects e-newsletter, CMS included a Provider Compliance Reminder for correct billing for device replacement procedures. The reminder provides links to resources to correctly bill and avoid overpayment recoveries. 

We often associate the term “it takes a village” with the raising of children. It is true that parents, grandparents, relatives, teachers, coaches, church members, healthcare providers, and/or others often play key roles in bringing up a physically and emotionally healthy, well-adjusted young person. But what brought the “it takes a village” phrase to my mind today was listening to a replay of Palmetto GBA’s webcast on Inpatient Psychiatric Facility (IPF) coverage and documentation requirements.

Palmetto likely offered this educational session in preparation for and in response to their Targeted Probe and Educate (TPE) medical review of DRG 885, Psychoses. This is a target review area for both Palmetto’s Jurisdictions -  J and M. First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, also has a planned TPE review for this DRG. The Palmetto webcast reminded providers that other Medicare review entities such as the CERT contractor, Recovery Auditors, and the Office of Inspector General (OIG) could review inpatient psych or any other Medicare services.

According to the webcast, the “villagers” involved and their concerns and responsibilities for IPF services are listed below. Many tasks will involve the input of multiple staff and are a shared responsibility – more evidence that “it takes a village.”

Physicians

• Patient must be under the care of a physician
• Write admission and other orders for patient’s care
• Perform a psychiatric evaluation of the patient at admission to include
• Medical history and mental status
• Onset of illness and admission circumstances
• Patient attitudes and behaviors
• An estimate of intellectual functioning, memory functioning & orientation; and
• A descriptive inventory of patient’s assets
• Certify/recertify the need (medical necessity) for inpatient care, which includes
• Patient psychiatric condition severe enough to warrant inpatient care
• Need for active treatment
• Intensive, comprehensive, multimodal treatments exceeding the level and intensity of those that may be rendered in an outpatient setting
• Generally, an expectation of improvement of the patient’s condition or for diagnostic purpose
• Establish a treatment plan that includes
• Substantiated diagnosis
• Short-term & long-range goals
• Specific treatment modalities utilized
• Each treatment team member’s responsibilities
• Adequate documentation to justify diagnosis & treatment/rehabilitation activities carried out
• Document H&P, evaluations, examinations, treatment plan, progress notes, and discharge summary

Clinicians (Nurses, Social Workers)

• Perform and document assessments and interviews
• Provide and document treatments including description of service, content and purpose, patient’s response and correlation to treatment plan goals

Utilization Review, Social Services, Discharge Planning

• Appropriate utilization of patient benefit days and lifetime reserve days in appropriate setting

Billing

• Submit correct type of bill (TOB) with appropriate revenue and occurrence codes
• Special considerations for
• Admission source “D” for patients transferred from acute care hospital to their psych distinct part unit (prevents overpayment due to ER adjustment)
• One day payment window
• Interrupted stays and occurrence span code 74
• Services provided by other facilities during IPF stay

Coders

• Assignment of correct primary and secondary diagnosis codes to the highest degree of specificity
• Discharge status code

These are just some of the coverage and documentation requirements to support Medicare inpatient psychiatric services. I recommend providers who offer inpatient psychiatric services listen to this webcast (located on Palmetto’s Past Events webpage) whether you are in Palmetto’s jurisdictions or not. The information applies universally to all Medicare inpatient psych services. Palmetto also shared some of their findings from TPE reviews so far as well as some of the CERT findings. Providers need to pay special attention to make sure their records include:

• Physician’s orders for admission and other services. Be sure all orders include a legible signature, a date, and the author’s credentials. If signatures are illegible, send an attestation log with the documentation upon review.
• Valid and timely certifications and recertifications.
• An initial psychiatric evaluation at the time of admission or no later than 60 hours after admission
• Documentation that services and treatments are related to improving the patient’s condition
• A valid, individualized treatment plan that supports psychotherapy with type, amount, frequency, duration, diagnosis & anticipated goals
• Documentation of active treatments during billing period
• Complete and sufficient documentation

You may want to hold a town hall meeting for all the villagers to communicate, coordinate and understand their individual and shared responsibilities. Sometime it takes a village meeting to guide a village.

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”

• Social Determinants of Health World Health Organization definition

The Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative includes a Social Determinants of Health (SDOH) topic area. They note that “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks…resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”

In general, since the Wednesday@One focuses on topics related to Medicare Rules and Regulations in the acute hospital setting, you may be asking, this is interesting but what does it have to do with the hospital? Well, I am glad you “asked.”

ICD-10-CM codes included in categories Z55-Z65 identify patients with potential health hazards to socioeconomic and psychosocial circumstances. Information represented in this code block is information that would typically be identified by a Social Worker, Case Manager, or admitting nurse as a hospital begins the discharge planning process as soon as the patient is admitted.

In Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, a question was asked to verify whether or not these codes could be assigned based on non-physician documentation. Advice given was that these codes represent social information and it would be acceptable to report them based on documentation from other clinicians following the patient.

To help you begin to understand what information is represented in these codes categories, the following table provides a high-level detail of the code categories and examples of codes within each category.

In MMP’s 2019 IPPS Proposed Rule series of articles, there was a related article discussing CMS’ efforts to account for social risk factors in several of the Hospital Quality Reporting Programs.

The Health People 2020 SDOH topic area has a goal to “create social and physical environments that promote good health for all.” A key to this is analyzing and acting upon data. As a hospital it is important that you begin to identify and utilize these codes.

If you are interested in learning more about SDOH’s, you can visit the Centers for Disease Control and Prevention (CDC) Social Determinants of Health web page at https://www.cdc.gov/socialdeterminants/.

MEDICARE TRANSMITTALS

Revisions to the Telehealth Billing Requirements for Distant Site Services

Implements requirements for billing modifier GT for Telehealth Distant Site Services. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10583.pdf

Implementation of Changes to the Pre-Payment Additional Documentation Request (ADR) Letters for Medical Review

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2083OTN.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10642.pdf

Updates to Publication 100-04, Chapters 1 and 27, to Replace Remittance Advice Remark Code (RARC) MA61 with N382

MACs will use N382 in place of MA61 to communicate reject/denials for patient identifiers (HICN or MBI) in all remittance advices and 835 transactions. However, MACs will continue to use RARC MA61 only when/if communicating rejections/denials related to a missing/incomplete/invalid social security number.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10619.pdf

Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Extensions per the Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act Included in the Bipartisan Budget Act of 2018

Information and implementation instructions for:

• Section 50204 – Extension of Increased Inpatient Hospital Payment Adjustment for Certain Low-Volume Hospitals
• Section 50205 – Extension of the Medicare-Dependent Hospital (MDH) Program
• Section 51005 – Adjustments to the LTCH Site Neutral Payment Rate

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10547.pdf

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) – REVISED

The article was revised on May 15, 2018, to clarify that one of the requirements of the SET program is it must be conducted in a hospital outpatient setting or in a physician’s office.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10295.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update – REVISED

A sentence is added to show that Part B payment for Q9995 includes the clotting factor furnishing fee.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10624.pdf

Intent to Reopen

Provides instructions for contractors to: provide notification of the reopening process and to notify the provider or supplier of their intent to reopen a specific claim when requested documentation is received after a denial of the claim has been made.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R796PI.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10620.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2018 Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10644.pdf

 

MEDICARE COVERAGE UPDATES

 International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)

CR10622 makes coding and clarifying adjustments to the following NCDs:

• NCD 110.18 Aprepitant
• NCD 150.3 Bone Mineral Density Studies
• NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR)
• NCD 220.6.16 Positron Emission Tomography (PET) for Infection/Inflammation
• NCD 220.6.17 PET for Solid Tumors
• NCD 220.13 Percutaneous Image-Guided Breast Biopsy

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10622.pdf

 

MEDICARE PRESS RELEASES

CMS Announces Agency’s First Rural Health Strategy

The agency’s first Rural Health Strategy intended to provide a proactive approach on healthcare issues to ensure that the nearly one in five individuals who live in rural America have access to high quality, affordable healthcare.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-08.html

CMS Unveils Enhanced “Drug Dashboards” to Increase Transparency on Drug Prices

For the first time, the dashboards include year-over-year information on drug pricing and highlight which manufactures have been increasing their prices.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-15.html

 

MEDICARE EDUCATIONAL RESOURCES

Palmetto JM Provider Contact Center (PCC) Frequently Asked Questions (FAQs): January 2018 - April 30, 2018

https://www.palmettogba.com/palmetto/providers.nsf/ls/JM%20Part%20A"AYKQC62336?opendocument&utm_source=J11AL&utm_campaign=JMALs&utm_medium=email

MLN Fact Sheet Complying with Medicare Signature Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

Targeted Probe and Educate Video

https://my.happify.com/hd/why-gratitude-is-the-best-gift-we-can-give-our-children/?et=e2e969ce-70c2-474e-873b-a6e3fb839cf1

 

MEDICARE RULES

 Hospital IPPS and LTC 2019 FY Proposed Rule

The proposed rule proposes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). Also includes proposal concerning Quality Programs, EHR Incentive Programs, Cost-Reporting and Physician Claim Certifications.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08705.pdf

Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program

This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09015.pdf

Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019

This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08961.pdf

FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 2019)

This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs), which include psychiatric hospitals and excluded psychiatric units of an acute care hospital or critical access hospital.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09069.pdf

 

OTHER MEDICARE UPDATES

Kepro Case Review Connections, Acute Care Edition, Spring 2018

A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

https://www.keproqio.com/providers/spring-2018-acute-newsletter/

Trump Administration Releases Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs

https://www.hhs.gov/about/news/2018/05/11/trump-administration-releases-blueprint-lower-drug-prices-and-reduce-out-pocket-costs.html

“We rarely talk about cost. We talk about waste, quality, and safety, and we find our costs go down.”

• Patrick Hagan, former COO of Seattle Children’s Hospital

Risk Factor: Socio-economic Status

The Establishing Beneficiary Equity in the Hospital Readmission Reduction Program Act of 2015 (S. 688 and H.R. 1343) would have required the CMS to account for socio-economic status when calculating risk-adjusted readmission penalties. This bill garnered support from the Association of American Medical Colleges as well as the American Hospital Association. You can read more about this Act in a related MMP article.

A year later the House Ways and Means Committee released the Helping Hospitals Improve Patient Care Act of 2016 (H.R. 5273) that included a modified version of H.R. 1343. This latest version of the bill was passed in the House and was sent to the Senate where it was read twice and referred to the Committee on Finance. 

Fast Forward to the 2019 IPPS Proposed Rule which includes a discussion about “Accounting for Social Risk Factors” (including socioeconomic status) in the following Programs discussed in the Proposed Rule:

• Hospital Readmission Reduction Program (HRRP),
• Hospital Value Based Purchasing (VBP) Program,
• Hospital Acquired Condition (HAC) Reduction Program,
• Hospital Inpatient Quality Reporting (IQR) Program,
• IPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and
• Long Term Care Hospital Quality Reporting Program (LTCH QRP).

Accounting for Social Risk Factors

CMS notes their “commitment to ensuring that medically complex patients, as well as those with social risk factors, receive excellent care. We discussed how studies show that social risk factors, such as being near or below the poverty level as determined by HHS, belonging to a racial or ethnic minority group, or living with a disability, can be associated with poor health outcomes and how some of this disparity is related to the quality of health care.”

Specific CMS aims within their core objectives include:

• Improving health outcomes,
• Attaining health equity for all beneficiaries, and
• Ensuring that complex patients as well as those with social risk factors receive excellent care.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the National Academy of Medicine

The ASPE and National Academy of Medicine have examined the influence of social risk factors in the CMS value-based purchasing programs. To date, as required by the IMPACT Act of 2014, ASPE has provided a report to Congress where they found that “in the context of value-based purchasing programs, dual eligibility was the most powerful predictor of poor health care outcomes among those social risk factors they examined and tested.” ASPE is continuing to examine this issue in a second report required by the IMPACT Act that is due to Congress in the fall of 2019.

National Quality Forum (NQF)

CMS noted in the FY 2018 IPPS/LTCH PPS Final Rule, that the NQF “undertook a 2-year trial period in which certain new measures and measures undergoing maintenance review have been assessed to determine if risk adjustment for social risk factors is appropriate for those measures.” This period ended April 2017.

NQF Trial Conclusion:

The NQF notes in the July 2017 Social Risk Trial Final Report Abstract that “the trial period has illuminated the feasibility of adjusting measures for social risk, with 17 measures endorsed by NQF for factors such as a person’s level of education.” The NQF has extended the socioeconomic status (SES) Trial, allowing further examination of social risk factors in outcome measures.

The Centers for Medicare and Medicaid Services

CMS solicited feedback in the FY and CY 2018 Proposed Rules on which social risk factors provide the most valuable information to stakeholders for illuminating differences in outcome rates among patient groups. Commenters encouraged CMS to stratify measures by other social risk factors such as age, income, and educational attainment (82 FR 38404).

CMS Next Steps

As next steps, CMS is considering the following:

• Options to reduce health disparities among patient groups within and across hospitals by increasing the transparency of disparities as shown by quality measures,
• Implementing a hospital-specific disparity method that would promote quality improvement by calculating difference in outcome rates among patient groups within a hospital while accounting for their clinical risk factors,
• Implementing a method to assess hospitals’ outcome rates for subgroups of patients, such as dual eligible patients, across hospitals, allowing for a comparison among hospitals on their performance caring for patients with social risk factors.

Specific to the Hospital IQR Program, CMS acknowledges the complexity of interpreting stratified outcome measures and plans to stratify Pneumonia Readmission measure (NQF #0506) data by highlighting both hospital-specific disparities and readmission rates specific for dual-eligible beneficiaries across hospitals for dual-eligible patients in hospitals’ confidential feedback reports beginning Fall 2018. CMS is considering expanding confidential hospital feedback reports for other measures and eventually making this data publicly available on the Hospital Compare website.

CMS believes “the stratified results will provide hospitals with information that could illuminate disparities in care or outcome, which could subsequently be targeted through quality improvement efforts. We further believe that public display of this information could drive consumer choice and spark additional improvement efforts.” CMS plans to continue to work with the ASPE, the public and key stakeholders to “identify policy solutions that achieve the goals of attaining health equity for all beneficiaries and minimizing unintended consequences.”