Knowledge Base Category -
MEDICARE TRANSMITTALS
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update
The April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment.
E/M Service Documentation Provided By Students (Manual Update)
Allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
New ADR limits for the Recovery Audit Program.
Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
Updates to diagnosis codes required in order to allow add-on payments under the Inpatient Prospective Payment System (IPPS) for blood clotting factor administered to hemophilia inpatients.
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Changes in the April 2018 quarterly update to the Clinical Laboratory Fee Schedule (CLFS).
Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services – REVISED
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits – REVISED
Revised to add HCPCS code G0475 as a code that is subject to CLIA edits effective, April 13, 2015.
Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System
Enables MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system.
Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
A maintenance update of the International Classification of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
MEDICARE COVERAGE UPDATES
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
Effective May 25, 2017, new NCD to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD).
Decision Memo for Implantable Cardioverter Defibrillators (CAG-00157R4)
Changes to the ICD NCD from the 2005 reconsideration.
OTHER MEDICARE UPDATES
Medicare Fee-for-Service Recovery Audit Program Additional Documentation Limits for Medicare Institutional Providers (i.e. Facilities)
Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs
https://www.gpo.gov/fdsys/pkg/FR-2018-01-31/pdf/C1-2017-27949.pdf
Targeted Probe and Educate (TPE) Website Update
New resources available on the TPE website.
MEDICARE EDUCATIONAL RESOURCES
Transition to New Medicare Numbers and Cards FACTSHEET
DECISION
CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). CMS finalized what they describe as “minimal changes” to the ICD NCD from the 2005 reconsideration. After you have finished reading this article I will leave it to you to decide if you agree with their definition of “minimal changes.”
DECISION SUMMARY OF THE CHANGES
Patient Criteria
- Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
- Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
- Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
- Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
- Note: This includes all patient’s receiving an ICD for primary prevention.
Additional Patient Criteria
- Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)
Exceptions to Waiting Periods
- Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
- Add an exception for patients with an existing ICD and qualifying replacement
- End the data collection requirement
Evidence
When developing a National Coverage Determination (NCD), CMS in general “evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a findings that an item or service falling within a benefit category is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
The evidence review primarily focused “on randomized controlled trials that assess the clinical utility of defibrillators compared to optimal medical therapy, and relevant formal Technology Assessments and professional society guidelines. While reading through this part of the Decision Memo, some of the conclusions were reminiscent of statements made when Jack Handy shared “Deep Thoughts” on Saturday Night Live in the 1990’s. The following table highlights four of the studies.
PUBLIC COMMENTS
A significant portion of this Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses related to the “minimal changes” being made.
ANALYSIS
Patient Shared Decision Making
In addition to the example SDM tool for ICDs, CMS notes that a website was also developed “which leads patients step-by[step through some information on ICDs designed to increase patients’ knowledge of their medical condition, the risks and benefits of available treatments and to empower patients to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.
CONSIDERATIONS MOVING FORWARD
Shared Decision Making
There are now 6 covered indications listed in the NCD. All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.”
Questions to Consider:
- Who will be the healthcare provider to provide the SDM encounter?
- What tool will you utilize?
- When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
- Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?
Optimal Medical Therapy
Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement.
Questions to Consider:
- Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
- Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?
MMP strongly encourages key stakeholders take the time to read the entire Decision Memo.
Beth Cobb
“If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.”
-George Bernard Shaw
Probe & Educate Target: Emergency Room Services
This past November, the Medicare Administrative Contractor (MAC) WPS announced that they would begin reviewing facilities billing emergency room services (CPT codes 99281-99285) as part of the Targeted Probe and Educate (TPE) review process.
The TPE process includes MACs utilizing data analysis to identify:
- Providers and suppliers who have high claim error rates or unusual billing practices, and
- Items or services that have high national error rates and are a financial risk to Medicare.
WPS provides the following guidance in the announcement for a successful review of emergency department visits for facility services (Type A Emergency Rooms):
- The number and type of interventions under the facility charge,
- The visit record showing the signs/symptoms that support medical necessity for the interventions, and
- The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed.
WPS is currently the MAC for Jurisdiction 5 (IA, KS, MO, and NE Providers) and Jurisdiction 8 (IN, MI Providers). For those of you in a different MAC Jurisdiction, take note now as in general when one MAC targets a specific service it is not long before other MACs follow suit.
Are you an Outlier?
The question is, how do your E.R. levels codes compare to other facilities? Now, the Program for Evaluating Payment Patterns Electronic Report for short-term acute care hospitals (ST PEPPER) can assist you in analyzing your volume of emergency room services claims and comparing your data to your state, MAC jurisdiction and at the national level.
As of the 4th Quarter of the 2017 CMS IPPS Fiscal Year (July – September 2017), Emergency Department Evaluation and Management Visits (ED E&M) is a new PEPPER Target Area.
Target areas are approved by CMS because they have been identified as prone to improper payments. The Twenty-fourth Edition of the ST PEPPER User’s Guide notes that “concerns with overuse/misuse of higher level E&M codes have been prevalent for several years. The Office of Inspector General identified increasing trends of E&M coding for higher-level services (https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf ) as well as improper payments associated with E&M coding errors (https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf).”
PEPPER Recommendations for Outliers?
High Outliers could represent coding and billing errors related to over-coding of CPT code 99285. Appendix 5 of the User’s Guide notes attributes CPT 99285 as when “usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.” The ST PEPPER recommends reviewing a sample of claims coded to 99285 to validate the code is supported by documentation in the medical record.
Low Outliers could represent coding errors related to under-coding 99285. The ST PEPPER recommends reviewing a sample of claims coded to 99281, 99282, 99283 or 99284 should be reviewed to validate the code level is supported by documentation in the medical record.
Related article about the ST PEPPER: http://www.mmplusinc.com/news-articles/item/pepper-resources-guide-updates.
To learn more about the TPE Review Process visit the CMS TPE webpage at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html
Beth Cobb
Happy Cardiac Rehabilitation Week to all the therapists and specialists who work with patients to improve their cardiac health! According to the American Heart Association website, cardiac rehab is a medically supervised program consisting of exercise counseling and training, education for heart-healthy living, and counseling to reduce stress designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty or heart surgery. It is a beneficial program for those who need it and is covered as a Medicare benefit.
However, as with all things Medicare, there are coverage requirements and I often see denials of cardiac rehab services. One of the main reasons for Medicare denials of cardiac rehab services is the duration of services, specifically denials with Medicare claims denial reason code (CARC) 151 – “Payment adjusted because the payer deems the information submitted does not support this many services.” It is likely some, if not most, of these denials could be prevented with proper billing – application of the KX modifier for services exceeding 36 sessions.
Medicare covers a maximum of two 1-hour cardiac rehab sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor. Some patients need those additional sessions and Medicare will pay for these when the cardiac rehab CPT code (93797 or 93798) is appended with a KX modifier. Medicare considers the KX modifier “an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy.” Upon completion of a cardiac rehab program (up to 72 sessions), beneficiaries must experience another indication in order to be eligible for coverage of more cardiac rehabilitation.
Other common reasons for Medicare denials of cardiac rehab services are lack of a covered diagnosis code reported on the claim (generally automated denials) and lack of all the required components of cardiac rehab services (complex denials). Diagnoses supporting coverage of cardiac rehabilitation services are:
- An acute myocardial infarction within the preceding 12 months; or
- A coronary artery bypass surgery; or
- Current stable angina pectoris; or
- Heart valve repair or replacement; or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- A heart or heart-lung transplant; or
- Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.
If your record is selected for a complex review by Medicare, it must contain documentation supporting the diagnosis reported. Be sure your records contain copies of relevant patient history including intervention procedure reports and documentation of specific heart failure classification and ejection fractions when applicable.
Also upon Medicare complex reviews, the reviewer will be looking for documentation of all the required components of cardiac rehab therapy. These include:
- Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
- Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
- Psychosocial assessment;
- Outcomes assessment; and
- An individualized treatment plan detailing how components are utilized for each patient.
For complete information on the billing of cardiac rehab services, see the Medicare Claims Processing Manual, Chapter 32, Section 140.
Again, Happy Cardiac Rehab Week and make sure you are receiving appropriate payment for the wonderful services you provide by documenting and billing correctly.
Debbie Rubio
“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,
Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”
You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.
Patients over Paperwork
On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”
CMS is keeping stakeholders informed through Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.
December 2017 Newsletter
In this inaugural edition, CMS noted that they have the following three aims for this initiative:
- Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
- Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
- Increase the proportion of tasks that CMS customers can do in a completely digital way.
CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.
January 2018 Newsletter
The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:
- Quality Measures,
- Quality Payment Program (QPP) (5522-FC),
- Appropriate Use Criteria for Advanced Diagnostic Imaging,
- Documentation Review,
- Quality and Safety Oversight,
- Promote Affordability for Consumers,
- States,
Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.
Clarified Signature Requirements
“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.
After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.
To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”
Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims
“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.
We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.
To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”
E/M Service Documentation Provided by Students (Manual Update)
Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)
While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.
Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.
You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.
Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.
Beth Cobb
Medicare Transmittals
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2018.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2018
Changes in the April 2018 quarterly release of the edit module for clinical diagnostic laboratory services.
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration.
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
The new Healthcare Common Procedure Coding System (HCPCS) codes for 2018 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 2nd Qtr Notification for FY 2018
Medicare contractors shall implement an interest rate of 10.625 percent effective January 19, 2018 for Medicare overpayments and underpayments.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R297FM.pdf
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
Replaces Transmittal 1975. A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf
Medicare Special Edition Articles
Proper Use of Modifier 59 – REVISED
Revised on January 3, 2018, to conform with the latest Modifier 59 article on the NCCI website.
Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures
Inform providers that Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable.
Medicare Coverage Updates
Proposed Decision Memo for Magnetic Resonance Imaging (MRI)
Proposing to modify the national coverage determination to eliminate the collection of additional information under the Coverage with Evidence Development.
Rules and Regulations
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction
This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on December 14, 2017 entitled ‘‘Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.’’
https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf
State Survey Memorandums
Texting of Patient Information among Healthcare Providers
Memorandum clarifies 1) Texting patient information among members of the health care team is permissible if accomplished through a secure platform; 2) Texting of patient orders is prohibited regardless of the platform utilized; 3) Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.
Medicare Press Releases
New Payment Model
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).
Medicare Educational Resources
Medicare Quarterly Provider Compliance Newsletter – January 2018
Topics include Advanced Care Planning and proper use of modifier 59 for physicians and non-physician practitioners
Major Joint Replacement (Hip or Knee) MLN Booklet
Due to the high volume of major joint replacement claims, CMS has had multiple auditing entities, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
Ambulance Inflation Factor for CY 2018 and Productivity Adjustment
The Calendar Year (CY) 2018 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services is 1.1 percent.
Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans
Sets system edits to zero out payment on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED).
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set- Aside Arrangements (NFMSAs) - RESCINDED
Clarifying Signature Requirements
Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. Claim denials shall be limited to those instances in which signatures that are required by Medicare policies are flawed or missing.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf
Clinical Laboratory Improvement Amendments of 1988 (CLIA); Fecal Occult Blood (FOB) Testing
Clarifies CLIA regulations that the waived test categorization applies only to non- automated fecal occult blood tests.
https://www.gpo.gov/fdsys/pkg/FR-2017-10-20/pdf/2017-22813.pdf
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals – REVISED
Re-issued to revise several policy statements and to address how to handle certain impacted claims.
New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) – REPLACED
Removes provider education requirements from original transmittal.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1954OTN.pdf
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Final Rule
Revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-13/pdf/2017-23932.pdf
Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018
Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to update payment systems to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.
https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC)
Announces CMS has awarded the JJ A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Alabama (AL), Georgia (GA) and Tennessee (TN) to Palmetto GBA LLC.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1960OTN.pdf
Update to Pub 100-04, Chapter -18 Preventive and Screening Services -Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
Adds ICD-10 diagnosis codes: F17.210 (Nicotine dependence, cigarettes, uncomplicated), F17.211 (Nicotine dependence, cigarettes, in remission), F17.213 (Nicotine dependence, cigarettes, with withdrawal), F17.218 (Nicotine dependence, cigarettes, with other nicotine-induced disorders), or F17.219 (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders), for LDCT coverage.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3901CP.pdf
Billing Requirements for Ophthalmic Bevacizumab
Clarifies HCPCS code for billing ophthalmic bevacizumab.
Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review
ALJ hearing requests amount for 2018 will remain at $160. Federal District Court appeals amount will increase to $1,600 for 2018.
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2018
Fact Sheet describing VBP program and updates. Estimates the total amount available for value-based incentive payments for FY 2018 discharges will be approximately $1.9 billion.
Additional Appeals Settlement Option
CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
NCD coding changes the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
CMS Posts RAC Review Topics
CMS has begun to post a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page.
Partial Settlement of 2-Midnight Policy Court Cases
Provides instructions to Medicare Administrative Contractors (MACs) on how to ensure hospitals receive additional payments due to a partial settlement agreement regarding the 0.2 percent downward adjustment beginning in Fiscal Year ("FY") 2014.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1969OTN.pdf
New Waived Tests
New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the 2018 annual update to the list of Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare systems to enforce consolidated billing of home health services.
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP), and PC Print Update
Updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print.
Claim Status Category Codes and Claim Status Codes Update
MAC and shared systems changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.
Therapy Cap Values for Calendar Year (CY) 2018
For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010.
New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes
CMS has created two new PET radiopharmaceutical unclassified tracer codes that can be used temporarily pending the creation/approval/implementation of permanent CPT codes that would later specifically define their function: A9597 - Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified; A9598 – Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified.
2018 Medicare Parts A & B Premiums and Deductibles
On November 17, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html
Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
Provides the quarterly update of HCPCS codes used for HH consolidated billing effective April 1, 2018.
Fall is without a doubt my favorite time of year. The one downside is that the days get shorter leaving fewer hours of daylight. Fewer hours of daylight leads to prioritizing what I want to get accomplished on my off days. While deciding where to start is an easy choice when it comes to chores around the outside of my house versus driving through a state park to catch a glimpse of the fall foliage, deciding how to prioritize “at risk” issues for a hospital can be a challenge. One good starting point is knowing what issues the Comprehensive Error Rate Testing (CERT) Program has found to be “at risk.”
CERT Program Background
The objective of the CERT program is to calculate the Medicare Fee-for-Service (FFS) program improper payment rate. “The CERT program considers any payment that should not have been made or that was paid at an incorrect amount (including both overpayments and underpayments) to be an improper payment. It is important to note that the improper payment rate does not measure fraud. It estimates the payments that did not meet Medicare coverage, coding, and billing rules.”
The CERT Review contractor performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. A claim review entails checking for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and provisions in the CMS instructional manuals. A stratified random sample is chosen by claims types for review and using statistical weighting, the findings from the sample are projected to the total universe of Medicare FFS claims submitted during the report period.
Reconciliation of Improper Payments
The CERT program notifies the MACs of improper payments identified through the CERT process. The MACs then repay underpayments and recoup overpayments. MACs can recover the overpayments identified in the CERT sample but cannot recoup projections made to the claims universe.
Medicare Fee-For-Service 2016 Improper Payments Report
Annually, an Improper Payments Report is released as well an Appendices of tables breaking down the findings. The Medicare FFS 2016 Improper Payments report was posted on the CMS CERT Reports webpage in July of this year. This report includes claims submitted during the 12-month period from July 1, 2014 through June 30, 2015 and highlights the services and supplies that were the largest drivers of the 2016 improper payment rate.
2016 Report by the Numbers:
- 89% - The estimated Medicare FFS Payment Accuracy Rate.
- $332.6 billion – the estimated amount paid correctly by Medicare for services and supplies provided to Medicare beneficiaries.
- 11% - The estimated Medicare FFS Improper Payment Rate
- $41.1 billion – the estimated amount paid incorrectly by Medicare.
- $22 million or 86% - the amount of actual overpayment dollars identified during the 2016 report period that the MACs had collected as of the time the 2016 report was published.
The report indicates that “the major contributor to the Medicare FFS improper payment rate decrease from 12.1 percent in 2015 to 11.0 percent in 2016, were implementation of CMS’ “Two Midnight” rule and corresponding educational efforts.” Also, as in prior years, “the most common cause of improper payments (accounting for 64.1 percent of total improper payments) was lack of documentation to support the services or supplies billed to Medicare. In other words, the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary.”
2016 Part A Driver of the Improper Payment Rate
The majority of hospital IPPS improper payments were due to the record not supporting a reasonable expectation that the admitting practitioner expected the patient to require a hospital stay that crossed two midnights. During the 2016 report period the CERT denied 733 claims for this reason totaling $7.4 million in actual overpayments. The projected overpayment to the universe of Medicare claims was $2.1 billion.
CMS goes on to note that errors are more likely to occur when the length of stay is shorter and where there is an elective surgical procedure. In fact, 18.6% of improper payments made to Part A IPPS Hospitals was for claims with a length of stay 0 or 1 days.
CMS Key Effort to Prevent and Reduce Improper Payments
One way that CMS and its contractors are working to reduce improper payments is by developing “medical review strategies using the improper payment data to ensure the areas of highest risk and exposure are targeted. MACs use improper payment data analysis to determine which claims to review on either a pre-payment or post-payment basis. Improper payment data analysis also guides the MAC’s corrective actions and educational efforts.
What Hospital Can do to Reduce Improper Payments
Examples of efforts hospitals can undertake to prevent and reduce improper payments include:
- Visit the CERT Provider Website that provides information about the CERT, how to submit records, sample request letters and much more.
- Become familiar with NCDs, LCDs and coverage articles that provide guidance on what is needed to support the medical necessity of the services you provide. The CERT Provider Website contains a link to a CMS CERT Presentation. Below is an example from the presentation reinforcing the need to be familiar with coverage determinations:
Medical Necessity Example
- “The CERT program received medical records from two different physicians documenting that a patient who underwent implantation of an AICD had severe dementia. The National Coverage Determination (NCD 20.4) specifies that the patient must not have irreversible brain damage from preexisting cerebral disease.
- The CERT contractor reviewers made an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies.”
- Visit the CERT A/B MAC Outreach & Education Task Force page on the CMS website which includes Education Resources, Web-based Training, Presentations and information about any upcoming events.
- Become familiar with and utilize your hospitals Program for Evaluating Payment Patterns Electronic Report (PEPPER).
- And last but not least be familiar with the improper payment issues identified in the Annual CERT Reports.
Beth Cobb
It was Miss Peacock in the Dining Room with the Candlestick is just one of the many possibilities in solving the murder mystery in the game of Clue. Learning to put the pieces together to solve the mystery as a child has served me well when it comes to the world of Clinical Documentation Improvement where each chart is a new mystery and I am the detective. When reviewing a chart you may find clinical indicators without a diagnosis that provides you with the needed “clues” to query the physician. You may also find a diagnosis lacking the supporting “clues” (clinical indicators) that again require querying the physician. And, if all goes well, at the end of the hospitalization the mystery is solved and there is clear documentation supporting a principal diagnosis, secondary diagnoses, the resources utilized and the medical necessity of the admission.
More and more emphasis is being put towards outpatient Clinical Documentation. For many this is an entirely new and different mystery to be solved. One key to solving this mystery is having a basic understanding of Hierarchical Condition Categories (HCCs). This article is meant to be a starting point to unraveling the mystery of HCCs.
Background
- Medicare Advantage (Part C) plans are paid a monthly capitation rate to provide health care services to enrolled beneficiaries.
- Historically, payments to Medicare Advantage (Part C) plans were linked to Fee-for-Service expenditures. “Research showed that the managed care program was increasing total Medicare Program expenditures, because its enrollees were healthier than FFS enrollees.”¹
- The Benefits Improvement Protection Act (BIPA 2000) required the implementation of a risk adjustment model using not only diagnoses from inpatient hospital stays, but also from ambulatory setting beginning in 2004.
- The CMS-HCC model was implemented in 2004 as a risk-adjustment model. Per CMS this allows them “to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk and risk scores are used to adjust payments for each beneficiary’s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.”²
- CMS-HCC data is calculated once a year based on information reported on claims.
- To continue to be factored into an enrollees risk adjustment, all chronic conditions, including past surgeries, must be documented annually during a face-to-face encounter.
CMS-HCC Model Basics
- An HCC is a category of disease type (e.g., congestive heart failure) with multiple individual ICD-10 diagnoses that map to that HCC category.
- Similar to severity weighted MS-DRGs in the acute hospital inpatient setting, each HCC is assigned a Risk-Adjustment Factor (RAF) This score is a total of all relative factors related to one patient for a total year. Specifically, demographic (age and whether the patient is community-based or living in a skilled nursing facility (SNF) and disease complexity factors. There is an Interaction Factor for certain conditions indicating the presence of several conditions at the same time.
- Diagnoses from inpatient, outpatient and professional practice encounters are used to calculate the RAF score.
- There are currently 79 HCC Categories (e.g., Infection, Diabetes with Acute Complications, Diabetes with Chronic Complications, Cerebrovascular Disease).
CMS-HCC Model: Guiding Principles
The CMS-HCC model uses demographic information (age, sex, Medicaid dual eligibility, disability status) and a profile of major medical conditions in the base year to predict Medicare expenditures in the next year. The following 10 principles guided the creation of the CMS-HCC diagnostic classification system:
- Principle 1: Diagnostic categories should be clinically meaningful,
- Principle 2: Diagnostic categories should predict medical expenditures.
- Principle 3: Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures.
- Principle 4: In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate.
- Principle 5: The diagnostic classification should encourage specific coding. “Vague diagnostic codes should be grouped with less severe and lower-paying diagnostic categories to provide incentives for more specific diagnostic coding.”²
- Principle 6: The diagnostic classification should not reward coding proliferation. “Neither the number of times that a particular code appears, nor the presence of additional, closely related codes that indicate the same condition should increase predicted costs.”²
- Principle 7: Providers should not be penalized for recording additional diagnoses.
- Principle 8: The classification system should be internally consistent.
- Principle 9: The diagnostic classification should assign all ICD-10-CM codes as each code potentially contains relevant clinical information.
- Principle 10: Discretionary diagnostic categories should be excluded from payment models.
CMS-HCC Model: Disease Hierarchy
Similar to the surgical hierarchy in the inpatient setting. The CMS-HCC model follows a disease hierarchy. The hierarchy addresses “situations when multiple levels of severity for a disease, with varying levels of associated costs, have been reported for a beneficiary. The hierarchies prioritize the inclusion in a risk score of multiple HCCs where diagnoses are clinically related and ranked by costs. In the case of a disease hierarchy, Part C payment is based only on the most severe and costly manifestation of the disease. Hierarchies are published in the Rate Announcement for the years when CMS recalibrated the CMS-HCC model.”²
CMS-HCC Model: Risk Adjustment Data Submission Requirements
The following bullets can be found in Chapter 7 of the Medicare Managed Care Manual and detail some of what plan sponsors must do when submitting data.
- “Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face-to-face visit. The diagnosis must be coded according to International Classification of Diseases, (ICD) Clinical Modification Guidelines for Coding and Reporting.
- Implement procedures to ensure that diagnoses are from acceptable data sources. The only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities, and physicians. Plan sponsors are responsible for determining provider type based on the source of the data.
- Submit the required data elements from acceptable data sources according to the coding guidelines.
- Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at least once during the risk adjustment data-reporting period. Submitters must filter diagnosis data to eliminate the submission of duplicate diagnosis clusters.
- For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit diagnosis codes under the same rules as for a beneficiary with both Parts A and B. The plan should also submit diagnosis codes for Part A services provided under a non-Medicare contract.
If upon conducting an internal review of submitted diagnosis codes, the plan sponsor determines that any diagnosis codes that have been submitted do not meet risk adjustment submission requirements, the plan sponsor is responsible for deleting the submitted diagnosis codes as soon as possible.”²
HCCs beyond Medicare
The CMS-HCC Model is just one example of HCCs being used. Examples of different ways HCCs are being used includes the following:
- The CMS-RxHCC Model is used separately to address Medicare Part D (Medicare prescription drug coverage),
- The Department of Health and Human Services maintains the HHS-HCC Model to address commercial payer populations;
- Accountable Care Organizations (ACOs) participating with the Medicare Shared Savings Program (MSSP); and
- The Medicare Hospital-Value-Based Purchasing Program measure Medicare Spending per Beneficiary.
Risk-Adjustment Payment Models are an integral part of CMS’s move away from paying for volume and towards payment for quality. To accurately reflect risk, there should be no mystery as to what the physician meant in the documentation. Documentation needs to reflect all medical conditions being managed, evaluated, assessed and treated and be detailed enough so the conditions can be coded to the highest specificity.
Resources:
- Pope G, Kautter J, Ellis R, Ash A, Ayanian J, Iezzoni L, Igber M, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing 2004; 25:119-141. Accessed August 31, 2017 at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/04Summerpg119.pdf
- Medicare Managed Care Manual, Chapter 7 – Risk Adjustment Accessed August 31, 2017 at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c07.pdf
Beth Cobb
It’s hard to believe that school is back in session and fall is just around the corner. Here in the Deep South, fans celebrate the return of high school football on Friday night and SEC football on Saturday. Whether you are on a team or a supportive spectator, to truly enjoy the game, you need to have an understanding of the game rules.
This is also the time of year when the IPPS Final Rule and ICD-10-CM Official Guidelines for Coding and Reporting are released for the coming Fiscal Year (FY). For Professional Coders and CDI Specialists, to accurately reflect the severity of illness and resource consumption for your patient population, you need to have an understanding of the changes. This week we focus on highlights from the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting.
NARRATIVE Changes
Narrative changes within the Guidelines appear in bold text.
“With”
“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
In the 2017 Guidelines update, guidance was changed to include that “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. New in 2018 this guidance goes on to include the following: “or when another guidelines exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”). For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.”
“Code also” note
“A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”
Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer-Stages, Coma Scale, and NIH Stroke Scale
Prior to ICD-10 there was no way to capture the National Institutes of Health Stroke Scale (NIHSS). Coding the NIHSS was first included in this section of the Guidelines in 2017 and instructed that coders may code this “based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient… codes should only be reported as secondary diagnoses.”
In the FY 2018 IPPS Final Rule, CMS finalized the proposal to refine the Stroke 30-Day Mortality Rate Measure for the FY 2023 payment determination by including the National Institutes of Health (NIH) Stroke Scale.
Key Takeaway’s for Hospitals
CMS “proposed this measure now to inform hospitals that they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”
- You will need to work with your Physicians to ensure that they are measuring and recording stroke severity.
- Coders will need to include the appropriate ICD-10 code from the Physician’s documented NIH Stroke Scale score.
- CMS clarified in the FY 2018 IPPS Final Rule that “The intent of the risk adjustment for stroke severity is to account for patients’ clinical status at the time they are admitted to the hospital. Therefore, the refined Stroke 30-Day Morality Rate measure would utilize only the initial NIH Stroke Scale score, which is administered upon admission.”
- Advice on the subcategory to report the NIH Stroke Scale scores can be found in Coding Clinic 2016, 4th Quarter, page 61.
In addition to narrative changes, it is essential for the Professional Coder and/or CDI Specialist to pay close attention to when there is guidance to query the provider. The following table details when a query is advised.
This article provides an overview, be aware that there are several additions to the Chapter-Specific Coding Guidelines (i.e., patient admission/encounter for the insertion of implantation of radioactive elements, diabetes mellitus, blindness, pulmonary hypertension, acute myocardial infarction (AMI) and non-pressure chronic ulcers). Reading the Guidelines is a must for Coding and CDI Professionals as you prepare for the rule changes to the “game” with the start of the 2018 IPPS Fiscal Year on October 1.
Beth Cobb
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