Knowledge Base Category -
The Program for Evaluating Payment Patterns Electronic Report or PEPPER is one resource available to providers to help guide your selection of meaningful review targets for audits. According to the PEPPER User’s Guide for Short-Term Acute Care, this report “contains a single hospital’s claims data statistics for Medicare-Severity Diagnosis-Related Groups (MS-DRGs) and discharges at risk for improper payment due to billing, coding, and/or admission necessity issues…All of the data tables, graphs, and reports in PEPPER were designed to assist the hospital in identifying potential overpayments as well as potential underpayments.”
If you attempted to access the PEPPER Resources website in December 2023, you were directed to a blank page. This week I once again checked this website and the following notice has been posted:
“Updates to the Program for Comparative Billing Reports (CBRs) and Evaluating Payment Patterns Electronic Report (PEPPERs) Coming Soon
There will be a temporary pause in distributing CBRs and PEPPERs as CMS works to improve and update the program and reporting system. This pause will remain in effect through the fall of 2024. We recognized the importance of these reports to your practice. Therefore, during this time, CMS will be working diligently to enhance the quality and accessibility of the reports. In fulfilling this commitment, your feedback is requested. In the near future, CMS will release a Request for Information (RFI) to obtain information from you, the provider community, about how the program can better serve you.
Please visit CBR and PEPPER website for periodic updates. If you have further questions please send them to Medicaremedicalreview@cms.hhs.gov.”
About CBRs
In addition to PEPPERs, CMS has paused CBRs. According to the CMS webpage Data Analysis Support and Tracking, “a Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider. CBR’s contain actual data-driven tables and graphs with an explanation of findings that compare provider’s billing and payment patterns to those of their peers on both a national and state level. Graphic presentations contained in these reports help to communicate a provider’s billing pattern more clearly. CBR study topic(s) are selected because they are prone to improper payments. For additional information and examples of CBRs, you can access the eGlobalTech website at http://www.cbrinfo.net/.” Note, this website currently can’t be reached.Beth Cobb
Question
We have outpatient lab orders on patients that frequently have a host of lab tests performed including Microalbumin/Creatinine Ratio and Urine Drug Screen, CPT® codes 82570, 82043, 80307. There are separate orders & results for all 3 tests. All may have the same diagnoses or different diagnoses.
I have read the NCCI edit about specimen validity, but in this case, these tests appear to be ordered for specific diagnoses, they have separate orders and results. Would 59 be appropriate on 82570?
Answer
Yes, modifier 59 can be used when CPT® code 82570 (urine creatinine) is ordered and resulted separately, and when the urine creatinine is “not” performed for specimen validity testing.
To support this opinion, we used the NCCI policy statement you referenced above (NCCI Policy Manual, chapter X, section E.2, page X-7) Link
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2023 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Jeffery Gordon
Question:
Are there any updates for rehabilitative therapy services’ threshold amounts for the coming year?
Answer:
Yes. Change Request (CR) 13371 issued September 14, 2023 and re-communicated November 6, 2023 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2024. These thresholds were previously known as “therapy caps.”
CY 2024 KX Modifier Threshold Amounts
- $2,330 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
- $2,330 for Occupational Therapy (OT) services.
Providers can track a patient’s year-to-date therapy amounts on Medicare eligibility screens. The KX modifier must be appended to therapy services’ line-items on the claim for medically necessary therapy services above the threshold amounts. The medical necessity of services beyond the threshold amount must be justified by appropriate documentation in the medical record. Services provided beyond the threshold that are not billed with the KX modifier will be denied with Claim Adjustment Reason Code 119 - Benefit maximum for this time period or occurrence has been reached.
There is also a therapy threshold related to the targeted medical review process, now known as the Medical Record (MR) threshold amount. This threshold remains at $3,000 for PT and SLP combined and a separate $3,000 for OT until CY 2028.
Resource
Beth Cobb
Medicare Transmittals & MLN Articles
November 22, 2023: MLN MM13452: Medicare Physician Fee Schedule Final Rule Summary: CY 2024
This article highlights changes in the CY 2024 Physician Fee Schedule final rule. For example, starting in CY 2024, telehealth services provided to people in their homes will be paid at the non-facility PFS rate. https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf
November 30, 2023: Change Request (CR) 13312: Indian Health Services (IHS) Rural Emergency Hospital (REH) Provider Enrollment
Beginning January 1, 2024, a tribal or IHS operated hospital that converts to an REH (IHS-REH) that provides hospital outpatient services to a Medicare beneficiary may be paid under the outpatient hospital All-Inclusive rate that is established and published annually by the IHS, rather than the rate for REH services. This CR updates Chapter 10 of the CMS Publication 100-08 (Medicare Program Integrity Manual) to include provider enrollment guidance regarding IHS-REHs. https://www.cms.gov/files/document/r12217pi.pdf
December 7, 2023: MLN MM13333: Medicare Program Integrity Manual: CY 2024 Home Health Prospective Payment System Updates
This article includes information about expanding the HHS 36-month rule, moving hospices into the high level of categorical risk-screening, and other updates to Chapter 10 of the Medicare Program Integrity Manual. https://www.cms.gov/files/document/mm13333-medicare-program-integrity-manual-cy-2024-home-health-prospective-payment-system-updates.pdf
December 7, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised
The December 7th revision of this special edition MLN article adds information on how to verify and update service locations for Medicare enrollment and what claim modifier to use. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
December 12, 2023: MLN MM13463: DMEPOS Fee Schedule: CY 2024 Update
Make sure your billing staff knows about CY 2024 fee schedule amounts for new and existing codes and payment policy changes. For example, the CY 2024 HH PPS final rule established a new benefit category for standard and custom fitted compression garments and additional lymphedema compression treatment items under Medicare Part B. https://www.cms.gov/files/document/mm13463-dmepos-fee-schedule-cy-2024-update.pdf
December 20, 2023: Change Request (CR) 13222: Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92
Effective January 1, 2024, Section 4124 of the Consolidated Appropriations Act of 2023 establishes Medicare coverage and payment for IOP services for individuals with mental health needs when furnished by hospital outpatient departments, Critical Access Hospital outpatient departments, and Community Mental Health Centers. The original Transmittal 12125 has been rescinded and replaced by Transmittal 12423 (CR 13222) dated December 20, 2023. The purpose of this CR is to implement the new condition code 92 for IOP services and enforce billing requirements (https://www.cms.gov/files/document/r12423cp.pdf). Additional information about condition code 92 is available in a related MLN article 13496. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf
December 21, 2023: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update
Make sure your billing staff knows about system updates for January, including new codes for covered devices for pass-through payments, biology-guided radiation therapy, dental services, surgical procedures, drugs and biologicals, and skin substitutes. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf
December 26, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – REVISED
This article was originally published March 26, 2019. In this most recent revision CMS clarified that these instructions do not apply to separately enrolled provider-based rural health clinics and add information on the 09/23 version of the paper-based enrollment form. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdfBeth Cobb
Fiscal Year 2023 Supplemental Improper Payment Data
On December 7, 2023, the Comprehensive Error Rate Testing (CERT) published the 2023 Medicare Fee-for-Service Supplemental Improper Payment Data ( https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports).
This report supplements the FY 2023 HHS Agency Final Report for Fiscal Year 2023, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.
Estimated Improper Payment Rates
Calculation for the FY 2023 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2021 through June 30, 2022. As compared to FY 2020 and 2021, the improper payment rate is trending up:
Improper Payment Rate
- FY 2020: 6.27%
- FY 2021: 6.26%
- FY 2022: 7.46%
- FY 2023: 7.38%
Improper Payment Amount
- FY 2020: $25.74 billion
- FY 2021: $25.03 billion
- FY 2022: $31.46 billion
- FY 2023: $31.23 billion
“It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
Unfortunately, “insufficient documentation” continues to be the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.
While the CERT data reports on improper payments in various settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.
“0 or 1 day” Length of Stay Claims
A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this annual report since the October 1, 2013 implementation of the Two-Midnight Rule:
- 2014: “0 or 1 Day” stay claims highest improper payment rate to date at 37.18%,
- 2021: “0 or 1 Day” stay claims lowest improper payment rate to date at 16.8%.
- 2022: The “0 or 1 Day” claims rate increased to 20.1% with projected improper payments of $1.5 billion.
- 2023: The “0 or 1 Day” claims rate again increased to 21.7% with projected improper payments of $1.7 billion.
In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who is actively requesting short stay claims across the nation on a monthly bases.
In early 2023, Livanta published their year one review results. Of the 18,672 short stay claims reviewed, 2,663 (14%) of the claims were denied. You can read more about their review results in a related MMP article (https://www.mmplusinc.com/kb-articles/national-medicare-claims-review-contractor-year-one-review-results).
Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS
Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories.
Overall, 52.9% of the errors in the top 20 service types were due to error category medical necessity. This is an increase from 44.4% in FY 2022. A claim is placed in this category when the CERT contractor reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. The following three DRG types had the highest percent of errors attributed to medical necessity:
- DRG Pair 469 and 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity,
- DRG Group 091, 092, and 093: Other Disorders of Nervous System, and
- DRG Group 518, 519, and 520: Back and Neck procedures Except Spinal Fusion.
Beth Cobb
In a November 16th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”
White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)
HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:
- Pillar 1: Expanding Data Gathering and Sharing,
- Pillar 2: Support Flexible Funding to Address Social Needs,
- Pillar 3: Support Backbone Organization.
HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework
In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”
HHS Resource: HHS’s Call to Action to Address Health Related Social Needs
The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”
Z-Codes: Identifying and Coding Social Determinates of Health
Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:
- Z59.00: Homelessness, unspecified,
- Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
- Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).
CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.”
To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.
A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.
Beth Cobb
Coverage Updates
October 30, 2023: MLN MM13017: Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening – Revised
The initial release of this MLN article was February 2, 2023. Now in it’s third iteration, CMS has added clarifying information about the -KX modifier for screening colonoscopy claims in the context of a complete colorectal cancer screening. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf
November 20, 2023: MLN MM13429: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease
On October 13, 2023 CMS published a Final Decision Memo announcing a final decision to remove this NCD and now permitting Medicare coverage determinations to be made by the MACs. Removing the NCD also removes the current limitation of one PET beta-amyloid scan per lifetime from the coverage requirements.
CMS notes in MLN article MM13429 that “your MAC will adjust any PET beta amyloid claims processed incorrectly that you bring to their attention, effective for claims with DOS on or after October 13, 2023. https://www.cms.gov/files/document/mm13429-beta-amyloid-positron-emission-tomography-dementia-and-neurodegenerative-disease.pdf
Compliance Education Updates
MLN Educational Tool: Medicare Payment Systems
CMS has updated this tool to include FY 2024 updates to the:
- Acute Care Hospital Inpatient Prospective Payment System,
- Hospice Payment System & Coverage,
- Inpatient Psychiatric Facility Prospective Payment System,
- Inpatient Rehabilitation Facility Prospective Payment System,
- Long-Term Care Hospital Prospective Payment System, and
- Skilled Nursing Facility Prospective Payment System.
Substantive changes to this tool are in dark red. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html
October 2023: MLN Booklet: Independent Diagnostic Testing Facility
CMS has updated this booklet to include more information on several topics, including supervising physicians, interpreting physicians, and technicians. https://www.cms.gov/files/document/mln909060-independent-diagnostic-testing-facility.pdf
New and Updated CMS National Training Program (NTP) Products
You can order CMS products in bulk by visiting our product ordering website.
Beth Cobb
October 30, 2023: MLN MM13390: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 1 of 2)
CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13390-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-1-2.pdf
October 30, 2023: MLN MM13391: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 2 of 2)
CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13391-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-2-2.pdf
November 3, 2023: MLN MM13244: Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Claims
Effective January 1, 2024, Medicare will make separate payment for HCPCS code A9272 on type of bill (TOB) 032x, instead of 034x. Also, Medicare Administrative Contractors (MACs) will apply deductible and coinsurance.
November 6, 2023: MLN MM13055: Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order – Revised
Initially published June 1, 2023, this article was revised on November 6, 2023 to add two new CPT codes effective January 1, 2024, based on Change Request (CR) 13279.
https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdfBeth Cobb
Did You Know?
On November 6, 2023, the Office of Inspector General (OIG) released General Compliance Program Guidance (GCPG).
Per the OIG’s announcement, “the GCPG is a reference guide for the health care compliance community and other health care stakeholders. The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other items useful for understanding health care compliance. The GCPG is voluntary guidance that discusses general compliance risks and compliance programs. The GCPG is not binding on any individual or entity.”
You can download the complete guidance or individual sections.
Why it Matters?
The OIG first published compliance program guidance documents (CPGs) in 1998. Historically, guidance has been published in the Federal Register. However, moving forward, updates or new guidance will no longer be published in the Federal Register.
GCPG
The GCPG guidance applies to all individuals and entities involved in the health care industry and addresses:
- Key Federal authorities for entities engaged in health care business.
- The seven elements of a compliance program,
- Adaptations for small and large entities, other compliance,
- Other compliance considerations, and
- OIG processes and resources.
Moving forward, the OIG anticipates updating the GCPG as changes in compliance practices or legal requirements may warrant.
ICPGs
Starting in 2024, the OIG will begin publishing industry specific CPGs (ICPGs) that “will be tailored to fraud and abuse risk areas for each industry subsector and will address compliance measures that the industry subsector participants can take to reduce these risks. ICPGs are intended to be updated periodically to address newly identified risk areas and compliance measures and to ensure timely and meaningful guidance from the OIG.”
Moving Forward
Ultimately, the goal of both guidance documents (GCPG and ICPGs) “has been, and will continue to be, to set forth voluntary compliance guidelines and tips and to identify some risk areas that OIG believes individuals and entities engaged in the health care industry should consider when developing and implementing a new compliance program or evaluating and updating an existing one.”
I encourage you to take the time to read this latest guidance, pay close attention to the information in the blue boxes and tips throughout this document. For example, in the “Auditing and Monitoring” section of this document an OIG tip reminds providers that “Medicare requires, as a condition of payment, that items and services be medically reasonable and necessary. Therefore, entities should ensure that any claims reviews and audits include a review of the medical necessity of the item or service by an appropriately credentialed clinician. Entities that do not include clinical review of medical necessity in their claims audits may fail to identify important compliance concerns relating to medical necessity.”
Finally, if you are not already signed up for the OIG newsletter, I encourage you to do so. You can sign up on the website by scrolling to the bottom of page and clicking “Subscribe to Our Newsletter.”
Beth Cobb
Did You Know?
Effective October 1, 2023, the Alphabetic Index to the code book changed how we are to code elevated Troponin level again.
Why It Matters?
Prior to October 1, 2023, the Alphabetic Index led coders to assign R77.8, Other Specified Abnormalities of Plasma Protein, for an elevated Troponin level, while the advice from Coding Clinic, 2Q 2019, page 6 instructed coders to use R79.89, Other Specified Abnormal Lab Findings of Blood Chemistry. Even though the code book instructions take precedence over Coding Clinic advice, this confused many coders and caused coding errors when coding this condition.
What Can I Do?
Inform coders that the Alphabetic Index has now changed and that R79.89, Other Specified Abnormal Lab Findings of Blood Chemistry is the correct code for an elevated Troponin level.
Resources:
Coding Clinic, 2Q 2019, page 6
Alphabetic Index from the code book, 10/01/2023
Anita Meyers
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