Knowledge Base Category -

Sometimes providers do not pay as much attention to the Medicare documentation requirements for diagnostic tests as they do for therapeutic services. There are several reasons for this. Diagnostic tests generally do not pay as much as therapeutic services, they are less likely to have a coverage policy, the documentation required is not as extensive as the documentation requirements for therapeutic services, and they are less likely to be reviewed by Medicare contractors. Therefore, the financial risk, even if some claims are reviewed, is not that significant for an individual provider. For Medicare however, due to the large volumes of diagnostic services, overpayments could result in significant costs.

The Medicare Comprehensive Error Rate Testing (CERT) program contractor audits random claims to determine if the Medicare Administrative Contractors (MACs) are paying claims appropriately. This means the CERT contractor looks at all types of claims, including those for diagnostic tests. WPS, the MAC for Jurisdictions 5 and 8, recently published an article containing documentation reminders related to CERT denials of diagnostic tests. Those documentation reminders are:

• “Only the treating physician, nurse practitioner, clinical nurse specialist or physician assistant can sign and date an order.
• The order must specify the exact test(s) ordered. Stating “x-ray” is not sufficient.
• The physician or non-physician must document the medical necessity in a signed and dated progress note.
• Medicare will not consider unsigned and/or undated orders; this includes laboratory requisition forms.
• Providers cannot use a signature attestation statement used in place of an unsigned order.”

These are the basics of which every provider should already be aware. But the article states the CERT contractor has “noted significant error findings for diagnostic services.” So, where do providers go wrong? First, nurses in a physician’s office cannot sign an order. Physicians and non-physician practitioners may delegate the writing of orders to others in the office, but they have to actually be the ones to validate and sign the orders. Remember that Medicare contractors do not accept late signatures or signature attestations for orders. Unsigned orders are “ignored” by Medicare reviewers – an unsigned order is the same as a non-existent order. Orders and progress notes describing the orders must be specific – for example, a progress note that states “labs ordered” or “x-rays ordered” is not sufficient.

The other big issue for diagnostic tests besides signed and dated orders is documentation supporting the medical necessity of the test. Years ago, if you had a signed and dated order that included a diagnosis or a diagnosis code, that was sufficient for medical necessity. These days, most Medicare reviewers want to also see the documentation from the physician, such as an office progress note, describing the medical necessity for the test. And remember any physician progress notes submitted to a Medicare contractor also have to be signed and dated by the practitioner. The good thing about CERT reviews is that the CERT contractor generally communicates the need for any additional documentation needed and gives the provider several chances to submit that before denying the claim.

Some other diagnostic services are also being targeted by other Medicare reviewers and entities. For example, Novitas (JH/JL MAC) is looking at cardiovascular nuclear medicine testing, sleep testing is part of the OIG Work Plan, and the Recovery Auditors (RACs) have complex reviews involving the medical necessity/coding of chest x-rays and the medical necessity of transthoracic echocardiography.

One new complex issue recently approved by all of the Recovery Auditors is for the diagnostic test Computed Tomography (CT) Coronary Angiography. The issue details reiterate the documentation reminders discussed above -

“All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage.”

How can hospitals ensure compliance with the signature and medical necessity requirements of diagnostic tests without undue effort? Train hospital personnel who first encounter orders for diagnostic testing to reject or obtain corrected orders when order requirements are not met – unsigned orders, orders not dated, orders lacking diagnoses, non-specific orders, etc. This could be the Scheduling, Registration, or Ancillary departments, for example. Hopefully, the practice of only accepting appropriate orders will encourage your physicians and practitioners to get it right the first time. On the back end, if a Medicare reviewer requests claims for diagnostic tests ensure all the required documentation is sent to the reviewer. The request for records should detail the specific medical record elements the reviewer needs. If required, contact the ordering physician’s office to obtain office progress notes for submission to the Medicare contractor.

With a little effort, denials of diagnostic tests can be eliminated or at least, minimized. Though not always a large financial impact, every penny helps and proactive processes also reduce the costs of additional time and effort.

There are no MAC Medical Review Activity updates for this month.

Another good resource for Providers is the CMS YouTube presentation Provider Minute: The Importance of Proper Documentation at https://www.youtube.com/watch?v=10pmw4czf08.

My first thought when I hear the word “smorgasbord,” in keeping with its primary definition, is a large well-stocked buffet meal. Can’t you just see and smell the seafood, soups, salad bars, meats, vegetables, side dishes and of course, desserts? It is hard to know where to begin and when to stop. The word “smorgasbord” has also come to mean any extensive array or variety. Recently, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published a smorgasbord of articles about various DRGs. These articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information.

As a reminder, CERT, which stands for Comprehensive Error Rate Testing (program), was established by CMS to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. CERT contractors select random claims out of the total claims’ submissions for a contractor for review. This random review of claims differs from that of other Medicare review entities who review selected topics based on risk and data analysis of aberrant utilization and/or billing patterns. A random review results in lower error rates since high-risk areas are not targeted, but it is also able to identify a broader array of issues.

CERT findings are used by other Medicare contractors, especially the MACs, to select topics for targeted reviews. According to Palmetto’s CERT webpage, “The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for our Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).” This means the CERT is sort of a report card on the MACs and in order to make a better “grade” the MACs educate providers based on the errors identified by the CERT. This can be accomplished through targeted reviews as mentioned above or through educational articles such as those that are the topic of this article.

The Palmetto articles offer a variety of information from documentation requirements to information on assignment of principal and secondary diagnosis to coverage requirements to consideration of an alternate DRG. Below is a listing of the DRGs featured in a Palmetto article so far, at the time of the writing of this article. It is possible Palmetto may be adding other articles, so check the links above to watch for more articles.

DRG 266 - Endovascular Cardiac Valve Replacement with MCC

• Addresses Transcatheter Aortic Valve Replacement (TAVR) and Tricuspid Valve Replacement
• Provides requirements for and a listing of ICD-10-PCS procedure codes
• “The correct procedure code must depict: Initial placement, Replacement, Removal, or Adjustment”
• TPE review topic for Jurisdiction N MAC, First Coast.

DRG 460 – Spinal Fusion

• Provides documentation requirements and strategies to support payment for spinal fusion-related hospital care, to reduce audit errors, and to substantiate the medical necessity of the procedure for a particular patient
• “The most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: “Failed outpatient therapy, admit for spinal fusion” are simply not sufficient evidence of medical necessity for the admission or the surgery.”
• Palmetto recently released a new LCD for Spinal Fusion services.
• TPE review topic for CGS, J15; new 2019 topic for Supplemental Medical Review Contractor (SMRC); and PEPPER target.

DRG 193, 194, and 195 - Simple Pneumonia and Pleurisy

• Addresses appropriate assignment of the principal and secondary diagnoses
• “Abnormal billing practices are seen when the principle and secondary diagnoses are improperly assigned, which can result in overpayments. The most common areas were related to sequencing of the principal diagnosis and improper coding of secondary diagnosis. Secondary diagnoses errors are related to selecting the improper code based on physician documentation or the addition of a secondary diagnosis that was not documented within the medical record.”
• DRGs 193 and 194 are PEPPER targets.

DRG 313 – Chest Pain

• Includes a listing of the principal diagnoses, a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• “The Principal Diagnoses are:
• R072 Precordial pain
• R0782 Intercostal pain
• R0789 Other chest pain
• R079 Chest pain, unspecified”
• Palmetto has an LCD that addresses Chest Pain

DRG 884 – Organic Disturbances and Mental Retardation and DRG 885 - Psychoses

• Provides information on coverage/benefits and documentation/billing requirements including the most common errors and reasons for denials
• The most common CERT errors are insufficient documentation and medically unnecessary service or treatment
• DRG 885 is currently a topic of review for both Palmetto JJ and JM Targeted Probe and Educate (TPE) program

DRG 092: Other Disorders of Nervous System with Complication or Comorbidity (CC) 

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 493 – Lower Extremity and Humerus Procedures except Hip, Foot, Femur w/CC)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also addresses medical record documentation requirements such as H&P, evidence of prior conservation treatment, outpatient records supporting medical necessity of procedure, imaging reports and operative reports.

DRG 682 - Renal Failure with Major Complication or Comorbidity (MCC)

• Contains a listing of the documentation required to support the principal and secondary diagnoses.
• This includes signs and symptoms, elevated urine protein, documented treatment, potential underlying cause, and specificity of whether acute or chronic failure
• Palmetto recently added this DRG as a TPE review topic for both JJ and JM

DRG 057 – Degenerative Nervous System Disorders W/O MCC

• Describes situations that can cause a neuropathic condition
• “The most common medical condition to cause peripheral neuropathy is diabetes mellitus. … Other medical conditions, such as HIV, kidney disorders, hormonal imbalances and cancers may also damage nerve cells. Heredity can play a role, as can traumatic situations such as a crush injury or fractured bone, which can result in compression, stretching, or severing of the nerve cell, leading to a neuropathic condition.”
• Also includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 227 – Cardiac Defibrillator Implant W/O Cardiac Catheterization w/o MCC

• Reviews the covered indications for implantation of a cardiac defibrillator
• “Medicare defines the requirements for coverage of an implantable cardioverter-defibrillator (ICD) insertion in National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators.”
• All MACs have a coverage article that addresses “Implantable Automatic Defibrillators – Coding and Billing” which can be found on the Medicare Coverage Database or your MAC’s website.

DRG 518 (Back and Neck Procedures except Spinal Fusion w/ Major Complications or Comorbidity (MCC) or Disc Device or Neurostimulator)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 312 – Syncope and Collapse

• Addresses the causes and clinical considerations of syncope, process and approach of key components, and principal diagnosis.
• Clinical considerations include other DRGs that might be more appropriate if the cause and underlying conditions can be determined.
• Consideration of appropriate patient status - “People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present.”
• PEPPER target

DRG 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis

DRG 556 (Signs and Symptoms of Musculoskeletal System and Connective Tissue without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
• “Do not use this DRG if the signs and symptoms are attributable to a specific condition:
• DRG 542 — Fatigue, stress or pathological fracture, initial encounter
• DRG 557 — Tendonitis, Myositis and Bursitis with MCC”

A smorgasbord indeed – lots to choose from and lots to digest. Happy reading!

I have really good intentions. I plan to do this and plan to do that, but sometimes “the best-laid plans of mice and men often go awry.” This is often simply a failure on my part to follow through, but other times, things happen that impede my plans. This can happen to anyone – rain on the day of a planned outdoor outing, an injury that prevents a planned activity, or extenuating circumstances that prevent a planned medical procedure.

The problem with planned medical procedures that have to be canceled is that the hospital often has already invested resources into preparing for the planned service. Thankfully, Medicare has a means to report canceled services that allows the hospital to recoup some or all of their expenses through the use of modifiers. It is incumbent on the hospitals to appropriately use these modifiers and maintain documentation in their medical records that support their use. As with all reimbursements, there is a risk that payments may be made when not appropriate. A couple of weeks ago, Medicare approved a new issue for the Recovery Auditors (RACs) regarding “Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements.” This is to be a complex review, meaning the RACs will request and review medical record documentation to determine if payment was appropriate. The review is for Ambulatory Surgical Centers (ASCs) and outpatient hospitals. As of the date of this article, none of the RACs have posted this issue on their Approved Issues websites. Also note that at this time, the link for the details of the issue on the CMS RAC Approved Issues webpage is not working.

However, the instructions for the use of modifiers for discontinued services can be found in Chapter 4 of the Medicare Claims Processing Manual, section 20.6.4. There are two modifiers for services which require the use of anesthesia and one modifier for services that do not require anesthesia. According to the manual reference above, “Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued.”

For the modifiers for services requiring anesthesia (modifiers -73 and -74), anesthesia is defined as:

• Local anesthesia,
• Regional blocks,
• Moderate sedation/analgesia (“conscious sedation”),
• Deep sedation/analgesia, or
• General anesthesia.

Modifier -73 is used when procedures requiring anesthesia are terminated prior to administration of anesthesia.  Other considerations for using modifier -73 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Termination occurs after the patient had been prepared for the procedure (including procedural pre-medication when provided), and has been taken to the room where the procedure was to be performed.
• Procedures reported with modifier -73 will be paid at 50% of the full OPPS payment amount.
• Payment for device-intensive procedures (device offset amount exceeds 30% of the procedure’s mean coast) reported with modifier -73 will be reduced by 100% of the device offset amount prior to applying the additional payment adjustments.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.

Modifier -74 is used when procedures requiring anesthesia are terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). Other facts about modifier -74 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Modifier -74 may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia.
• Procedures reported with modifier -74 will be paid at the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient received anesthesia and include the progress of the procedure.

Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. For modifier -52,

• The patient has been prepared and taken to the room where the procedure is to be performed.
• Procedures reported with modifier -52 will be paid at 50% of the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.
• This modifier is often used for radiologic procedures that cannot be completed as planned.

NOTE: The elective cancellation of a procedure should not be reported.

When things do not work out as planned, it is good to have a back-up plan, or in the case of medical procedures, a way to recoup your cost. Just make sure you code, document, and bill appropriately.

Social Determinants of Health (SDOH) are economic and social conditions (i.e., food insecurity, homelessness) that can impact an individual’s health status. As the number of Social Determinants of Health (SDOH) increases the potential for a patient to have poorer health and increased healthcare utilization also increases.

In the May 2, 2019 issue of mlnconnects, CMS included the following tools that organizations can use to measure these factors to help achieve health equity:

• Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
• Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
• Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window  : Collect the data needed to better understand and act on patients’ social determinants of health
• Health Leads Screening Toolkit - Opens in a new window  : Comprehensive way to assess patients for adverse social determinants

In the newsletter, CMS went on to indicate they are proposing that some data elements specific to SDOH’s has been proposed in several post-acute care provider settings to help “strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services.”

As a reminder, the SDOH Z-code Z59.0 Homelessness is being proposed for a CC severity designation in the FY 2020 IPPS Proposed Rule. You can read more about this in a related article at: http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-proposed-rule.

Over the past several weeks, MMP has written about what is being proposed in the FY 2020 IPPS Proposed Rule. Prior to its release, there seemed to be a high probability that the proposed rule would include additional guidance regarding hospital charges transparency. My assumption was based on the following from a March 8, 2019 Kaiser Health News article written by Steven Findlay:   

• This article highlighted the fact that CMS Administrator Seema Verma took to twitter in March by posting a Where’s the Price challenge? Specifically, she challenged consumers to visit the website of their local hospital to see if they could find the hospital’s pricing information posted in an electronic format, if you can’t she wants to know by sending her a tweet with the hashtag #WheresThePrice to help drive #PriceTransparency!
• The article ended by indicating a CMS spokesperson said the agency plans to issue its next regulation on hospital price transparency this year.

While this “next regulation” was not in the Proposed Rule, a May 29th Washington Post article, indicated that President Trump is preparing to issue an executive order regarding greater price transparency that is likely to be announced mid-June. While we wait, this article provides a very high level background of what CMS has required of hospitals in regards to price transparency to date and highlights what the data can tell you by utilizing COPD claims data from our sister company RealTime Medicare Data (RTMD).

Hospital Price Transparency Background

Initially, the Price Transparency requirement was included in the Affordable Care Act. Specifically, section 2718(e) of the Public Health Service Act, required that ‘‘[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.’’

CMS reminded hospitals of their obligation to comply with this section of the Act and reiterated the following specific guideline for hospitals in the 2015 IPPS Final Rule:

• “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or have a policy for allowing the public to view a list of those charges in response to an inquiry.” (FY 2015 IPPS/LTCH Final Rule (79 FR 50146)

Four years later in the 2019 IPPS Final Rule, CMS finalized their proposal, that effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

Subsequent to the FY 2019 Final Rule, CMS released two FAQ documents answering questions from the health care community. First was an October 2019 FAQ document followed by the December 2018 release of “Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet” document.  

The second FAQ document included a question regarding what will happen if a hospital does not comply with this requirement. CMS answer was to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

Analyzing the Data

So, you have posted your chargemaster information on your website, do you know how you compare to your competitors? I turned to our sister company RealTime Medicare Data (RTMD) to take a look at what the average inpatient charges are for patients admitted with COPD. The specific parameters of the data review includes the following:  

• The data is for Medicare fee-for-service claims with a date of service from 10/1/2018 through 12/31/2018.
• The data is focused on one disease type, chronic obstructive pulmonary disease.
• DRG 190: Chronic Obstructive Pulmonary Disease with MCC
• DRG 191: Chronic Obstructive Pulmonary Disease with CC
• DRG 192: Chronic Obstructive Pulmonary Disease without CC/MCC
• Hospitals have been compared to their “Defined Market.” Simply stated, defined markets for a hospital are developed by the facility and all reports are from this perspective. It answers the question: Where did my patients go for treatment?
• Paid claims data was analyzed for five distinct Defined Markets:
• Huntsville Hospital in Huntsville, AL
• Mobile Infirmary in Mobile, AL
• MUSC in Charleston, SC
• UAB Hospital in Birmingham, AL
• University of Kansas Health System, St. Francis Campus

The following table highlights the variation in charges for the care of COPD patients.

For those interested, the links in the above table are to pdf downloads which provide a view of each of these hospital’s defined market average COPD charges.  

Additional Price Transparency Resources:

In November 2018 CMS launched new online tools displaying cost differences for certain surgical procedures (link to CMS press release: https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures).

AHA Toolkit for Achieving Price Transparency

Guroo.com cost data includes 40M insured individuals and was created with the goal “to give you insight into health care costs and quality so you can be informed and get the most out of every dollar you spend” (www.guroo.com).

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente. 

You know that old saying, time flies by when you are having fun? Well, the older I get, it is more apt to say that time flies by regardless of the fun factor. I will leave it up to you, the reader, to decide if the 2014 QIO Program Transition was fun. Fun or not, here we are five years later and the 11th Scope of Work (SOW) is coming to an end.

On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th SOW that will run from 2019-2023. This article highlights fun activities related to this transition for you the provider and provides information about a temporary pause of Short Stay and Higher Weighted DRG (HWDRG) Reviews.

BFCC-QIO 12th Scope of Work, What You Need to Know and Do

Know Your Region

With the 11th SOW, KEPRO and LIVANTA provided services in 5 distinct Regions with each Region having a specific phone number and contact information.  CMS has restructured the coverage areas for the 12th SOW based on the Medicare Regional Offices. Effective June 8, 2019 there will be ten Regions as outlined in the following table:

‍Update Your Appeals Notices

Acute care providers will need to update the Important Message from Medicare (IM) with the correct BFCC-QIO name and phone number for your region. Both LIVANTA and KEPRO have indicated that it is acceptable to use labels to cover the existing information on your current appeals notices.

Memorandum of Agreement 

A new Memorandum of Agreement (MOA) is required for ALL Medicare health care providers (even if your BFCC-QIO is not changing). KEPRO has a page dedicated to MOA updates, and includes FAQs and a link to sign up for an email distribution list to receive updates from KEPRO.

Phone Numbers for BFCC QIO Services

Again, effective June 8th, all calls should be directed to phone numbers provided on the BFCC-QIO websites. As this time, KEPRO and LIVANTA will continue to handle all discharge appeals, quality complaints and immediate advocacy for Medicare patients and families.

All transition updates, including phone numbers, are available on KEPRO and LIVANTA’s websites at:

• KEPRO Transition webpage: https://www.keproqio.com/providers/transition
• LIVANTA Transition webpage: https://livantaqio.com/en/provider/transition.

Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews

In the 11th SOW the BFCC-QIOs were responsible for HWDRG and Short Stay Reviews. As of May 8, 2019, a temporary pause was placed on both types of reviews. Per CMS, this action was taken to procure a new BFCC-QIO contractor and going forward HWDRG and Short Stay reviews will resume with a single organization performing these reviews on a national basis.

CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019. MMP will continue to follow this story and report as soon as a contract is awarded. In the meantime, have fun identifying your BFCC-QIO, updating your Appeals Notices, and completing a new MOA. 

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the third article in our series about the 2020 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications.

 

Pre-MDC

Extracorporeal Membrane Oxygenation (ECMO)

In FY 2019, three new procedure codes were finalized describing different types of ECMO treatments being used (central and peripheral). However, the codes were not finalized prior to the release of the FY 2019 IPPS Proposed Rule meaning there was no proposed Major Diagnostic Category (MDC), MS-DRG or O.R. vs. Non-O.R. designation made for the new codes.  

Given this unique situation, CMS Clinical Advisors reviewed the predecessor central ECMO code (5A15223) and determined the new peripheral codes should not sequence to Pre-MDC MS-DRG 3 where the central ECMO code is assigned.

Instead the new Peripheral ECMO codes were designated as Non-O.R. Procedures impacting MS-DRG assignment for specific medical MS-DRGs. The following table reflects the differences in ECMO Procedures DRG assignment:

In the FY 2020 IPPS Proposed Rule, stakeholders expressed the following concerns:

• MS-DRG assignment for ECMO should not be based on how the patient is cannulated as most of the cost can be attributed to a patien’ts severity of illness,
• There was a lack of opportunity for public comment on the final MS-DRG assignments,
• Patient access to ECMO treatment and programs is now at risk because of inadequate payment, and
• CMS did not appear to have access to enough patient data to evaluate for appropriate MS-DRG assignment.

On review, Clinical Advisors support the assignment of the new ICD-10-PCS procedure codes for peripheral ECMO procedures to the same MS-DRG as the open central ECMO. Therefore, CMS is proposing the following:

• Reassign peripheral ECMO codes from MS-DRGs 207, 291, 296 and 870 to Pre-MDC MS-DRG 003,
• Remove ECMO from the description of these MS-DRGs, and
• Maintaining the assignment of peripheral ECMO codes of Non-O.R. affecting MS-DRG assignment.

Allogenic Bone Marrow Transplant

A request was made to create new MS-DRGs for cases that would identify patients undergoing an allogeneic hematopoietic cell transplant (HCT) procedure according to the donor source (related or unrelated donor source). The requester indicated this would more appropriately recognize the clinical characteristics and cost differences in allogeneic HCT cases.

CMS data analysis of MS-DRG 014 cases reporting HCT related donor source, HCT unrelated donor source and unspecified donor source had comparable average length of stay and average costs. Thus, no proposal was made to create new MS-DRGs. However, as a result of CMS’ review of procedure codes they are proposing to:

• Reassign 4 ICD-10-PCS codes for HCT procedures specifying autologous cord blood stem cell as the donor source from MS-DRG 014 to MS-DRGs 016 and 017, and
• Delete 128 clinically invalid codes from the transfusion table describing arterial access as transfusion procedures always use venous access rather than arterial access.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

• XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
• XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures impacting MS–DRG assignment.

For FY 2019, CMS finalized their proposals to:

• Assign ICD-10-PCS procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
• Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
• CAR T-cell therapy was approved for new technology add-on payments in FY 2019.
  

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. The requestor noted this would improve payment in the inpatient setting. CMS does not believe enough data is available to make a change at this time. However, CMS is seeking comments on payment alternatives for CAR-T cell therapies and have proposed to continue the new technology and add-on payments for FY 2020.

 

MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures

Current logic for case assignment to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively) “is comprised of two lists of logic that include procedure codes for operating room (O.R.) procedures involving dilation of a carotid artery (common, internal or external) with intraluminal device(s).”

CMS identified 46 ICD-10-PCS procedures codes in the second list that do not describe dilation of a carotid artery with intraluminal device. CMS is proposing to remove these 46 codes from MS-DRGs 034, 035 and 036. (The 46 codes are available in a table on pages 19182 – 19183 of the Proposed Rule in the Federal Register.)

These 46 ICD-10-PCS codes are also assigned to MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC, respectively.) Therefore, CMS also examined claims data for this MS-DRG group and are proposing to:

• Remove 96 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from the logic for MS-DRG group 037-038 and 039,
• Reassign 6 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from MS-DRG group 037, 038 and 039 to MS-DRG group 034, 035, and 036.

 

MDC 4: Diseases and Disorders of the Respiratory System

Pulmonary Embolism

A request was made to reassign the following three ICD-10-CM diagnosis codes for Pulmonary Embolism (PE) with acute core pulmonale from MS-DRG 176 (PE without MCC) to MS-DRG 175 (PE with MCC):

• I26.01 – Septic pulmonary embolism with acute cor pulmonale,
• I26.02 – Saddle embolus of pulmonary artery with acute cor pulmonale, and
• I26.09 – Other pulmonary embolism with acute cor pulmonale.

The requestor noted with the FY 2019 IPPS Final Rule special logic change where a Principal Diagnosis could no longer be its own CC or MCC this resulted in these three codes being assigned to MS-DRG 176 when no other MCC is present. The requestor stated MS-DRG 176 does not appropriately account for cost and resource utilization associated with these cases.

CMS claims analysis supported the requestor’s statement about cost and resource utilization. Therefore, CMS is proposing to:

• Reassign cases reporting diagnosis codes I16.01, I26.02 and I26.09 to MS-DRG 175, and
• Revise the MS-DRG 175 title to “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”

The difference in RW, GMLOS and National Payment Rate are reflected in the following table.

‍MDC 5: Diseases and Disorders of the Circulatory System

Transcatheter Mitral Valve Repair (TMVR) with Implant

CMS received a request to modify the current MS-DRG assignment for TMVR with implant procedures (MS-DRG 228 and 229: Other Cardiothoracic Procedures with MCC and without MCC, respectively). CMS provides a detailed discussion of the MitraClip® System (MitraClip®) for transcatheter mitral valve repair in previous rulemakings:

• FY 2014 IPPS Final Rule: CMS was unable to consider the application for a new technology add-on payment for MitraClip® because it did not receive FDA approval by the July 1, 2013 deadline.
• FY 2015 IPPS Final Rule:
• Proposal was finalized to not create a new MS-DRG or to reassign cases reporting ICD-9 procedure code 35.97 describing MitraClip® to another MS-DRG, and
• Under a new application, the request for new technology add-on payments for the MitraClip® System was approved.
• FY 2016 IPPS Final Rule: For ICD-10 based MS-DRGs to fully replicate for ICD-9-CM based MS-DRGs, ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) which identified MitraClip® technology in ICD-10-PCS code translation was assigned to new MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with MCC and without MCC, respectively) and continued to be assigned to MS-DRGs 231 and 232 (Coronary Bypass with PTCA with MCC and without MCC, respectively).
• FY 2017 IPPS Final Rule:
• The new technology add-on payment was discontinued.
• ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) was reassigned from MS-DRGs 273 and 274 to the new “collapsed” MS-DRG pair MS-DRG 228 and 229 (Other Cardiothoracic Procedures with MCC and without MCC, respectively).
  

The requestor in the FY 2020 IPPS Proposed Rule believes that TMVR is more similar to the replacement procedures in MS-DRGs 266 and 267 compared to other procedures currently assigned to MS-DRGs 228 and 229 and “noted that both TMVR procedures and endovascular cardiac valve replacements use a percutaneous approach, treat cardiac valves, and use an implanted device for purposes of improving the function of the specified valve.”

In the Proposed Rule CMS indicates “Our clinical advisors continue to believe that transcatheter cardiac valve repair procedures are not the same as a transcatheter (endovascular) cardiac valve replacement.

However, they agree with the requestor and, based on our data analysis, that these procedures are more clinically coherent in that they also describe endovascular cardiac valve interventions with implants and are similar in terms of average length of stay and average costs to cases in MS-DRGs 266 and 267 when compared to other procedures in their current MS-DRG assignment. For these reasons, our clinical advisors agree that we should propose to reassign the endovascular cardiac valve repair procedures (supplement procedures)…to the endovascular cardiac valve replacement MS-DRGs.”

After additional data analysis, CMS is making the following proposals:

• Modify the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing transcatheter cardiac valve repair (supplement) procedure,
• Revise the title of MS-DRG 266 from “Endovascular Cardiac Valve Replacement with MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC,”
• Revise the title of MS-DRG 267 from “Endovascular Cardiac Valve Replacement without MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedure without MCC,”
• Create two new MS-DRGs with a two-way severity split for the remaining (non-supplement) transcatheter cardiac valves.
• Proposed New MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC), and
• Proposed New MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC).

Pacemaker Leads

CMS noted that ICD-10-PCS procedure code 02H60JZ (Insertion of pacemaker lead into right atrium, open approach) was inadvertently omitted from the GROUPER logic for MS-DRGs 260, 261, and 262. They are proposing to add this procedure code to the list of Non-O.R. procedures that would impact MS-DRGs 260, 261, and 262 when reported as a stand-alone procedure code.

 

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Knee Procedures with Principal Diagnosis of Infection

CMS received a request to add ICD-10-CM diagnosis codes M00.9 (Pyogenic arthritis, unspecified) and A54.42 (Gonococcal arthritis) to the list of principal diagnoses for MS-DRGs 485, 486, 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively) in MDC 8.

Currently, when reported as the principal diagnosis, these two ICD-10-CM diagnosis codes group to MS-DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection with and without CC/MCC, respectively) when a knee procedure is also reported on the claim. CMS notes that neither of these codes is specific to the knee.

After analysis, CMS is proposing the following:

• Add ICD-10-CM diagnosis code M00.9 to the list of principal diagnosis codes for MS-DRGs 485, 486 and 487. Note, clinical advisors did not recommend the same for ICD-10-CM diagnosis code A54.42 as this code is not specifically indexed to include the knee or any infection in the knee.
• Add 10 additional ICD-10-CM diagnosis codes specific to the knee and describing an infection, and
• Remove 8 ICD-10-CM diagnosis codes from the list of principal diagnosis for MS-DRG 485, 486 and 487 as they do not describe an infection of the knee.

Scoliosis: Neuromuscular and Secondary Scoliosis and Kyphosis

Requests were made to add ICD-10-CM diagnosis codes describing neuromuscular scoliosis and ICD-10-CM diagnosis codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458 (Spinal Fusion except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, without CC/MCC, respectively).

After analysis, CMS is proposing to add 5 codes describing neuromuscular scoliosis and 8 codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458. CMS also identified 34 ICD-10-CM diagnosis codes describing conditions involving the cervical region that are not clinically appropriate for assignment to MS-DRGs 456, 457, and 458. CMS has proposed to remove these 34 codes from this MS-DRG group.

 

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Extracorporeal Shock Wave Lithotripsy (ESWL)

Data analysis revealed a steady decline in inpatient cases reporting urinary stones and an ESWL procedure over the past five years. CMS indicates that due to an ESWL procedure being a Non-O.R. procedure and the decreased usage of this procedure in the inpatient setting, clinical advisors believe there is no longer a reason to subdivide the MS-DRGs for urinary stones (MS-DRGs 691 &692, and 693 & 694) based on ESWL procedures.

CMS is proposing to:

• Delete MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC respectively) and
• Revise the MS-DRG title for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC.”

 

MDC 12: Diseases and Disorders of the Male Reproductive System

Currently, four ICD-10-CM diagnosis codes describing body parts with male anatomy are assigned to MDC 5 (Diseases and Disorders of the Circulatory System) in MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively).

There was a request to review these codes and consider reassignment to MDC 12. Based on this request and claims data analysis, CMS is proposing to reassign these four codes from MDC 5 in MS-DRGs 302 and 303 to MDC 12 in MS-DRGs 729 and 730 (Other Male Reproductive System Diagnosis with CC/MCC and without CC/MCC, respectively).

 

MDC 14: Pregnancy, Childbirth and the Puerperium

Proposed Reassignment of Diagnosis Code 099.89 (Other specified Diseases and Conditions complicating pregnancy, childbirth and the puerperium)

CMS is proposing to reclassify ICD-10-CM diagnosis code 099.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) from a postpartum condition to an antepartum condition.

If finalized, coding logic would assign a case with an O.R. procedure and this code to MS-DRGs 817, 818, or 819 (Other Antepartum Diagnoses with O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

When no O.R. procedure is reported on the claim, the logic would assign the case to MS-DRGs 831, 832, and 833 (Other Antepartum Diagnoses without O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

 

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Proposed Assignment of Diagnosis Code R93.89 (Abnormal finding on diagnostic imaging of other specified body structures)

There was a request to reassign ICD-10-CM diagnosis code R93.89 from MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in the Circulatory MDC 5 to MDC 23. The requestor did not suggest a specific MS-DRG assignment in MDC 23.

After analysis, CMS is proposing to reassign ICD-10-CM diagnosis code R93.89 to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

There are several proposals being made to move diagnosis and procedures codes back into a specific MDC for FY 2020. For those interested, you can find these proposals on pages 19216 – 19229 of the Proposed Rule in the Federal Register.

MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 24, 2019. 

This is the second article in a series of 2020 IPPS Proposed Rule Articles. Last week’s article provided details of the significant proposed changes to the CC and MCC severity designations. This week we take a look at proposed payment rate changes and the wage-index adjustment proposal being touted by CMS as a key priority of “Rethinking Rural Health.”

Proposed Payment Rate Changes by the Numbers

“By law, CMS is required to update payment rates for IPPS hospitals annually, and to account for changes in the prices of goods and services used by these hospitals in treating Medicare patients, as well as for other factors. This is known as the hospital “market basket.” The IPPS pays hospitals for services provided to Medicare beneficiaries using a national base payment rate, adjusted for a number of factors that affect hospitals’ costs, including the patient’s condition and the cost of hospital labor in the hospital’s geographic area.”

• 3.2% is the projected market basket update for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users.
• 3.7% is the CMS estimated total increase in IPPS payments for FY 2020.
• $4.7 Billion is the increase in total Medicare spending on inpatient hospital services, including capital, projected by CMS for FY 2020.

Hospital Readmission Reduction Program (HRRP)

• 2,599 is the number of hospitals that CMS estimates will have base operating DRG payments reduced based on their hospital readmission rates.
• $550 Million the estimated amount CMS will save in FY 2020 as a result of decreased payments to the estimated 2,599 hospitals.

Hospital Inpatient Quality Report (IQR) Program

CMS estimates that proposed changes for this program will result in changes to the information collection burden compared to previously adopted requirements. Specifically, the proposal to adopt the Hybrid Hospital-Wide All-Cause Readmission (Hybrid HWR) measure. Estimated impact of this change:

• 2,211 hours in total collection burden increase, and
• $83,266 total cost increase for all participating IPPS hospitals annually.

Hospital Value-Based Purchasing (VBP) Program

This program is a budget neutral program because “by law, the amount available for value-based incentive payments under the program in a given year must be equal to the total amount of base operating MS-DRG payment amount reduction for that year.”

• $1.9 Billion is the estimated amount available for value-based incentive payments for FY 2020 discharges.

 

“Rethinking Rural Health:” Proposed Changes to the Inpatient Hospital Wage Index

Public Comments

In the FY 2019 IPPS Proposed Rule, CMS solicited comments, suggestions and recommendations for changes to the Medicare inpatient hospital wage index. Fast forward to the April 2019 release of the FY 2020 IPPS Proposed Rule where CMS shares that “many of the responses received…reflect a common concern that the current wage index system perpetuates and exacerbates the disparities between high and low wage index hospitals.” There was also a concern “that the calculation of the rural floor has allowed a limited number of States to manipulate the wage index system to achieve higher wages for many urban hospitals at the expense of hospitals in other states, which also contributes to wage index disparities.”

Inpatient Hospital Wage Index, What is it?

In the April 23, 2019 Press Release CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation, CMS notes the following about the Inpatient Hospital Wage Index:

• It specifies how inpatient payment rates are adjusted to account for local differences in wages that hospitals face in their respective labor markets,
• It is intended to measure differences in hospital wage rates across geographic regions,
• It is updated annually based on wage data reported by hospitals, and
• Hospitals located in areas with wages less than the national average receive a lower Medicare payment rate than hospitals located in areas with wages higher than the national average.

An example provided in the Press Release is that of hospital in a rural community receiving about $4000 in payment for treatment of a Medicare beneficiary with pneumonia while a hospital in a high wage area could receive nearly $6,000 for the same case due to differences in the wage index. CMS goes on to note that, “high wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals. Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals decline.”

 

FY 2020 Inpatient Hospital Wage Index Proposals

Stopping the “Downward Spiral”

First, CMS is proposing to increase the wage index for hospitals with a wage index value below the 25th percentile wage index. For FY 2020, the 25th percentile wage index value across all hospitals is 0.8482.

Specifically, the increase would be equal to half the difference between the otherwise applicable final wage index value for a year for that hospital and the 25th percentile wage index value for that year across all hospitals.

To better understand what the increase would be, CMS provides the following example in the Proposed Rule:

• First, assume the wage index for a geographically rural Alabama hospital is 0.6663,
• Second, note the 25th percentile wage index value for FY 2020 is 0.8482.
• Third, determine half the distance between the hospital wage index and the 25th percentile (0.8482 – 0.6663/2) = 0.0910
• Fourth, add the Rural Alabama hospital wage index with half the difference to get the new FY 2020 wage index value for the hospital (0.6663 + 0.0910) = wage index 0.7573.

This proposal would be effective for at least 4 years beginning in FY 2020.

Budget Neutrality

Second, CMS believes that “it would be appropriate to maintain budget neutrality for the low wage index policy proposed…by adjusting the wage index for high wage index hospitals.” Specifically, CMS is proposing to identify high wage index hospitals as hospitals in the highest quartile. This would be hospitals above the 75th percentile wage index across all hospitals for a fiscal year.

The methodology would be analogous to methodology used for hospitals below the 25th percentile. Following is the example provided in the Proposed Rule:

• First, assume high wage index Hospital A has a wage index value of 1.7351,
• Second, CMS notes that based on data for the proposed rule, the 75th percentile wage index value is 1.0351.
• Third, determine the distance between the hospital wage index and the 75th percentile (1.7351 – 1.0351) = 0.7000,
• Fourth, CMS would estimate the uniform multiplicative budget neutrality factor needed to reduce those distances for all high wage index hospitals so the estimated decreased payments offset the estimated increased aggregate payments to low wage index hospitals. For FY 2020 the estimated factor is 3.4 percent. Therefore, Hospital A’s wage index would be reduced by 0.0238 (Prior distance of 0.7000 x 0.034) = 0.0238.
• Fifth, the new wage index for Hospital A would be 1.7113 (that is, current value 1.7351 – wage reduction of 0.0238) = 1.7113.

To help mitigate any significant wage index decreases, CMS is “proposing to place a 5-percent cap on any decrease in a hospital’s wage index from the hospital’s final wage index in FY 2019. In other words, we are proposing that a hospital’s final wage index for FY 2020 would not be less than 95 percent of its final wage index for FY 2019.”

Rural Floor Calculation Change

Commenters to the FY 2019 Proposed Rule “indicated that another contributing systemic factor to wage index disparities is the rural floor….for discharges on or after October 1, 1997, the area wage index applicable to any hospitals that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State.”

CMS is proposing to remove the urban to rural reclassifications from the calculation of the rural floor beginning in FY 2020. You can read a detailed discussion about this on pages 19396 – 19398 of the FY 2020 IPPS Proposed Rule in the Federal Register.

April 29, 2019 CMS.Gov Newsroom Article: “What they are Saying / CMS Advances Agenda to Re-Think Rural Health and Unleash Medical Innovation”

Less than a week after the FY 2020 IPPS Proposed Rule was released, CMS posted a CMS.Gov Newsroom Article with reaction from key healthcare stakeholders to the Proposed Rule. Since I live in Alabama and work for a company located in Birmingham, I wanted to share what Alabama leaders are saying about “Rethinking Rural Health.”

Executive Vice President and Chief Policy Officer Danne Howard
Alabama Hospital Association

“We could not be more grateful to CMS Administrator Seema Verma and her staff for listening to our concerns and taking action,” Howard said.  “Alabama has been penalized for decades by this flawed formula, which has resulted in some states being paid three times as much as Alabama’s hospitals for the exact same procedure.  Alabama’s entire congressional delegation worked tirelessly in a non-partisan manner to make this happen, and we specifically would like to acknowledge Sens. Richard Shelby and Doug Jones and Rep. Bradley Byrne for leading the charge.”

Sen. Richard Shelby (R-Ala)

“The Medicare Wage Index has negatively affected Alabama hospitals for over 20 years,” said. [sic], who wrote a letter last month signed by the state’s congressional delegation to Center for Medicare and Medicaid Services Administrator Seema Verma requesting a change to the index. After two decades of working to address a problem that significantly contributes to heightened hospital closures throughout our state, I am glad to see Administrator Verma and CMS taking steps to solve this dire issue. I look forward to continuing my work with the agency to make sure that this sort of careless imbalance is eliminated moving forward.”

Sen. Doug Jones (D-Ala)

“The decision by CMS to propose a new reimbursement formula is welcome news and a great first step for the health care providers across our state who have struggled for years with an inexplicably low reimbursement rate,” the senator said. “These hospitals provide care to all Alabamians, regardless of their insurance status, and they have to absorb the costs when that care isn’t reimbursed. That puts the entire system on slippery financial footing and can hurt the broader community if a hospital is forced to close its doors.”

CMS is accepting comments to the Proposed Rule no later than 5 p.m. EDT on June 24, 2019.

Resources:

CMS 2020 IPPS Proposed Rule Home Page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Proposed-Rule-Home-Page.html

CMS Fact Sheet Announcing Release of 2020 Proposed Rule: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

CMS April 23, 2019 Press Release: CMS Advances Agenda to Re-think Rural Health and Unleash Medical Innovation: https://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovation

MEDICARE TRANSMITTALS – RECURRING UPDATES

 

July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11225.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11224.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.2 Effective July 1, 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11227.pdf

 

OTHER MEDICARE TRANSMITTALS

 

Billing for Hospital Part B Inpatient Services

Provides billing instructions for hospital Part B inpatient services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11181.pdf

Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment – REVISED

Revised to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11137.pdf

Pub. 100-04, Chapter 29 – Appeals of Claims Decisions – Revisions

Incorporates the following policy updates to the Medicare Claims Processing Manual:

• The policy on use of electronic signatures
• Timing of signatures on transfer of appeal rights and the appointment of representative forms
• Tolling an adjudication timeframe when trying to cure a defective appointment form
• Limiting scope of redetermination review in certain instances
• Application of good cause for late filing involving beneficiary accessibility
• Application of good cause where there is a declared disaster

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11042.pdf

New Waived Tests

Informs MACs of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11231.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

 

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

Claim information for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19007.pdf

 

MEDICARE COVERAGE UPDATES

 

CMS Proposes Updates to Coverage Policy for Transcatheter Aortic Valve Replacement (TAVR)

CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program.

https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-transcatheter-aortic-valve-replacement-tavr

 

MEDICARE EDUCATIONAL RESOURCES

 

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing
• Provider Minute Video: The Importance of Proper Documentation

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

 

April 2019 Patients Over Paperwork Newsletter

Updates on ongoing work to reduce administrative burden and improve the customer experience for hospitals.

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/April2019PoPNewsletter.pdf

GAO Report for Medicare and Medicaid:
CMS Should Assess Documentation Necessary to Identify Improper Payments

GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information.

https://www.gao.gov/products/GAO-19-277

The kicker to the saying that “time flies when you’re having fun,” is that time also flies when you are not. However, I have been extremely fortunate over the past 10 years to actually enjoy my job. Last October marked my 10-year anniversary as an employee of Medical Management Plus, Inc. (MMP). Yes, it is nerdy that I actually enjoy reading Medicare regulations, but I do. I enjoy even more writing articles, such as this one, which I hope share Medicare and related guidance in an easy-to-read and understandable format and help our readers do their own challenging healthcare jobs better. The rapid passing of time is relevant because the very first article I wrote at MMP over ten years ago was about the 2008 AHIMA (American Health Information Management Association) article, “Managing an Effective Query Process.”

In February of this year, the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) jointly produced “Guidelines for Achieving a Compliant Query Practice (2019 Update).”  This Practice Brief is the recommended industry standard for provider queries and describes best practices for coding and clinical documentation improvement (CDI) professionals performing query functions. It supersedes the 2016 and all prior versions.

Coders and CDI professionals should carefully review and follow the practices described in this Brief, but other healthcare team members also need to be aware of this guidance. For example, case management, quality management professionals, and infection control clinicians educate physicians to document a certain way. Since these interactions could ultimately affect coding, these healthcare professionals need to be aware of and comply with query compliance standards. Other healthcare professionals, such as compliance, revenue cycle, patient financial services, physician groups, facility leaders, and any who work with documentation and coding also need to be familiar with this guidance. The Brief also points out that it serves as a resource for external reviewers, such as the Office of Inspector General (OIG), government contractors, payor review agencies, and others.

According to the Brief, a query is a communication tool “used to clarify documentation in the health record for documentation integrity and accurate code assignment.” In addition to ensuring a medical record that accurately reflects patient complexity and the facts of the encounter, an effective query process ensures appropriate reimbursement and accurate risk-adjustment and quality of care statistics derived from claims data.

The Practice Brief states, “The objective of a query is to ensure the reported diagnoses and procedures derived from the health record documentation accurately reflect the patient’s episode of care.” Among other functions, some of the main uses of queries are to:

• Determine if a clinical condition is present when supported by clinical indicators within the record,
• Clarify conflicting documentation,
• Add specificity in certain situations,
• Establish “cause and effect” relationships, and
• Clarify when a documented diagnosis does not appear to be clinically supported.

I am not going to list all of the requirements of a compliant query and encourage those affected to read the entire Practice Brief for all the guidance provided. Here are some of the main points from the Brief that caught my attention.

Leading Queries

Bearing in mind that my background is compliance, I will start with the rule that queries should not be leading – they should not “lead” the physician or other practitioner to the preferred answer or to a specific diagnosis or procedure. Multiple choice queries are acceptable, but be sure to include options that allow the provider to explain other clinical options or to reply that the answer may be clinically undetermined. In the words of the Brief, “the choices provided as part of the query must reflect reasonable conclusions specific to the clinical scenario of the individual patient.”

Impact on Reimbursement

At one time, reimbursement seemed to be the major driver of the query process. This should not be – querying is about obtaining accurate documentation and coding, which often can affect a facility’s payment. However, keep your focus on accuracy and completeness and never include the impact on reimbursement or on quality measures in the query. It is best not to even discuss the effects of querying on reimbursement or quality measures with your physicians or others. If your records are accurate and complete, your facility will receive the appropriate reimbursement and accurate quality measures.

Specificity

Queries can be helpful for determining a more specific code in some situations. However, bear in mind “that code accuracy is not the same as code specificity.” Although some payors resist unspecified codes, there are times when unspecified codes are appropriate based on the clinical situation.

Clinical Indicators

When querying for documentation of medical diagnoses or conditions that are clinically evident, be sure to include clinical indicators that:

• “Are specific to the patient and episode of care
• Support why a more complete or accurate diagnosis or procedure is sought
• Support why a diagnosis requires additional clinical support to be reportable”

Clinical indicators can be such things as the physical exam and assessment, diagnostic findings, and treatments. Clinical indicators should be relevant and clearly support the clinical condition. More is not always better, as the Brief states, “The quality of clinical indicators—how well they relate to the condition being clarified—is more important than the quantity of clinical indicators.”

Patient History and Prior Encounters

Coding from prior encounters without documentation in the current record is not allowed, but generating a query based on information from a prior encounter may be acceptable, but only if the information is clinically pertinent to the current encounter. The Brief includes a list of example situations where information from a prior encounter could be used to query, such as specificity, baseline status, present on admission (POA) status, cause and effect, and etiology. The Brief cautions that “it is inappropriate to “mine” a previous encounter’s documentation to generate queries not related to the current encounter.”

Documentation and Retention of Queries

Sometimes it is easier to explain a situation to a provider in person. Verbal queries are acceptable, but the exchange, including the provider’s response, should be documented and maintained. And like written queries, conversations should not be leading. When documenting these interactions, be sure to include the same components you would include in a written query – the details of the discussion, the reason for the query, the clinical indicators, options discussed and the provider’s decision. Also, date, time, and sign your documentation.

It is recommended the query be part of the permanent medical record. Another option is to keep queries as part of the business record. They should be easily retrievable for auditing, monitoring, and compliance. Facilities should have a policy that addresses query retention and it should apply to all queries, regardless of provider response.

Clinical Validation and Escalation

Sometimes it may appear that a documented diagnosis is not clinically supported. These clinical validation queries can be more challenging than other types of queries. AHIMA has developed a separate Practice Brief to address these concerns titled “Clinical Validation: The Next Level of CDI.” AHIMA members can view this Brief in the AHIMA HIM Body of Knowledge at http://bok.ahima.org.  

Clinical validation may be a good time to involve a physician advisor or the chief medical officer. Facilities should have a documented escalation policy for certain situations, which may include clinical validation situations, failure to respond, or other issues. There should also be policies defining the role and expectations of those issuing the queries and the responders.

Again, this is a high-level overview of the Practice Brief on Compliant Queries. The Brief contains much more information, including query examples in Appendix B, which I found to be particularly enlightening. Be sure to read the entire Brief carefully – study it, discuss it with other stakeholders within your facility, and use it to develop your policies, procedures and practices. Be sure to include initial training for new employees and on-going education for all employees. Also, watch for updated guidance - I will not promise to be around in another 10 years to share the information.