Knowledge Base Category -

CMS published the CY 2024 OPPS/ASC Proposed Rule on July 13, 2023. By now, many news outlets have authored articles about this proposed rule. This article highlights topics that historically our clients have reached out to us to learn about.

Medicare Inpatient Only (IPO) Procedure List

Although CMS received several requests recommending services for removal from the IPO list, CMS did not find sufficient evidence that met the criteria and did not propose to remove any service from the IPO list for CY 2024.

 

CMS has proposed to add nine services with newly created codes by the AMA CPT Editorial Panel which will be in effect January 1, 2024 to the list and to reassign CPT code 0646T (Transcatheter tricuspid valve implantation (ttvi)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed) from status indicator “E1” to status indicator “C.” The proposed changes are available in Table 47 of the proposed rule.

 

OPPS Payment Methodology for 340B OPPS Payment Methodology for Purchased Drugs and Biologicals

On July 7, 2023, CMS published a proposed rule, referred to as “remedy proposed rule” to address reduced payment amounts to 340B hospitals for CYs 2018 through 2022 and to comply with the statutory requirement to maintain budget neutrality. The “remedy proposed rule” proposes changes to the calculation of the OPPS conversion factor beginning in CY 2025.

 

In the “remedy proposed rule,” CMS proposes to make one time lump-sum payments to each of the approximately 1,600 340B covered entity hospitals. Addendum AAA to the proposed rule lists the proposed lump-sum payment for each eligible hospital.

 

For CY 2024, CMS proposes to continue to pay the statutory default rate, which is generally ASP plus 6 percent.

 

340B Modifiers “JG” and “TB”

The Inflation Reduction Act of 2022 expanded the provider types that must report one of these modifiers no later than January 1, 2024 to now include critical access hospitals, Maryland All-Payer or Total Cost of Care Model Hospitals, and Non-excepted off-campus provider-based departments (PBD).

 

In the CY 2023 OPPS/ASC final rule, CMS maintained the requirements that 340B hospitals report one of two modifiers, “JG” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes, or “TB” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes for select entities.

 

In the CY 2024 OPPS/ASC proposed rule, CMS notes they “now believe utilizing a single modifier will allow for greater simplicity, especially because both modifiers are used for the same purpose: to identify separately payable drugs and biologicals acquired under the 340B program.”

 

CMS is proposing that all 340B covered entity hospitals would report the “TB” modifier effective January 1, 2025, even if the hospital previously reported the “JG” modifier. The “JG” modifier will remain effective through December 31, 2024. Beginning January 1, 2025, the “JG” modifier would be deleted.

 

CMS notes hospitals currently using the “JG” modifier could choose to continue to use it in CY 2024 or choose to transition to the “TB” modifier during that year.

 

Payment for Intensive Cardiac Rehabilitation Services (ICR) Provided by an Off-Campus Non-Excepted Provider Based Department (PBD) of a Hospital

CMS identified a disparity in payment for ICR services between services provided in a physician’s office and the same services provided by an off-campus, non-excepted PBD and notes that this “creates a significant barrier to beneficiary access to an already underutilized service.”

 

To eliminate this unintended outcome CMS is proposing the following:

“Pay for ICR services provided by an off-campus, non-excepted provider-based department of a hospital at 100 percent of the OPPS rate for CR services (which is also 100 percent of the PFS rate) rather than at 40 percent of the OPPS rate,” and

“Effective January 1, 2024, we propose to exclude ICR from the 40 percent Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session) and G0423 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session) so that 100 percent of the OPPS rate for CR is paid irrespective of the presence of the “PN’’ modifier (signifying a service provided in a non-excepted off-campus provider-based department of a hospital) on the claim.”

 

Proposed Additions to the ASC Covered Procedures List (CPL) for CY 2024

CMS is proposing to update the ASC CPL by adding 26 dental surgical procedures. They note that they “expect to continue to gradually expand the ASC CPL, as medical practice and technology continue to evolve and advance in future years,” and encourage stakeholders to submit procedure recommendations to be added to the ASC CPL.

 

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging

Although this falls under the purview of the CY 2024 Physician Fee Schedule Proposed Rule, I often receive questions from clients regarding when CMS plans to fully implement this program.

 

In the proposed rule, CMS notes that they “exhausted all reasonable options for fully operationalizing the AUC program,” and “propose to pause implementation of the AUC program for reevaluation and rescind the current AUC program regulations from §414.94.” They “expect this to be a hard pause to facilitate thorough program reevaluation and, as such…are not proposing a time frame within which implementation efforts may recommence.”

 

The comment period for the CY 2024 Hospital OPPS/ASC and Physician Fee Schedule Proposed Rules ends on September 11, 2023. I encourage you to take the time to review the proposed rules and submit comments.

 

Resources

Hospital Outpatient Prospective Payment-Notice of Proposed Rulemaking with Comment Period CY

2024: https://www.federalregister.gov/documents/2023/07/31/2023-14768/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

 

Hospital Outpatient Prospective Payment Remedy for the 340B-Acquired Drug Payment Policy-Notice of Proposed Rulemaking with Comment Period: https://www.cms.gov/medicare/medicare-fee-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations-and/cms-1793-p

 

MLN Fact Sheet: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier (MLN4800856 March 2023): https://www.cms.gov/files/document/mln4800856-medicare-part-b-inflation-rebate-guidance-use-340b-modifier.pdf

 

CY 2024 Physician Fee Schedule Proposed Rule: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched

June 29, 2023 HHS Press Release: CDC Recommends Older and Immunocompromised Adults to Receive the RSV Vaccine

HHS Secretary Xavier Becerra issued the following statement in response to the CDC recommendation of the Respiratory Syncytial Virus (RSV) vaccine for seniors over 60: “For the first time in U.S. history, people 60 years and older can now receive a vaccine for protection against RSV virus…As we prepare for the fall vaccine campaign, we will follow the data and science to protect our nation’s most vulnerable adults, those living in nursing or long-term care facilities, and the immunocompromised.” https://tinyurl.com/yw9buepd

June 29, 2023: MLN Connects: New TCET Pathway

CMS published the following information in the June 29, 2023 edition of MLN Connects:

CMS is committed to fostering innovation while ensuring that people with Medicare have faster and more consistent access to emerging technologies that will improve health outcomes. As part of this commitment, CMS announced a proposed Transitional Coverage for Emerging Technologies pathway. This announcement includes a proposed procedural notice and several proposed guidance documents that propose a substantial transformation to our approach to coverage reviews and evidence development. Comment on the Federal Register notice by August 28. More Information:

Related CMS Blog: https://www.cms.gov/blog/transforming-medicare-coverage-new-medicare-coverage-pathway-emerging-technologies-and-revamped, and

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/notice-comment-transitional-coverage-emerging-technologies-cms-3421-nc

June 29, 2023: MLN Connects: New Details of Plan to Cover New Alzheimer’s Drugs

CMS released new details about how people can get drugs that may slow the progression of Alzheimer’s disease covered by Medicare.  Medicare will cover drugs with traditional FDA approval when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. Clinicians will be able to submit this information through a nationwide, CMS-facilitated portal. Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-announces-new-details-plan-cover-new-alzheimers-drugs

July 7, 2023: OPPS: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022 Proposed Rule (CMS 1793-P)

In response to the Supreme Court’s decision in American Hospital Association v. Becerra (142 S. Ct. 1896 (2022), and the district court’s remand, CMS published a proposed rule to remedy the payment rates the Court held were invalid and noted that aspects of this proposed rule policy will affect nearly all hospitals paid under the OPPS. The proposed rule contains the calculations of the amounts owed to each of the approximately 1,600 affected 340B covered entity hospitals. The 60-day comment period will end on September 5, 2023.

Proposed Rule: https://www.cms.gov/medicare/medicare-fee-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations-and/cms-1793-p

Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/hospital-outpatient-prospective-payment-system-remedy-340b-acquired-drug-payment-policy-calendar

July 12, 2023: Medicare Dental Services

CMS has created a Medical Dental Coverage webpage for health care providers. You will find links to information about what Medicare does and does not cover, what are inextricably linked dental services, if Medicare pays for multiple dental visits, who can provide and bill for dental services, how to submit a claim and additional resources. https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage

Beneficiary Notice of Noncoverage, Form CMS-R-131 Renewed

Reminder, the ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The renewed form has an expiration date of January 31, 2026, and became mandatory on June 30, 2023. Any ABN signed on or after June 30, 2023, with a prior expiration date will not be considered valid. https://www.cms.gov/medicare/medicare-general-information/bni/abn

July 20, 2023: The Joint Commission Eliminates Additional 200 Standards Across All Accreditation Programs

The Joint Commission announced in a press release that they are eliminating and consolidating more than 200 standards, effective August 27, 2023. “The second phase of this project includes a focus on The Joint Commission’s other accreditation programs in addition to the Hospital Accreditation Program (i.e., Ambulatory Health Care, Behavioral Health Care, and Laboratory). https://www.jointcommission.org/resources/news-and-multimedia/news/2023/07/the-joint-commission-eliminates-additional-200-standards-across-all-accreditation-programs/

Question:

There is confusion about coding an elevated troponin level. Should we use R77.8 per codebook or R79.89 per advice from Coding Clinic, Second Quarter 2019, pg. 6?

Answer:

The correct code assignment for an elevated troponin level is R77.8, Other Specified Abnormalities of Plasma Proteins. Coding Clinic, Second Quarter 2019, page 6 was superseded by the changes to the index that were effective with the discharges October 1, 2020. The ICD-10-CM Conventions and Coding Guidelines take precedence over Coding Clinic advice. 

 

References:

Coding Clinic Correspondence dated June 9, 2023

Coding Clinic, Second Quarter 2019, page 6

Coding Clinic, Fourth Quarter 2018, page 90

 

Did You Know?

The 2024 ICD-10-CM Official Guidelines for Coding and Reporting were posted to the CMS website on July 6, 2023 (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm). You can also find the guidelines on the CDC ICD-10-CM webpage (https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm).

Why It Matters?

“These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” As of July 19^th, there are only 73 days to become familiar with the October 1, 2023, changes.

Narrative guideline changes appear in bold text in this document.

What Can You Do?

For Coding and Clinical Documentation Integrity professionals, reading the new guidelines should be a requirement on your summer reading list. In addition to identifying the bolded text, pay attention to each time the guidelines tell you to query the provider if documentation is unclear.

For example, Section 1.A.19: Code Assignment and Clinical Criteria

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”

Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1^st start of the 2024 CMS Fiscal Year.

 

 

There are five covered indications in section B of National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) for when PTA is covered.  

In June 2022, the Multispecialty Carotid Alliance (MSCA) submitted a letter to CMS for reconsideration of covered indication B4 (concurrent with carotid stent placement in patients at high risk for carotid endarterectomy (CEA).

Last week, on July 11, 2023, CMS published Proposed Decision Memo CAG-00085R8: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting. CMS notes, the scope of this reconsideration is limited to PTA concurrent with CAS including transcarotid artery revascularization (TCAR) procedures.

CMS summarizes that their proposals, which affect NCD 20.7 sections B4 and D, will revise Medicare coverage for PTA of the carotid arteries concurrent with stenting by:

1. Expanding coverage to individuals previously only eligible for coverage in clinical trials.
2. Expanding coverage to standard surgical risk individuals by removing the limitation of coverage to only high surgical risk individuals.
3. Removing facility standards and approval requirements.
4. Adding formal shared decision-making with the individual prior to furnishing CAS; and
5. Allowing MAC discretion for all other coverage of PTA of the carotid artery concurrent with stenting not otherwise addressed in NCD 20.7.

CAS By the Numbers

CY 2022 PTA of Carotid Artery Concurrent with Stenting Top 5 States by Volume & Overall Nationwide
Provider State	Claims Volume	Total Claims Payment
FL	1,250	$19,318,373.57
TX	1,158	$20,279,078.22
CA	1,007	$24,699,603.30
PA	541	$10,394,841.24
NY	523	$13,379,059.31
Nationwide	13,471	$246,555,039.68
Data Source: RealTime Medicare Data (RTMD) Medicare Fee-for-Service paid claims data for DOS CY 2022

Moving Forward

CMS is seeking comments on whether the shared decision-making interaction should require the use of a validated shared decision-making tool and/or if there are other options to achieve the goal of truly informed decision-making. The comment period is from July 11, 2023 through August 10, 2023.  

Resources

NCD 20.7: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=201

Proposed Decision Memo CAG-0085R8: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=311&fromTracking=Y&

Coverage Updates

 

June 7, 2023: Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)

The CMS issued a National Coverage Analysis (NCA) Tracking Sheet. CMS has received a complete, formal request to reconsider NCD 110.23, they requested full coverage of allogeneic HSCT for individuals with MDS and the removal of the Coverage with Evidence Development (CED requirement currently tied to coverage for HSCT for Medicare beneficiaries with MDS. CMS is soliciting public comments relevant to the request and is accepting comments from 6/7/2023 – 7/7/2023. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=312

 

June 22, 2023: CMS Fact Sheet: Details of Plan to Cover New Alzheimer's Drugs

CMS notes that if the FDA grants traditional approval, then Medicare will cover the drug in appropriate settings that also support the collection of real-world information to study the usefulness of these drugs. This fact sheet gives more details on how a registry will work to make sure coverage will be available for any Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease that received FDA traditional approval. https://www.cms.gov/files/document/fact-sheet-june-2023.pdf

 

June 22, 2023: CMS Proposed Transitional Coverage for Emerging Technologies (TCET) Pathway

On June 22, 2023 CMS announced a proposed Transitional Coverage for Emerging Technologies (TCET) pathway as part of its commitment to fostering innovation while ensuring faster and more consistent access to emerging technologies. In addition, CMS released three proposed guidance documents: 1) Coverage with Evidence Development; 2) Evidence Review and 3) Clinical Endpoints Guidance for Knee Osteoarthritis. Additional information on today’s releases can be found here: https://www.cms.gov/blog/transforming-medicare-coverage-new-medicare-coverage-pathway-emerging-technologies-and-revamped and https://www.cms.gov/newsroom/fact-sheets/notice-comment-transitional-coverage-emerging-technologies-cms-3421-nc

 

Education Updates

 

MLN Fact Sheet: Medicare Part D Vaccines

This MLN Fact Sheet was updated this month to clarify that Medicare Part B covers vaccines and vaccine administration and Part D patient cost-sharing may include a vaccine administration fee. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/vaccines-part-d-factsheet-icn908764.pdf

 

Other Updates

June 5, 2023: OIG Publishes Spring 2023 Semiannual Report to Congress

The OIG notes that this semiannual report is intended to keep the HHS Secretary and Congress fully and currently informed of OIG’s crucial findings and recommendations during the reporting period October 1, 2022 through March 31, 2023. https://oig.hhs.gov/reports-and-publications/archives/semiannual/2023/spring-sar-2023.pdf

Medicare Transmittals & MLN Articles

 

June 1, 2023: MLN MM13055: Audiologists May Provide Certain Diagnostic Tests Without a Physician Order

Effective July 1, 2023, one visit to an audiologist without a physician or NPP order is permitted, per patient, once every 12 months. This change was finalized in the CY 2023 Physician Fee Schedule (PFS) rulemaking. https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf

 

June 2, 2023: MLN MM13056: New JZ Claims Modifier for Certain Medicare Part B Drugs

CMS advises that your billing staff know about using JW modifier data to show discarded amounts of drugs in a single-dose container or single-use package and reporting requirements for the new JZ modifier starting July 1, 2023. https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b-drugs.pdf

 

June 5, 2023: MLN MM13235: DMEPOS Fee Schedule: July 2023 Quarterly Update

Make sure your billing staff knows about the fee schedule adjustment relief for rural and non-contiguous areas and supplier education on power wheelchair repair. https://www.cms.gov/files/document/mm13235-dmepos-fee-schedule-july-2023-quarterly-update.pdf

 

June 7, 2023: MLN MM13164: Skilled Nursing Facility Probe and Educate Review

Medicare Administrative Contractors (MACs) will be reviewing a small sample of five SNF claims for each SNF in their jurisdiction. This strategy is in response to the CERT identifying SNF services as a top driver of the overall Medicare Fee-for-Service improper payment rate. CMS notes a contributing factor may be the change from the Resource Utilization Group (RUG) IV to the Patient Driven Payment Model (PDPM) for claims with dates of service on or after October 1, 2019.  https://www.cms.gov/files/document/mm13164-skilled-nursing-facility-probe-and-educate-review.pdf

 

June 13, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

CMS advised providers to make sure billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

 

June 15, 2023: MLN MM13235: New Waived Tests

This MLN highlights new waived tests effective October 1, 2023.  https://www.cms.gov/files/document/mm13253-new-waived-tests.pdf

 

June 22, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: July 2023 Update – Revised

This MLN article was initially released on May 25, 2023. With the June 22^nd iteration of this article, CMS added information about a corrected payment for CPT 0697T to agree with a revised CR 13216. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

It has been almost four years since the September 30, 2019 publication of the Discharge Planning Conditions of Participation (CoP) Final Rule in the Federal Register. At that time, CMS indicated that they would provide sub-regulatory interpretive guidance after the publication of the final rule, which will provide further clarification for implementing the final discharge planning requirements. You can read more about this final rule in a related MMP article.

In 2020, COVID-19 was declared a Public Health Emergency (PHE), and CMS used emergency waiver authorities so providers could rapidly respond to people impacted by COVID-19. Specific to the Discharge Planning CoPs, CMS waived the following requirements:

§482.43(A)(8) Quality and Resource Use Measures

“The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.”

 

§482.43 (C)(1) Patient Choice Lists

“The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.”

 

§482.61(e): Discharge Planning and Discharge Summary

“The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient’s condition on discharge.”

 

The discharge planning waivers expired on May 11, 2023 at the end of the COVID-19 PHE.

On June 6, 2023, CMS issued a Memorandum (QSO-23-16-Hospitals) to State Survey Agency Directors and noted in the Memorandum Summary that:

“CMS is committed to ensuring that the health and safety of patients are protected when discharges from hospitals and transfers to post-acute care providers occur. Therefore, we are providing the following information:

• Reminding state agencies (SAs), accrediting organizations (AOs), and hospitals of the regulatory requirements for discharges and transfers to post-acute care providers.
• Highlighting the risks to patients’ health and safety that can occur due to an unsafe discharge.
• Recommendations that hospitals can leverage to improve their discharge policies and procedures to improve and protect patients’ health and safety.”

   

  Areas of Concern

  Examples from the list of concerns identified by CMS related to missing or inaccurate patient information includes:

• Incomplete comprehensive list of all medications that have been prescribed to a patient during, and prior to, the hospitalization,
• Skin tears, pressure ulcers, bruising, or lacerations, including orders or instructions for cultures, treatments, or dressings, and
• A patient’s preferences and goals for care, such as their choices for treatment or their advance directives for end-of-life care.

 

After noting how missing and inaccurate patient information can have a negative impact for the patient, caregiver, and PAC providers, CMS reminds SAs and AOs about the discharge planning CoPs and advises that “when conducting surveys, SAs and AOs should be alert to the common issues identified above and ensure these discharges are occurring in a compliant and safe manner.”

 

Moving Forward

As of June 20, 2023, interpretive guidance for the Discharge Planning CoPs is still “pending and will be updated in future release” of the State Operations Manual – Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for hospitals. In the meantime, I encourage you to share this memorandum with your Discharge Planning staff so they can use the full list of areas of concern to make sure your medical record does not have missing or inaccurate patient information.

 

Resources

September 30, 2019 Discharge Planning CoP Final Rule: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf

Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHs: CMS Flexibilities to Fight COVID-19: https://www.cms.gov/files/document/hospitals-and-cahs-ascs-and-cmhcs-cms-flexibilities-fight-covid-19.pdf

June 6, 2023 CMS Memorandum (QSO-23-16-Hospitals): https://www.cms.gov/files/document/qso-23-16-hospitals.pdf

CMS State Operations Manual – Appendix A: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

 

Did You Know?

CMS recently published ICD-10-PCS and ICD-10-CM files for Fiscal Year 2024. Changes to the codes will be in effect for discharges occurring from October 1, 2023, through September 30, 2024.

 

 

ICD-10-PCS Files

The 2024 ICD-10-PCS files (https://www.cms.gov/medicare/icd-10/2024-icd-10-pcs) and FY 2024 ICD-10-PCS Guidelines for Coding and Reporting were published as of June 6, 2023.  

 

For FY 2024, there are 78 new codes and 5 deleted codes bringing the total number of ICD-10-PCS codes to 78,603. Note, with an increase of 40 codes for FY 2024, New Technology codes make up more than 50% of the new codes.

 

One change noted when compared to the FY 2023 PCS guidelines is in the Device General Guidelines section B6.1a. This section provides guidance that “if a device that is intended to remain after the procedure is completed requires removal before the end of the operative episode in which it was inserted, both the insertion and removal of the device should be coded.”

 

The FY 2023 guidelines included an example of when you would code both the insertion and the removal “(for example, the device size is inadequate or an event documented as a complication occurs).” The example has been removed from the FY 2024 guidelines.  

 

ICD-10-CM Files

The ICD-10-CM files (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm) became available on June 16, 2023. For FY 2024, there are 395 new codes and 25 deleted codes bringing the number of ICD-10-CM codes to 74,044.

 

CMS noted in their announcement that the FY 2024 ICD-10-CM Coding Guidelines, FY 2024 Conversion Table and FY 2024 Present on Admission (POA) Exempt Code List will be posted when available.

 

Why it matters?

CMS notes, on the opening page of the 2024 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

 

What can I do?

Share this information with coding and clinical documentation professions at your facility as you begin to prepare for the October 1, 2023, start of the CMS FY 2024.

Did You Know?
According to the American Lung, about 10 to 30% of adults in the U.S. may have sleep apnea and your risk increases with age and weight. One relatively new treatment for this condition is Hypoglossal Nerve Stimulation (HNS).

Effective January 1, 2022, there were three new CPT codes related to implantation, revision, or removal of the HNS system. A few months later, on June 7, 2022, the first RAC approved issue in 2022 was RAC Issue 0201 (Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements). You can read more about this in a related MMP article.

The affected CPT code for RAC Issue 0201 is 64582 (open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array). The following table highlights the place of service, volume and claims paid in CY 2022 for this CPT code.  

Place of Service	Procedure Volume	SumCPT Paid
Inpatient Hospital	113	$28,771.66
Outpatient Hospital	5,962	$2,702,754.78
Ambulatory Surgery Center (ASC)	958	$4,486,802.84
Overall Totals	7,033	$7,218,329.28
Data Source: RealTime Medicare Data (RTMD) CY 2022 Medicare Fee-For-Service nationwide paid claims.

 

Why It Matters?

Medicare Administrative Contractors (MACs) have published Local Coverage Determinations (LCDs) and related coding and billing articles for this procedure. Currently, two of the indications are a body mass index (BMI) less than 35 kg/m2, and a polysomnography (PSG) demonstrating an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 24 months of initial consultation for HNS implant.

 

In the U.S. Food & Drug Administration’s June 9, 2023 FDA Roundup, they announced they have approved an expanded indication for the Inspire Medical Systems’ Inspire Upper Airway Stimulation (UAS) System to include an updated AHI and BMI threshold.

 

“The safety and effectiveness data available now increased the AHI baseline to 100 and a BMI level of 40 for adults with moderate to severe Obstructive Sleep Apnea (OSA).”

 

What Can I Do?

With this device being on the RAC approved issue list you should:

• Be mindful of the timing of the FDA’s expanded indications in the event you receive a request for records for dates of service on or after June 9, 2023.
• Watch for updated indication information in your MACs related LCD.
• Share this information with key stakeholders.

 

Resources

American Lung Association article Learn About Sleep Apnea at https://www.lung.org/lung-health-diseases/lung-disease-lookup/sleep-apnea/learn-about-sleep-apnea

 

FDA Roundup: June 9, 2023: https://www.fda.gov/news-events/press-announcements/fda-roundup-june-9-2023