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LIVANTA is the New National Medicare Claim Review Contractor for Short Stay and Higher-Weighted DRG Reviews
Published on Apr 14, 2021

As a child of the 70’s in the south, the television line up at my house on Saturday night, when we were not at some type of ball game, was Looney Tunes, Hee Haw, Love Boat and Fantasy Island. That said, let us focus on Hee Haw’s Gossip Girls and their song that hopefully won’t get stuck on a loop in your head:

“Now, we’re not ones to go ‘round spreadin’ rumors, Why, really we’re just not the gossipy kind, No, you’ll never hear of us repeating gossip, So you’d better be sure and listen close the first time!”

Recently, I have read that Livanta, one of the current Beneficiary and Family Centered Care – Quality Improvement Organizations (BFCC-QIS), was going to be the new Medicare contractor responsible for Short Stay Reviews (SSRs) and higher-weighed-DRG (HWDRG) reviews nationwide. As background information, in May 2019, BFCC-QIO short stay reviews were put on hold as CMS planned to procure a new BFCC-QIO contractor who would perform SSRs and HWDRG reviews on a national basis. CMS anticipated awarding this contract by the 3rd quarter of calendar year 2019. As of last week, I had been unable to find an award notice from CMS and unlike the Gossip Girls, I have been waiting to find confirmation from CMS or Livanta before sharing information in our newsletter.

This past Friday April 9th, I found that Livanta has provided confirmation on their website, with the following bolded notice:

Attention Providers: Livanta was awarded the contract for performing claim reviews for Short Stay and Higher-Weight Diagnosis Related Group (HWDRG) claims in all U.S. states and territories.

Under the announcement there is a link to a new Livanta National Medicare Claim Review Contractor Webpage. Important information available to Providers on this webpage includes:

  • Frequently asked questions such as information about HWDRG and Short Stay Reviews (SSRs).
  • Information about a Memorandum of Agreement (MOA) that acute care inpatient hospitals, inpatient psychiatric hospitals, and long-term acute care (LTAC) hospitals are required to submit to Livanta. Note, the MOA template is available as a download on this page.
  • Information about medical record reimbursement and the process for submitting medical records to Livanta.
  • As to the timing of when these reviews will begin, Livanta offers the following information:

    “In the coming weeks, Livanta will begin conducting this work in all states, territories, and Washington, D.C. As part of the review activities, Livanta’s reviewers will evaluate whether the services performed were medically necessary and paid appropriately.”

Beth Cobb

OIG Hospital Provider Compliance Audits
Published on Apr 14, 2021
Add Hospital Provider Compliance Audits to the List of OIG Activities You Need to Know

My oldest nephew is in the midst of his second semester of college life. Academically speaking, he excelled during the first semester. Unfortunately, that is not the case with his Freshman English class this spring. Evidently, the class involves writing several papers and his Professor has been less than impressed with my nephew’s writing efforts. My nephew has met with his Professor to try and understand what he can do to improve his writing skills. Unfortunately, even though his Professor has taken the time to talk with him, my nephew doesn’t seem to be able to pinpoint exactly what he needs to do from this discussion.

The OIG has been conducting Medicare Hospital Provider Compliance Audits as far back as March of 2011. To date, they have completed 190 audits. You can find a table of all these audits on the OIG’s Hospital Compliance Reviews webpage. Unlike my nephew’s English Professor, the OIG is very clear about what their audits focus on. Specifically, they focus on what they describe as “risk areas that we identified as a result of prior OIG audits at other hospitals.”

Two years into their Hospital Provider Compliance Audits, the OIG began to extrapolate audit findings with adverse financial consequences for Providers. In May of 2013, Nashville Tennessee based Saint Thomas Hospital, was the first hospital subject to extrapolation. In the Saint Thomas audit, the OIG identified overpayments of $293,359 and extrapolated this amount over the claims during the audit period. Through extrapolation, the OIG recommended that the Hospital refund to the contractor $1,092,248. In general, every hospital that has been subject to extrapolation during an OIG Hospital Provider Compliance Audit has disagreed with the OIG’s method for extrapolation.

OIG Hospital Provider Compliance Audit: Sunrise Hospital & Medical Center The OIG’s most recent audit was released on April 1, 2021 and details their audit of Sunrise Hospital & Medical Center located in Las Vegas, Nevada. Medicare paid the Hospital approximately $245 million for 15 million inpatient and 25,308 outpatient claims from January 1, 2017, through December 31, 2018 (the audit period).

The OIG’s audit covered about $41 million in Medicare payments to the hospital for 2,117 claims potentially at risk for billing errors. Ultimately, the audit included a stratified random sample of 100 claims (85 inpatient and 15 outpatient) with payments totaling $2.4 million. The at risk areas specific to this audit included:

  • Inpatient rehabilitation facility claims,
  • Inpatient comprehensive error rate testing (CERT) DRG codes,
  • Inpatient high-severity level DRG codes,
  • Inpatient mechanical ventilation,
  • Inpatient claims paid in excess of $25,000,
  • Inpatient same day discharge and readmit,
  • Outpatient bypass modifiers,
  • Outpatient claims paid in excess of $25,000,
  • Outpatient claims paid in excess of charges, and
  • Outpatient skilled nursing facility (SNF) consolidated billing.

The OIG found that the hospital complied with Medicare billing requirements for 46 of the 100 inpatient and outpatient claims reviewed. For the remaining 54 claims, the OIG found that the hospital did not fully comply with Medicare billing requirements. Specific claims and monetary impact included:

  • 50 Inpatient claims had billing errors resulting in net overpayments of $1,002,049,
    • 36 of these claims were Inpatient Rehabilitation Facility admissions where the OIG believed the Hospital had incorrectly billed for stays not meeting Medicare criteria for acute inpatient rehabilitation.
  • 4 Outpatient claims had billing errors resulting in net underpayments of $2,099.
  • The OIG estimated that the Hospital received overpayments of at least $23,615,809 for the audit period.

Ultimately, the OIG extrapolated the audit findings and recommended that the Hospital refund to the Medicare contractor $23.6 million in net estimated overpayments. The Hospital disagreed with most of the OIG’s findings. However, at the end of the day, the OIG indicated that “after review and consideration of the Hospital’s comments, we maintain that our findings and recommendations are correct.”

Moving Forward

In spite of the COVID-19 pandemic, the OIG managed to publish the results from nine Hospital Provider Compliance Audits in 2020. Given that the OIG has been conducting this type of audit since 2011 and their propensity to extrapolate audit findings, understanding provider compliance “at risk” issues has become as important as knowing what items are on the OIG’s Work Plan.

Beth Cobb

COVID-19 in the News March 31st through April 5th, 2021
Published on Apr 07, 2021
 | Coding 

This week we highlight key updates spanning from March 31st through April 5th of 2021.


Resource Spotlight: Medicare COVID-19 Data Snapshot Updated March 24,2021

The Medicare COVID-19 Data Snapshot provides summary data and visuals from Medicare Fee-for-Service (FFS) claims data, Medicare Advantage (MA) plans encounter data, and Medicare enrollment information.


COVID-19 cases and hospitalization are identified by ICD-10-CM codes:

·        B97.29 from January 1st through March31st 2020, and

·        U071 effective April 1, 2021 forward.


The most recent update to the Data Snapshot represents claims data from January 1, 2020 through December 26,2020. As of late 2020 around 63.1 million Americans are enrolled in Medicare with 60% in Medicare FFS, and 40% in MA plans. CMS cautions that data is preliminary as there is always a “claims lag” between services provided and when the claim is in the database.  With that in mind the specific dates of service includes claims received by January22, 2021.


Since the last Data Snapshot release:

·        For the first time since CMS began publishing the Data Snapshot, rural cases of COVID-19 (4,271 per 100,000) is higher than in urban areas (4,151 per 100,00),

·        Medicare FFS spending associated with COVID-19hospitals grew to $10.3 billion, and

·        Hypertension remains the most prevalent chronic condition among Medicare FFS COVID-19 hospitalized beneficiaries at 78%.


You can read more about the recent Data Snapshot update in a related CMS Press Release.


April 1, 2021:  Advancements in Over-the-Counter (OTC) Tests for COVID-19

The FDA announced they had taken “swift action this week to get more tests for screening asymptomatic individuals on the market” by authorizing three tests with serial screening claims. They go on to note these tests had already been authorized for use by the agency to test individuals with COVID-19 symptoms, but this week’s authorization is for testing asymptomatic individuals when used for serial testing.


April 1, 2021: Repayment of COVID-19 Accelerated and Advance Payments began March 30, 2021

CMS published MLN article SE21004 on April 1stto inform all Medicare providers and suppliers who requested and receivedCOVID-19 Accelerated and Advance Payments (CAAPs) that they began recovering those payments as early as March 30, 2021. Also included in the article is information on how to identify recovered payments.


Additional information including a Press Release, Fact Sheet and Frequently Asked Questions is available on the CMS COVID-19 Accelerated and Advance Payments webpage.


April 1, 2021: No Out-of-Pocket Costs to Patients for COVID-19 Vaccine Administration

Currently, the United States Government has purchased all COVID-19 vaccine in the U.S. for administration exclusively by enrolled providers through the CDC COVID-19 Vaccination Program.The Thursday April 1, 2021 edition of the CMS MLN Connects newsletter includes the following reminders for participants in this program:


“If you participate in the CDC COVID-19 Vaccination Program, you must:

·        Administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine

·        Vaccinate everyone, including the uninsured,regardless of coverage or network status

You also can’t:

·        Balance bill for COVID-19 vaccinations

·        Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given

·        Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination

Report any potential violations of these requirements to the HHS Office of the Inspector General:

·        Call 1-800-HHS-TIPS

·        Submit an online complaint

Submit claims for administering COVID-19 vaccines to:

·        Medicare, if your patient has Medicare Part B coverage or, for 2020 and 2021, Medicare Advantage (Part C)

·        Private insurance company (PDF), including if your patient only has Medicare Part A coverage with supplemental coverage from a private insurer  

·        Your state’s Medicaid program for patients with Medicaid and Children’s Health Insurance Program (CHIP) coverage

·        Health Resources & Services Administration (HRSA) COVID-19 Uninsured Program ,including if your Medicare patient only has Part A coverage with no supplemental coverage”


April 2, 2021: International Travel During COVID-19 – CDC Guidance Updated

The CDC has updated their guidance regarding international travel during COVID-19 to note that “fully vaccinated travelers are less likely to get and spread COVID-19. However, international travel poses additional risks and even fully vaccinated travelers are at increased risk for getting and possibly spreading new COVID-19 variants. CDC recommends delaying international travel until you are fully vaccinated.” The update also includes tips for getting tested after travel and self-quarantining.


April 5, 2021: Acute Hospital Care at Home Program List of Approved Hospitals Updated

This program is an expansion of the CMS Hospitals Without Walls Initiative launched over a year ago now in March 2020. CMS once again updated the list of approved hospitals. The updated list also includes a note that this list will be moving to the CMS Hospital at Home webpage beginning April 9, 2021.

Beth Cobb

Claims Processing Instructions for Implantable Cardiac Defibrillators
Published on Apr 07, 2021

Reading CMS’s recently released Change Request (CR) 12104  titled Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) made me feel like I had entered the land of Fantasia from The Never Ending Story or as if I was waking up to Sonny and Cher singing I Got You Babe for the umpteenth time in the Bill Murray classic Ground Hog’s Day. Either way, it has been a long road from the release of a Proposed Decision Memo to the transmittal providing claims processing instructions.


The Never Ending Story, Gets It’s Ending

·        May 30, 2017: CMS announced the opening of a National Coverage Analysis (NCA)for Implantable Cardioverter Defibrillators.

·        November 20, 2017: CMS issued a Proposed Decision Memo.

·        February 15, 2018: CMS issued a Final Decision Memo.

·        November 21, 2018: Transmittal 209 (CR 10865) was issued reflecting the reconsideration of an updated version of NCD 20.4. CMS noted that a subsequent CR would be released at a later date containing a Claims Processing Manual update with accompanying instructions. Until that time, CMS instructed that Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.

·        February 15, 2019: Transmittal 211 was rescinded and replaced with Transmittal 213 to change the implementation date from February 26, 2019 to March 26, 2019.

·        March 26, 2019: CMS’ final implementation date for NCD20.4.

·        March 26, 2019: Eleven of the twelve MACs published a Local Coverage Article titled Billing and Coding: Implantable Automatic Defibrillators including:

        o   First Coast Service Options, Inc. (Jurisdiction N) – Article A56341,

       o   National Government Services, Inc. (Jurisdictions 6 and K) – Article A56326,

        o   Noridian Healthcare Solutions, LLC (Jurisdiction E) – Article A56340,

        o   Noridian Healthcare Solutions, LLC (Jurisdiction F) - Article A56342,

        o   Novitas Solutions, Inc. (Jurisdictions H and L) – Article A56355,

        o   Palmetto GBA (Jurisdictions J and M) – Article A56343, and

        o   Wisconsin Physician Service Insurance Corporation (Jurisdictions 5 and 8) – ArticleA56391.

·        March 2, 2020: CMS published MLN SE20006 updating providers on Medicare coverage rules and policies for NCD 20.4. Specifically, this article addresses concerns related to requiring the use of heart failure diagnosis codes. They end this article by stating that “it is incumbent upon the provider to select the proper code(s). We believe the listed covered codes encompass the various clinical scenarios that occur for patients who meet the NCD coverage requirements and are provided, not to write additional parameters into the NCD, but to ensure there is an appropriate code for the covered indications.”

·        March 23, 2021: CMS released CR 12104 and a related MLN MM12104 on March 24, 2021 detailing the claims processing instructions for NCD 20.4.


In Ground Hog’s Day, Bill Murry keeps reliving the same day over and over until he finally turns it around into the perfect day. Almost four years from the opening of the coverage analysis, CMS has provided the final piece to implantable cardiac defibrillators.  


Moving Forward to Your Happy Ending

·        First, now is a good time to review NCD 20.4 to understand the indications for when an ICD implantation is considered medically necessary by CMS.

·        Transmittal 12104 details the codes you “shall” use on your claims when billing for services provided. To assist in understanding the codes, I recommend that you read your MAC’s related coding and billing article as it outlines codes specific to each CMS indication for coverage in the NCD.

·        For patients clinically meeting the indications for a pacemaker and an ICD, all twelve MACs have published billing and coding: single chamber and dual chamber permanent cardiac pacemaker articles related to the single and dual chamber pacemaker NCD 20.8.3.

·        This is also a good time to review a sample of claims at your hospital for documentation supporting medical necessity as well as appropriate coding.

·        Be aware that all Recovery Auditors have been approved to perform audits for medical necessity and documentation requirements for implantable automatic defibrillators in the outpatient (Issue RAC Issue 0093) and inpatient (RAC Issue 0195) setting.  

·        Last, know that the implementation date for Transmittal 12104 is July 6, 2021. However, take note that CMS indicates that MACs will not search their files for claims for ICD services between February 15, 2018, and the implementation date of this transmittal. “However, MACs should adjust those claims that are brought to their attention.”

Beth Cobb

COVID-19 in the News March 23rd through March 30th, 2021
Published on Mar 31, 2021
 | Coding 

This week we highlight key updates spanning from March 23rd through the 30th of 2021.

March 24, 2021:  OIG Report – Hospitals Operating in Survival Mode

The OIG released the Report in Brief titled, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery. This report is a compilation of perspectives shared by front-line in hospital administrators at 320 hospitals nationwide during brief interviews conducted from February 22nd through the 26th of 2021. The OIG calls this process a “Pulse Survey.” The first Pulse Survey highlighting challenges hospitals are facing was conducted in March 2020. The OIG notes that “this pulse survey offers hospital administrators’ perspectives on the most significant strains that the response to COVID-19 has exerted on hospitals, as well as their perspectives on the longer-term implications of these strains.” The following list are examples of Hospital-Reported Challenges in this report:

  • Difficulty balancing the complex and resource-intensive care needs for COVID-19 patients with efforts resuming routine hospital care,
  • Staffing shortages have affected patient care,
  • Exhaustion and trauma have taken a toll on staff’s mental health, and
  • Challenges associated with vaccine distribution efforts and concerns about hesitancy to receive a vaccine.

March 24, 2021: FDA Consumer Update: Learn More About COVID-19 Vaccines from the FDA

In this Consumer Update, common questions about COVID-19 vaccines are answered by the FDA. The update also provides a link to a YouTube video providing four facts about COVID-19 vaccines.

March 25, 2021: COVID-19 Legislation Related to Sequestration Suspension

  • The Budget Control Act of 2011 included a 2.00% across-the-board sequestration reduction to Medicare Fee-for-Service claims payments.
  • The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended this payment adjustment from May 1, 2020 through December 31, 2020.
  • Subsequently, the Consolidated Appropriations Act, 2021, signed into law on December 27, 2020, extended this suspension to March 31, 2021.
  • On March 19, 2021, the U.S. House passed House Resolution (HR) 1868, which would extend the sequestration suspension through December 31, 2021.
  • On March 25, 2021, the U.S. Senate passed Senate Amendment SA 1410 titled, Extension of Temporary Suspension of Medicare Sequestration. Similar to HR 1868, this Amendment extends the Sequestration suspension through December 31, 2021.

In the March 25, 2021 Senate Congressional Record discussion, Senator Shaheen (D-NH) noted in her remarks that “this week, I heard from Wentworth-Douglass Hospital in Dover, NH. They highlighted that this legislation would result in $2.1 million in desperately needed additional revenue for the hospitals…by passing a continued moratorium through 2021, Wentworth-Douglass will be in a better place to care for those in need and respond to any future crisis affecting the health of our community.”

The American Hospital Association (AHA) released a Special Bulletin in response to passage of the Senate bill. The AHA notes in the bulletin that “the House is expected to take up the Senate-passed bill the week of April 13 when it returns to Washington D.C. It is expected that the Centers for Medicare & Medicaid Services will hold the Medicare claims until the bill is signed into law as it has done in the past.”

March 26, 2021: COVID-19 Accelerated/Advance Payments (CAAPs) Recoupment Fast Approaching

Palmetto GBA, the Medicare Administrative Contractor for Jurisdictions J and M sent the following notice regarding CAAPs to those subscribed to receive emails:

“Providers and suppliers requesting and receiving COVID-19 Accelerated/Advance Payments (CAAPs) in 2020 will receive an email in the coming days reminding them that the recoup period is fast approaching. The emails are being issued to a provider or supplier designated CAAP point of contact.

Included in the email is a copy of the October 2020 reminder email that includes details regarding any CAAPs issued to that entity. Please note the amount due as listed on the October 2020 email attachment does not reflect any amount already refunded towards that balance. There is no need to call the provider contact center. Your current amount owed can be located in eServices’ Financial Tools tab, under Overpayment Data. No offset will begin occurring unless there is still an outstanding CAAP balance for the provider, supplier or an affiliated provider with the same tax identification number.  

Resource: Accelerated and Advance Payment Repayment & Recovery Frequently Asked Questions (October 8, 2020) (PDF, 45 KB)”

March 26, 2021: CMS to Resume Hospital Survey Activities

On January 20, 2021, CMS issued a memo limiting hospital surveys for 30 days “to ensure quality of care oversight while providing hospitals the ability to focus on serving their patients and communities.” The limitations were extended on February 18, 2021 for an additional 30 days through March 22, 2021. On March 26, 2021, CMS issued the Memorandum titled Resuming Hospital Survey Activities Following 30-Day Restrictions to inform State Survey Agency Directors with their plan to resume survey activities.

March 26, 2021: Department of Justice and COVID-19 Fraud

The Department of Justice published a notice detailing actions they have taken to combat COVID-19 related fraud. They note that as of March 26th:

  • 474 defendants have been publicly charged with criminal offenses for fraud related schemes connected to the COVID-19 pandemic,
  • Cumulatively, this represents attempts to obtain over $569 million from the U.S. government and unsuspecting individuals.

Acting Assistant Attorney General Nicholas L. McQuaid of the Justice Department’s Criminal Division following message is included in this announcement: “To anyone thinking of using the global pandemic as an opportunity to scam and steal from hardworking Americans, my advice is simple – don’t…no matter where you are or who you are, we will find you and prosecute you to the fullest extent of the law.”

March 29, 2021: CDC Resource for Healthcare Providers: Caring for Patients at Higher Risks for Developing Severe Outcomes of COVID-19

The CDC has published this webpage specifically as an evidence-based resource for Healthcare Providers and notes that this page is distinct from the People with Certain Medical Conditions webpage which is intended for the general public. Following are examples of information shared on this webpage:

  • Age is the strongest risk factor for severe COVID-19 outcomes as people 65 years or older accounts for more than 80% of the U.S. COVID-19 related deaths.
  • Adults of any age with certain underlying medical conditions are at increased risk for severe illness from COVID-19. This risk increases as the number of underlying medical conditions for a person increases.
  • The most common comorbidities, based on key findings from a retrospective study of 64,781 patients with COVID-19, includes:
  • 46.7% of the patients had hypertension (HTN),
  • 28.9% of the patient patients had a diagnosis of hyperlipidemia,
  • 27.9% of the patients were a diabetic, and
  • 16.1% of the patients had a chronic pulmonary condition.

March 29, 2021: CDC Study Confirms Protective Benefits of mRNA COVID-19 Vaccines

The CDC announced in a Press Release the findings of a new study which “provides strong evidence that mRNA COVID-19 vaccines are highly effective in preventing SARS-CoV-2 infections in real-world conditions among health care personnel, first responders, and other essential workers.”  Results among study participants revealed the following:

  • Following a single dose of the Pfizer-BioNTech or Moderna mRNA vaccines the risk of infection with SARS-CoV-2 was reduced by 80% two or more weeks after vaccination, and
  • Following the second dose of vaccine, risk of infection was reduced by 90% two or more weeks after vaccination.

March 30, 2021: Special Edition MLN Connects: Temporary Claims Hold

CMS released the following notice in a Special Edition MLN Connects regarding the pending congressional action to extend the Sequestration Suspension:

“In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, we instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess if Congress extends the suspension; the MACs will automatically reprocess any claims paid with the reduction applied if necessary.”

Beth Cobb

How Can I Keep Up with Current Medicare Review Contractors’ Review Targets?
Published on Mar 31, 2021
 | CERT 
 | Coding 

My youngest nephew is currently the number one pitcher for his high school baseball team. His team recently participated in a spring break tournament in Memphis, Tennessee. Unfortunately, they only won one game. However, as my brother said, it was a valuable experience for the coaches to identify what the challenges are for the team for the rest of the season.

Similarly, hospitals are challenged with identifying who all of the players are that perform Medicare Fee-for-Service record reviews and what risk areas are they targeting. So, instead of Abbott and Costello trying to clarify “Who’s on First, What’s on second, and I Don’t Know’s on third,” this article identifies the Who’s (OIG, MAC, RAC, SMRC, CERT, and PEPPER), so you won’t feel like the third baseman “I Don’t Know.”

Office of Inspector General (OIG):

In June of 2017 the OIG began updating their once Annual Work Plan on a monthly basis. In an announcement they indicated that the Work Planning Process is “dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available. You can learn more about the work plan, recently added items, all active work plan items and a work plan archive on the OIG website. You can access the Work Plan on the OIG website.

Medicare Administrative Contractors (MACs):

In October 2017, CMS implemented a Target Probe and Educate (TPE) Review Process for the MACs. With this type of approach, MACs focus on providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. In general, MACs will post a current Active Medical Log to their website. Depending on the MAC, this can sometimes be a challenge to find.

At this time, due to the ongoing COVID-19 Pandemic, TPE Reviews are on hold. However, MACs are conducting Post-Payment Reviews. Similar to TPE Reviews, MACs have been posting their post-payment review targets and audit findings to their websites.

If you are unsure of who your MAC is, you can find out on the CMS MAC Website List webpage.

Recovery Audit Program (RACs)

The RACs review claims on a post-payment basis. CMS maintains a RAC webpage where you will find links to each of the RACs across the country, Proposed Topics and Approved RAC Topics for review. A few of their current Approved Topics includes Total Knee Arthroplasty, Polysomnography, and Implantable Automatic Defibrillators (ICDs) medical necessity and documentation requirements reviews.

Supplemental Medical Review Contractor (SMRC)

The SMRC performs reviews at the direction of CMS with the aim of lowering improper payment rates.

On February 13, 2018 CMS announced that Noridian Healthcare Solutions, LLC, was awarded the new $227 million contract. Similar to the RACs, one of the current projects for Noridian is polysomnography. They are also conducting a medical review of COVID-19 claims in response to the 20% add on payment as a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act enacted on March 27, 2020.

The Comprehensive Error Rate Testing (CERT) Program

CMS implemented the CERT program to measure improper payments in the Medicare Fee-for-Service program. Annually, the CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B MACs and Durable Medical Equipment MACs (DMACs) for review. It is important to keep in mind that the CERT reports a measurement of payments not meeting Medicare requirements and is not a “fraud rate.”

Every year an Annual Report and Report Appendices is published on the CERT CMS webpage. Reviewing these reports can help you identify high error prone case types. For example, in the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data, the top four service types with highest improper payments in the hospital inpatient setting included:

  • Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469 and 470),
  • Endovascular Cardiac Valve Replacements (MS-DRGs 266, and 267),
  • Spinal Fusion Except Cervical (MS-DRGs 459 and 460), and
  • Percutaneous Intracardiac Procedures (MS-DRGs 273 and 274).

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

In 2015, CMS made the decision to move Short Stay reviews from the MACs to the BFCC-QIOs. These reviews are for hospital inpatient admissions with a length of stay less than two midnights and focus on ensuring doctors and hospitals are following the Part A payment policy for inpatient admission. Effective May 8, 2019, CMS temporarily suspended Short Stay reviews to find one contractor to perform Short Stay and Higher Weighted DRG (HWDRG) reviews. To date, CMS has not announced who this will be. In the meantime, you can find out who your BFCC-QIO is at this website:

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

The PEPPER is an electronic data report containing a single hospital’s claims data statistics for MS-DRGs and discharges at risk for improper payment due to billing, coding and/or admission necessity issues. Each report compares a hospital to their state, MAC Jurisdiction and the nation. “The Office of Inspector General encourages hospitals to develop and implement a compliance program to protect their operations from fraud and abuse. As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the hospital’s auditing and monitoring activities.” In general, a hospital’s Quality Department can provide the report to key departments (i.e. Case Management and HIM).

MMP’s Protection Assessment Report (PAR)

In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide to measure the effectiveness of compliance programs.  Items 5.27-5.36 emphasize that a Risk Assessment is key to developing an effective Compliance audit/work plan.  As you can see from the list of Contractors above, the number of Medicare risk areas to consider can be overwhelming and the financial risk is great.

Medical Management Plus, Inc. (MMP) can help.  Our proprietary Protection Assessment Report incorporates current OIG, MAC, RAC, SMRC, CERT, and PEPPER risk areas into one report. Working closely with RealTime Medicare Data (RTMD), hospital specific Medicare fee-for-service paid claims data (volume, charges and payments) for risk areas is included in this report. If you are interested in learning more about this Report, please contact us using the form below or 205-941-1105.

Beth Cobb

Legislation Impact on MS-DRG Payments during the COVID-19 Public Health Emergency (PHE)
Published on Mar 23, 2021
 | Coding 

The U.S. government’s response to the COVID-19 pandemic and subsequent Public Health Emergency (PHE) has resulted in among other things, waivers and flexibilities for health care providers, expansion of

Telehealth services, an ever lengthening COVID-19 FAQs on Medicare Fee-for-Service (FFS) Billing document, and several legislative acts. This article focuses on legislative acts impacting payments to IPPS hospitals.


The Coronavirus Aid, Relief, and Economic Security (CARES) Act was enacted March 27, 2020. Section 3710 of this Act directed the Secretary to increase the IPPS weighting factor of the assigned diagnosis-related group (DRG) by 20 percent for patients diagnosed with COVID-19 and are discharged during the COVID-19 PHE. This increase in payment impacts patients discharges on and after January 27, 2020. Note, the CMS COVID-19 FAQs document referenced at the beginning of this article provides detail on how CMS implemented this increased payment.

The CARES Act also suspended the 2% sequestration payment adjustment applied to all Medicare FFS claims from May 1 through December 31, 2020. This payment adjustment was included in the Budget Control Act that was signed into law in August 2011 and became effective April 1, 2013. This Act required that $1.2 trillion in federal spending cuts be achieved over the course of nine years. With no action from Congress, sequestration would last until 2022. You can read more about the 2013 Sequestration in an American Medical Association FAQs document.

August 17, 2020: MLN SE20015 Updated to Address Potential Medicare Program Integrity List

CMS revised MLN article SE20015 by adding guidance “to address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.”

Consolidated Appropriations Act, 2021

This Act was signed into law on December 27, 2020 and among other things extended the sequestration suspension period to March 31, 2021.

March 19, 2021: U.S. House Resolution – To Prevent Across-the-Board Direct Spending Cuts, and for other Purposes

Representative John A. Yarmuth (D-KY) introduced House Resolution (HR) 1868 on March 12th. This resolution, passed in the House on March 19, 2021, includes an extension of the sequestration suspension through December 31, 2021. The resolution was received in the Senate on March 22nd leaving only eight days for the Senate to deliberate and vote before the current end to the suspension.

Public Health Emergency Declaration

An additional piece of the puzzle to the legislative impact on MS-DRG Payments is the COVID-19 PHE declaration. Remember that the 20 percent increase weighting for patients with a diagnosis of COVID-19 will occur during the COVID-19 PHE. As it stands at the time of this article, the most recent renewal of the COVID-19 PHE determination is set to expire April 21, 2021.

RealTime Medicare Data March 2020 Sepsis Infographic

Marvin Zick authored an April 7, 2020 article titled, Update: Can COVID-19 Cause Sepsis? Explaining the Relationship Between the Coronavirus Disease and Sepsis. He notes in the article that “now that more scientific data are available on COVID-19, the Global Sepsis Alliance can more definitively state that COVID-19 does indeed cause sepsis.”

RTMD Footprint Average Payment and Average Length of Stay (ALOS) for Sepsis

Given the relationship between COVID-19 and Sepsis, the March infographic in this week’s newsletter focused on MS-DRG 870 (Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours). Claims data was pulled from RTMD’s footprint, which included 48 states and DC. Specifically, the infographic highlights changes in average payment and average length of stay (ALOS) for January through September claims for CMS Fiscal Year (FY) 2019 and 2020. For MS-DRG 870:

  • The average payment increased 11.5% or $5,340, and
  • The ALOS increased 4.5% or 0.68 days.

Diving deeper into the claims data, state specific findings revealed a wide range in the averages.

  • State specific percent of change in the average payment ranged from -13.7% to 26.4%, and
  • In general, states realized an increase in ALOS that ranged from 0.08 days to 3.07 days.

National Average Payment and ALOS for Sepsis

The RTMD database contains actual Medicare Fee-for-Service paid claims information. To contrast actual changes to national average changes, below highlights MS-DRG 870 changes based on the Optum 360° DRG Expert for the same time periods.

  • The national average payment increase in contrast to RTMD’s actual paid claims data was only $1,095.15, and
  • The ALOS actually decreased by 0.1 days.

At the time the DRG Expert was published, we were not in the throes of a pandemic nor could the resulting Legislative Acts have been anticipated.

As hospitals try to forecast budgets for coming years, it becomes essential to keep in mind that the 20% increase in MS-DRG weighting will only last until the end of the COVID-19 PHE and at the time this article was written, the 2% sequestration could possibly become effective again on April 1, 2021.

Beth Cobb

COVID-19 in the News February March 16th through March 22nd, 2021
Published on Mar 23, 2021

This week we highlight key updates spanning from March 16th through 22nd of 2021.


March 15, 2021: FDA Launches COVID-19 Adverse Events Reporting System (FAERS) Public Dashboard

The FDA has launched this dashboard with the intent to make adverse event data publically available. In the Public Dashboard announcement, the FDA does note that there are limitations to the data. “For example, while FAERS contains reports on a particular drug or biologic, this does not mean that the drug or biologic caused the adverse event.”


March 16, 2021: CDC Updates Regarding SARS-CoV-2 Variants

The CDC updated their SARS-CoV-2 Variants webpage. Multiple variants have now been detected and a US government interagency group has developed a Variant Classification scheme to define the three classes of variants:

  • Variant of Interest,
  • Variant of concern, and
  • Variant of High Consequence.

To date, California has seen two variants of concern (B.1.427 and B.1.429). Both of the variants may be about 20 percent more transmissible.

Two variants in California are now considered “variants of concern”


March 17, 2021:  American Rescue Plan (ARP) Act of 2021 Funding for COVID-19

President Biden signed the ARP Act into law on March 11, 2021. The following list highlights how some of the $1.9 trillion will be allocated to continue the fight against COVID-19:

  • $10 billion will be used to ramp up screening testing to help schools reopen,
  • $2.25 billion to scale up testing in underserved populations, and provide new guidance on asymptomatic screening testing in schools, workplaces, and congregate settings, and
  • $255 million for the production and delivery of 50 million Abbot BinaxNOW rapid point-of-care antigen tests for COVID-19 to support continued screening testing in long-term care facilities.

You can read more about where funding is being allocated in a March 17, 2021 HHS Press Release


March 17, 2021: First SARS-CoV-2 Diagnostic Test Permitted to be Marketed beyond the Public Health Emergency

The FDA announced that the BioFire Respiratory Panel 2.1 (RP2.1) has been granted marketing authorization using the De Novo premarket review pathway. The BioFire Respiratory Panel is “a diagnostic test for the simultaneous qualitative detection and identification of multiple respiratory viral and bacterial nucleic acids in nasopharyngeal swabs (NPS) obtained from individuals suspected of COVID-19 and other respiratory tract infections.” This test is for use in patients suspected of respiratory tract infections, including COVID-19.


March 18, 2021: CPT Codes Inadvertently Added to Telehealth Services

The 2021 Physician Fee Schedule final rule was issued on December 1, 2020. A related CMS Fact Sheet indicates that CMS finalized a third temporary category of criteria for adding services to the list of Medicare telehealth services. “Category 3 describes services added to the Medicare telehealth list during the public health emergency (PHE)…for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends.”  CMS published final and interim final rule corrections in the March 18, 2021 Federal Register. Specific to the Category 3 list, CMS notes that the following four CPT codes were “inadvertently” added to the services for temporary addition to telehealth services list:

  • CPT code 96121: Neurobehavioral Status Examination,
  • CPT code 99221: New or established patient initial hospital inpatient care services,
  • CPT code 99222: New or established patient initial hospital inpatient care services, and
  • CPT code 99223: New or established patient initial hospital inpatient care services.


March 18, 2021: FDA Revises Fact Sheets to Address SARS-CoV-2 Variants for Monoclonal Antibody Products under EUA

The FDA announced revisions to health care provider fact sheets “to include additional information on the susceptibility of SARS-CoV-2 variants to each of the monoclonal antibody (mAb) therapies that are available through an Emergency Use Authorization (EUA) treatment of COVID-19.” Specifically, fact sheets for Bamlanivimab, Bamlanivimab and Etesevimab and REGEN_COV (Casirivimab and Imdevimab) has been revised.


March 19, 2021: U.S. House Passes Bill to Extend Halt on Sequestration

The Budget Control Act of 2011 included a 2.00% across-the-board sequestration reduction to Medicare Fee-for-Service claims payments. The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended this payment adjustment from May 1, 2020 through December 31, 2020. Subsequently, the Consolidated Appropriations Act, 2021 that was signed into law on December 27, 2020 extended this suspension to March 31, 2021. Now, as we are closing in on the end of March, the U.S. house has passed House Resolution (HR) 1868 that would extend this extension to December 31, 2021.

Beth Cobb

April 2021 Hospital Outpatient Prospective Payment System (OPPS) Update
Published on Mar 16, 2021

MLN Matter Article MM12175 was released March 9th and highlights changes in related CR12175 that have an effective date of April 1, 2021 and an implementation date of April 5, 2021. Following is a list of changes effective April 1st along with what you need to know:

Revised APC Assignments for Pfizer-BioNTech and Moderna COVID-19 CPT Administration Codes - What you need to know:

The APC assignments for the administration codes are being reassigned.

  • CPT codes 0001A (Pfizer Administration/Immunization code – first dose) and 0011A (Moderna Administration/Immunization code – first dose) from APC 1492 to APC 9397, and
  • CPT codes 0002A (Pfizer Administration/Immunization code – second dose) and 0012A (Moderna Administration/Immunization code – second dose) from APC 1493 to APC 9398.

You will find a link to Table 1 of CR 12175 that lists the APC titles for the two new COVID-19 vaccine administration codes in this article.

Janssen/Johnson & Johnson COVID-19 Vaccine and Vaccine Administration Code – What you need to know:

The American Medical Association (AMA) released 2 new CPT codes associated with this vaccine:

  • CPT code 91303 – vaccine product code, and
  • CPT cod 0031A – Administration/Immunization code.

The FDA issued an emergency use authorization (EUA) for this vaccine on February 27, 2021.

New Monoclonal Antibody Therapy Product Administration Codes – What you need to know:

Following is a list of new HCPCS codes for therapies that have been granted a EUA by the FDA and the effective date for the codes:

  • M0239 and Q0239 established effective November 9, 2020 for bamlanivimab,
  • M0243 and Q0243 established effective November 21, 2020 for casirivimab and imdevimab,
  • M0245 and Q0245 established effective February 9, 2021 for bamlanivimab and etesevimab administered together.

The MLN article provides detail regarding payment for a monoclonal antibody product.

CPT Proprietary Laboratory Analyses (PLA) Coding Change Effective April 1, 2021 – What you need to know:

Six new PLA codes have been established by the AMA CPT Editorial Panel with an effective date of April 1, 2021. This article provides a link to the table of new codes, which includes the code, long descriptor of the code and the OPPS Status Indicator (SI) for each code.

New HCPCS Codes – What you need to know:

The following two new HCPCS codes were established and are effective April 1, 2021:

  • HCPCS code C9776: describes the application of intraoperative near-infrared fluorescence imaging using indocyanine green on the extrahepatic ducts. The administration of this is associated with laparscopy cholecystectomy, and
  • HCPCS code C9777: describes the technology associated with esophageal mucosal integrity testing by Electrical Impedance.

Drugs, Biologicals, and Radiopharmaceuticals – What you need to know:

  • Three new HCPCS codes have been created and are effective April 1, 2021 for reporting drugs and biologicals in the hospital outpatient setting where there was no specific code available.
  • C9074 – Injection, lumasiran, 0.5 mg (Status Indicator G and APC 9407),
  • J7212 – Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram (Status Indicator G and APC 9395), and
  • Q5122 – Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg (Status Indicator G and APC 9406).
  • 10 HCPCS codes will have their pass-through status end on March 31, 2021. Table 11 of CR 12175 lists these codes and can be linked to from the MLN article. Effective April 1, 2021, the status indicator for all 10 HCPCS codes will change from G to K.
  • Seven new drug, biological, and radiopharmaceutical HCPCS codes have been established with an effective date of April 1, 2021. These codes are listed in Table 12 of CR 12175.
  • Two drug, biological, and radiopharmaceutical HCPCS codes will be deleted April 1, 2021:
  • J7333 – Hyaluronan or derivative, visco-3, for intra-articular injection, per dose, and
  • J7401 – Mometasone furoate sinus implant, 10 micrograms.
  • HCPCS code Q5122 (injection, pegfilgrasim-apgf, biosimilar, (Nyveprio), 0.5 mg) status indicator for January 1, 2021 through March 31, 2021 will be changed retroactively from E2 to K in the April I/OCE.

Drugs and Biologicals with Payments Based on Average Sale Price (ASP)

“Effective April 1, 2021, payment rates for many drugs and biologicals will change from the values published in the CY 2021 OPPS/ASC final rule with comment period as a result of the new ASP calculations based on sales price submissions from the third quarter of CY 2020. In cases where adjustments to payment rates are necessary, they will be incorporated into the April 2021 Fiscal Intermediary Shared System (FISS) release. We are not publishing updated payment rates in this CR implementing the April 2021 OPPS update. However, the updated payment rates effective April 1, 2021, are in the April 2021 update of the OPPS Addendums A and B.”

Note, this MLN article also includes additional changes to specific HCPCS codes (i.e. changes to the long descriptor of a code and status indicator changes/corrections). I encourage key stakeholders in your facility to read MLN MM12175 and Change Request 12175.

Beth Cobb

COVID-19 in the News March 10th through March 15th, 2021
Published on Mar 16, 2021

This week we highlight key updates spanning from March 10th through 15th of 2021.

Resource Spotlight: Long COVID Alliance

The Long COVID Alliance began in 2020 with a group of 21 science, post-viral disease and patient advocacy organizations calling for the government to invest in Long COVID research. To date 50+ partners have joined this alliance. Why is this collective so important? Long COVID also known as Post-acute COVID-19 syndrome, Long Haulers, Long-term COVID-19, or LTC-19 as a group, have lingering symptoms and has to date impacted 3.2 million Americans. In fact, “these symptoms persist in an estimated 25-35% of COVID-19 patients, regardless of infection severity, even after the patient no longer tests positive for the virus or antibodies…Long COVID generally refers to cases where symptoms continue to persist for 90 days or more.” I encourage you to check out the Alliance’s website to learn about their goals, and the impact to date that their efforts have made.


March 10, 2021: Trust for America’s Health Ready or Not 2021 Report

The Trust for America’s Health (TFAH) “develops reports and other resources and initiatives, and recommends policies, to advance an evidence-based public health system that is ready to meet the challenges of the 21st century.” On March 10th, TFAH released the report, Ready or Not 2021: Protecting the Public's Health Against Diseases, Disaster and Bioterrorism, measuring states’ performance on specific indicators. John Auerbach, President and CEO of TFAH is quoted in the announcement about this report that “The importance of this report is that it gives states actionable data to adopt policies that save lives. The COVID-19 crisis shows that we have much more work to do to protect Americans from health threats, particularly in the ways in which structural racism create and exacerbate health risks within communities of color. States need to take aggressive steps to shore up their preparedness for all types of public health emergencies.”


March 10, 2021: CMS Revises Nursing Home Visitation Recommendations

CMS has updated the September 17, 2020 memorandum titled Nursing Home Visitation – COVID-19. Revisions include new guidance for visitation in nursing homes during the COVID-19 Public Health Emergency (PHE), including the impact of COVID-19 vaccination. First and foremost, the Core Principles of COVID-19 Infection Prevention remains in place. The first principle has been updated to now include denial of entry to a facility for “those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor’s vaccination status).” You can also read more about the revisions in a related CMS Fact Sheet.


March 11, 2021: HHS News: Vaccine Program Expanded to 950 Community Health Centers

HHS announced in this Press Release that an additional 700 Health Resource and Services Administration (HRSA) supported health centers are to be invited to join the Health Center COVID-19 Vaccine Program. These 700 centers “serve high proportions of low-income and minority patients, provides services to rural or frontier populations, operate Tribal/Urban Indian Health Programs, and/or utilize mobile vans to deliver services.” 


March 11, 2021: Adults 18 and over Eligible for Vaccination no later than May 1st

President Biden announced in his first Prime Time speech to the nation that “All adult Americans will be eligible to get a vaccine no later than May 1. That's much earlier than expected. Let me be clear. That doesn't mean everyone's going to have that shot immediately, but it means you'll be able to get in line beginning May 1. Every adult will be eligible to get their shot, and to do this, we're going to go from a million shots a day that I promised in December before I was sworn in to beating our current pace of two million shots a day, outpacing the rest of the world.”


March 12, 2021: Emergency Use Authorization (EUA) for Propofol-Lipuro

The FDA’s March 12th COVID-19 Update Bulletin included the announcement of an EUA for Propofol-Lipuro 1% injection emulsion for use in patients older than 16 requiring sedation via continuous infusion who are in an intensive care unit on mechanical ventilation. The FDA notes that “Propofol-Lipuro 1% injectable emulsion for infusion is not FDA-approved and has important differences in its formulation compared to FDA-approved propofol drugs; providers should consult the Health Care Provider Fact Sheet for more information before administering it.”


March 12, 2021: Palmetto GBA Article – COVID-19 Laboratory Test Place of Service Limitation

Included in Palmetto GBA’s March 12, 2021 Daily Newsletter was an article indicating that “CMS has directed Medicare Administrative Contractors (MACs) to make any necessary Part B claim editing changes to ensure the following COVID-19 laboratory tests when billed with place of service 19 (off-campus outpatient hospital), 21 (inpatient hospital), 22 (on-campus outpatient hospital), or 23 (emergency room-hospital) are denied.”


March 15, 2021: OIG COVID-19 Portal Redesign

The OIG announced that their COVID-19 Portal has been redesigned and features additional resources, including a searchable list of their COVID-19 reports and downloadable graphics.


March 15, 2021: CMS Increases Medicare Payment for Administering COVID-19 Vaccine

CMS announced in a Press Release that the payment amount for administering the COVID-19 is increasing and noted that “this new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day.” Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies and other immunizers is increasing from approximately $28 to administer each dose of the vaccine to $40.

Beth Cobb

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