Knowledge Base Category -
Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, there have been updates issued about the new ABN form and the resumption of Medicare Contractor Medical reviews since first discussed in the July 2020 MAC Talk article.
New Fee-For-Service (FFS) Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131
Last month’s MAC Talk article alerted you to the June 24th modification found on the FFS ABN CMS webpage indicating form CMS-R-131 had been approved and use of the form was set to be mandatory on August 31, 2020.
On August 3rd CMS once again modified this CMS webpage further delaying the mandatory implementation date for the new ABN form:
“The ABN, Form CMS-R-131, and instructions have been approved by the Office of Management and Budget (OMB) for renewal. Due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023). At this time, the renewed ABN will be mandatory for use on 1/1/2021. The renewed form may be implemented prior to the mandatory deadline. The ABN form and instructions may be found in the download section.”
Medical Review during the COVID-19 Public Health Emergency
On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews indicating CMS’s intent to allow the resumption of medical reviews beginning on August 3, 2020, “regardless of the status of the public health emergency.”
On August 4th Palmetto GBA provided additional detail about the resumption of medical reviews. Specifically,
- MACs are resuming post-payment reviews of items/services provided prior to March 1, 2020,
- The Targeted Probe and Educate (TPE) program will restart later, and
- MACs will continue to offer detailed review decisions and education as appropriate.
On August 19th Palmetto GBA posted a related article Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review. In addition to details about receiving and responding to requests, this article provides a link to active service specific post-payment medical review topics for Part A inpatient and outpatient hospital services and Part B Physician Services.
August MAC Talk: The Local Scene
July 21, 2020: Noridian JE Article: Part B Provider Responsibility for Prior Authorization for Certain Hospital Outpatient Department Services
At the time of this month’s MAC Talk article, the Prior Authorization program is almost into its third month. Here at MMP we have had several clients seeking clarification on who is responsible for obtaining the prior authorization. The following comment and CMS response is excerpted from page 61453 of the Final Rule (CMS-1717-FC):
Who is Responsible for Obtaining Prior Authorization?
“Comment: We received comments with general questions regarding the proposed process such as who will be responsible for obtaining the prior authorization, that is, the physician or the hospital, and whether all related claims will be denied if prior authorization is not obtained. Some commenters expressed concern that physicians could be denied payment for services rendered if a hospital fails to submit a prior authorization request or fails to notify the physician of a denial.
Response: As noted above, this prior authorization process is being adopted under section 1833(t)(2)(F) of the Act, which is specific to OPD services, which provides payment only to hospital outpatient departments. In light of the different arrangements that could exist in different hospitals, we determined that enabling either the physician or the hospital to submit the prior authorization request on behalf of the hospital outpatient department was the best approach, though the hospital ultimately remains responsible for ensuring this condition of payment is met.”
In an article posted on July 21, 2020 by Noridian Healthcare Solutions, the JE MAC, they indicated the following regarding the physician’s involvement in the prior authorization process:
“Noridian has been receiving requests for prior authorizations from Part B providers, who bill on the CMS-1500 form.
This program is for outpatient hospital services billed on a UB-04 form, with type of bill 13X. Providers who bill on a CMS-1500 form should not submit prior authorization requests for the OPD services, because it is the facility’s responsibility to send in the request. A valid prior authorization request must contain the Part A Provider Transaction Access Number (PTAN), which is six digits. Requests that come from a physician’s office will be rejected.
It is the physicians’ responsibility to assist the facility by ensuring copies of the patient’s medical records are available for the following services:
- Botulinum Toxin Injections - use for chronic migraine treatment
- Vein Ablation.”
Noridian published the following subsequent article on August 18, 2020:
“While this prior authorization process is applicable to hospital OPDs, as specified in CMS-1717-FC, CMS allows the PA request to be sent by the physician/practitioner on behalf of the hospital OPD. If a PA request submitted by the physician/practitioner includes all necessary hospital OPD information, it is considered to be sent on behalf of the hospital OPD.
Please visit our Prior Authorization for OPD Services Webpage to learn about submitting requests. Last Updated Aug 18, 2020”
July 29, 2020: Palmetto GBA JJ Part B Claims Payment Issue (CPI) Regarding Stelara®
Palmetto GBA has identified an issue with Stelara®. Specifically, Stelara® billed with HCPCS codes J3357 denying as a self-administrated drug (SAD) when it should be excluded as indicated in the SAD Exclusion List Article #A53066. The issue affected claims with dates of service on or after April 20, 2020. As of July 29th Providers are asked to hold new claims for this HCPCS code until this CPI is updated, indicating editing has been updated. As of August 24, 2020, the status of this issue was the needed updates and adjustments were still pending.
August 3, 2020: Noridian Telehealth and Virtual Visits – During COVID-19 Webinar – September 17, 2020
Noridian Healthcare Solutions, the Medicare Administrative Contractor for jurisdictions E and F, Provider Outreach and Education (POE) staff will be hosting a webinar on September 17, 2020 at 1 p.m. PT. Topics for this session includes:
- Telehealth information
- Service Listings
- Waiver Changes
- Eligible Providers
- Billing Part A and Part B
- Other Telecommunication Services, and
- Questions and Answers
August 5, 2020: Who are the Medical Directors for Palmetto GBA?
Palmetto GBA posted an article highlighting their Medical Directors. Information about each of the Medical Directors includes their specific responsibility at Palmetto GBA (i.e. accountable for coverage policy activities, Director of the MolDX program) and details about their professional background.
August 7, 2020: COVID-19 FAQs on Medicare Fee-for-Service (FFS) Billing: Condition Code 44 FAQ
At the time this article was written this CMS FAQ Document was last updated on August 7th when a question regarding the use of Condition Code 44 was answered by CMS.
“Question: CMS is waiving the entire utilization review (UR) condition of participation at 42 CFR 482.30, which requires that a hospital must have a UR committee with a UR plan that provides for review for Medicare and Medicaid patients with respect to the medical necessity of the admissions to the institution, duration of stays, and professional services furnished, including drugs and biologicals. Does that mean that the use of Condition Code 44 is waived as well?
Answer: No, Condition Code 44 still applies. Although CMS has waived the UR condition of participation at 42 CFR 482.30, this does not mean that if a beneficiary’s status is changed from inpatient to outpatient and there is a determination that the inpatient admission does not meet the hospital’s inpatient criteria, that the hospital may bill an inpatient claim. Hospitals should report Condition Code 44 as appropriate.
August 14, 2020: First Coast Post-Payment Service-Specific Reviews
First Coast posted the following information about post-payment service-specific reviews:
“First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly coded, and medically reasonable and necessary.
First Coast performs data analysis on a regular basis on all services billed to Medicare to identify services that are frequently not billed and coded correctly per Medicare guidelines. Post-pay service-specific reviews are performed based on results of a widespread data analysis that focuses on specific topics. If you bill Medicare for these services, you may receive an additional development request (ADR) letter asking for documentation. This allows First Coast to validate that you have billed the services correctly according to Medicare guidelines. Once the ADR is received, you will have 45 days to respond to the request with the supporting medical record documentation. The review will be completed within 60 days of receipt of the documentation. When the review is completed, you will be notified of the results.”
August 17, 2020: WPS Billing and Coding Article: Nerve Blocks for Peripheral Neuropathy (A57598) Updated
WPS has updated their Local Coverage Article (A57589), “Billing and Coding: Nerve Blocks for Peripheral Neuropathy” to include ICD-10-CM codes that do not support medical necessity effective September 13, 2020. Use the Local Coverage Determination (LCD) and Billing and Coding/Policy Article Lookup to access our Billing and Coding/Policy Articles.
August 18, 2020: Palmetto GBA Posts Part A Ask the Contractor (ACT): Comprehensive Error Rate Testing FAQs from August 13, 2020 Call
Sandra Booker, Senior Provider Education Consultant for Palmetto GBA noted that “the ACT is intended to open the communication channels between the provider community and Palmetto GBA.” The August 13th call focused on providing education to and answering questions from providers regarding the Comprehensive Error Rate Testing (CERT) program.
One question asked during the call was related to whether or not the CERT is currently performing reviews or are reviews on hold due to COVID-19. Palmetto GBA’s response to the question was that “CMS has allowed them to start the process. Palmetto GBA is not doing the TPE process as of yet. We have not been directed by CMS to continue TPE. But all this information should be published on the Palmetto GBA web site. CERT is now sending letters, so you should be receiving those soon.”
August 21, 2020: Palmetto GBA’s Outpatient Department Prior Authorization Teleconference on September 16, 2020
Palmetto GBA posted an article announcing their next teleconference to provide up-to-date information as well as a chance for providers to ask questions about the Outpatient Department Prior Authorization Program. The teleconference is scheduled from 11 a.m. to 12 p.m. ET. You will find the dial in number and conference ID in the article.
August 21, 2020: Noridian Article – Incorrect Patient Status One of Most Common Errors on Part A Claims
Noridian indicates in this article that incorrect patient status is one of the most common errors on Part A claims. This article includes links to a Quick Reference Guide Patient Status webpage and Quick Reference Billing Guide Condition Codes webpage. Also, as a reminder, an incorrect patient status could have a negative impact for patient admissions assigned a DRG that is included in the post-acute care transfer (PACT) policy. You can read more about the PACT Policy in a related MMP article.
Welcome to this month’s MAC Talk article. Before diving into updates from the MACs, there are two issues I want to alert readers about. First, a reminder about the updated ABN form. Second, CMS’ indication that Medicare Contractor can resume medical reviews as of August 3, 2020.
New Fee-For-Service (FFS) Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131
On June 24th the FFS ABN CMS webpage was modified to add the following statement:
“The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 06/30/2023 will be mandatory on 8/31/2020. The ABN form and instructions may be found in the download section.”
Link to webpage: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN
Medical Review during the COVID-19 Public Health Emergency
On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews.
Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?
A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.
Link to document: https://www.cms.gov/files/document/provider-burden-relief-faqs.pdf
July MAC Talk: The Local Scene
June 16, 2020: Palmetto GBA Article: Botulinum Toxin Injections
In this article, Palmetto provides detail from their Local Coverage Determination (L33458) including dosage and frequency of botulinum toxin injections, documentation expectations for coverage of the services provided, and a checklist to ensure documentation requirements are in the medical record.
This was timely information in advance of the July 1, 2020 implementation date for the Prior Authorization Program for Certain Hospital Outpatient Department (OPD) Services.
June 29, 2020: CGS J15
CGS posted the following information to their website on June 29th:
On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment (CMS-1744-IFC) instructing the DME MACs to suspend or not enforce various requirements found in local coverage determinations and related policy articles. On May 8, 2020, CMS published CMS-5531-IFC extending non-enforcement of the clinical indications for coverage to therapeutic continuous glucose monitors (CGMs). These changes are effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE). Please see the full details regarding DME MAC implementation of CMS-1744-IFC and CMS-5531-IFC in the article here.”
July 2, 2020: Noridian JF Article: The Difference Between and Appeal and a Rebuttal
“When a provider does not agree with an overpayment determination, they may appeal the decision. An appeal disputes the overpayment and provides documentation to show medical necessity for the procedures in question. The limitation on recoupment provision mandates that no recoupment begins when a valid and timely request for a first level or second level appeal is received.
A rebuttal does not dispute the amount of the overpayment, nor does it dispute the overpayment determination. A rebuttal permits the provider a vehicle to indicate why the proposed recoupment should not be taken at the designated time. This allows providers to submit a statement advising if the recoupment occurs, it will cause financial hardship for their facility. The contractor, based on the rebuttal statement, determines whether to delay or begin recoupment. The rebuttal process is not an appeal and does not change anything regarding the debt owed.”
Internet Only Manual, (IOM), Publication 100-06, Chapter 3, Section 200.1.4: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/fin106c03.pdf
Link to Noridian JF webpage: https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/the-difference-between-an-appeal-and-a-rebuttal
July 6, 2020: WPS GHA eNews - Prior Authorization (PA) for Hospital Outpatient Department Services Facts
Effective June 17, 2020, providers billing on a 13x Type of Bill (TOB) should submit a PA request to their MAC before providing the following services:
- Botulinum toxin injections
- Vein Ablation
Providers should note the following:
- Prior authorization requests for botulinum toxin injections are only for injection CPT codes 64612 and 64615
- Prior authorization requests for botulinum toxin injections must include both the administration site and drug CPT codes
- Units of service for botulinum toxin injections should include the expected units of waste
- Each date of service requires its own prior authorization request
- CPT code 21235 no longer requires a prior authorization request
- Prior authorization is for dates of service July 1, 2020, and after
- Expedited requests must include justification that the standard review time for making a decision would seriously risk the health of the beneficiary
- Requests are not valid if they do not have the facility PTAN and NPI for the Hospital Outpatient Department
For additional information, see Prior Authorization for Hospital Outpatient Department Services (HOPD) Overview. Please note, you need to select J5A or J8A to see the entire article.
July 6, 2020: Noridian JF to Host ABN Webinar – August 6, 2020
Noridian announced they will be hosting an ABN webinar on August 6th at 11 a.m. CT. This event includes:
- The new ABN form
- ABN Basics
- ABN Completion
- ABN Tips
- ABN Resources
- Noteworthy information
The Noridian announcement provides a link to sign up for this webinar.
July 9, 2020: New and Improved ST PEPPER Format for Short-Term (ST) Acute Care Hospital PEPPER
The PEPPER Team sent a notice about a “new and improved” format for the PEPPER Report. Hospitals will notice changes with the release of the Q1FY20 report scheduled to be available on July 15th.
The PEPPER Team noted in the announcement that “while all of the data and information that you are used to seeing in your PEPPER will still be available, the new format will include the following improvements:
- Greater accessibility
- Cleaner presentation
- Improved readability.
July 13, 2020: First Coast JN Prior Authorization for Certain Hospital Outpatient Department Services Tips and Reminders
First Coast has posted the following information on their website regarding this program:
The PA team has been receiving and processing prior authorization requests (PAR) for certain hospital OPD services. View the following reminders prior to submitting your request:
- Providers are reminded that the PAR must include a PAR coversheet along with appropriate documentation.
- Providers are asked to make sure the PAR hospital outpatient procedures Medicare fax/mail coversheet is being used and that all fields on the PAR coversheet are completed.
- Remember that PA is only required for procedures on the CMS list
- The PA is only required for the hospital outpatient department (OPD) who will be billing on the type of bill (TOB) 13X
- PA for hospital OPD does not apply to Ambulatory Surgical Centers (ASCs)
- PAR resubmissions must include the following:
- A copy of the initial PAR cover sheet and all documentation from the initial submission
- Any additional information/documentation
Click here to view additional information related to the prior authorization program.
Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, I wanted to alert readers about Change Request (CR) 11695. This CR was published on May 15, 2020 and provides details regarding revisions to the Targeted Probe and Educate (TPE) Program in the Medicare Program Integrity Manual (IOM 100-08), chapter 3, section 3.2.5.
The TPE review strategy includes instruction to the MACs to refer providers/suppliers failing three rounds of TPE to the CMS for next steps. Prior to the release of CR 11695 there were no references available from CMS to the potential for more than three rounds of TPE review. As a result, CMS is revising the TPE language in section 3.2.5 in Chapter 3 of the Program Integrity Manual (Pub. 100-08) to include the possibility of additional rounds of TPE review.
The following language has been added to the guidance in section 3.2.5D. Post-Probe Activity – Final Results Letter:
“For providers/suppliers who will be released from review due to meeting the established error rate goal, results letters shall indicate that the provider is being released from review for one year, with the caveat that additional review may occur at any time should the MAC identified changes in billing pattern. For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the following language to remind providers of 42 CFR §424.535.
“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.””
May MAC Talk: The Local Scene
May 19, 2020: NGS Botulinum Toxin Injections for Chronic Headaches CERT Findings
This NGS article provides a list of the most common reasons the CERT determined there was insufficient documentation for the service provided.
- Missing evaluation to support patient is having 15 or more headaches a month for at least three months,
- Missing documentation to support a significant decrease in the number and frequency of headaches per month,
- Missing documentation to support the amount of waste for the botulinum toxin, and
- Missing electronic signature or legible signature.
You can learn more about NGS’ requirements for Botulinum Toxin Injections in their Local Coverage Determination (LCD): Botulinum Toxins (L33646) and related Coverage Article (A52848). As a reminder, Botulinum Toxin Injections is one of the procedures that will require a prior authorization beginning with dates of service on or after July 1, 2020. You can read more about the Prior Authorization Program for certain outpatient department procedures in a related MMP article.
May 20, 2020: First Coast Guidance for Submitting Prior Authorization for Certain Outpatient Department (OPD) Services
First Coast provided guidance in their May 20th eNews about the elements that must be submitted in a Prior Authorization Request (PAR) for services requiring one as part of the new Prior Authorization Program set to begin on July 1, 2020. First Coast is set to begin accepting PARs for these services as of today June 17, 2020, for services to be provided on or after July 1, 2020. You can read the full announcement under the Medical Review tab on the First Coast website.
May 27, 2020: Palmetto GBA Daily Newsletter: Medicare Secondary Payer (MSP) Basics Modules
Palmetto GBA posted information about an educational series available on their website on MSP guidelines. They note in the announcement that “this series provides guidance with condition payment provisions and common MSP billing questions.” They encourage you to review the modules with your staff.
May 28, 2020: CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Open Door Forum (ODF)
The CMS held a special ODF to go over the basics of this program. The presentation was followed by a very robust Q&A session. The slides from this session as well as an Operational Guide and FAQs document have been added to the downloads section of the CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webpage.
June 5, 2020: Noridian Article: SNF PDPM Assessment Diagnosis COVID-19 ICD-10 Code U07.1 and SNF Waiver to Extend Benefit Period
In this article, Noridian offers the following guidance for providers experience claims processing problems related to the April 1, 2020 effective date of applying the new U07.1 – 2019-nCoV acute respiratory disease ICD-10-CM code when the 5-day assessment window overlaps March into April dates of service:
“Based on the following guidance from the CMS PDPM FAQs Question 1.8 that states ‘Is it required that the principal diagnosis on the SNF claim match the primary diagnosis coded in item I0020B? While we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement'. Providers with a 5-Day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification. However, the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and is valid in the month of March.”
This article also provides details regarding the impact on typical billing and assessment processes when a beneficiary qualifies for renewed SNF benefits under the SNF waiver as a result of the COVID-19 pandemic.
June 8, 2020: WPS GBA Medicare eNews: Intravenous Immunoglobulin Therapy (IVIG)
WPS posted the following information regarding IVIG therapy in their June 8th eNews:
“Do you bill for IVIG? Before you bill for these services, read the Local Coverage Article: Billing and Coding: Immune Globulins (A57554). Why read the article? The Centers for Medicare & Medicaid Services (CMS) identified a potential vulnerability in the WPS GHA jurisdictions. Providers should follow the guidance in the local coverage article if they expect payment.”
June 12, 2020: Novitas eNews: Prior Authorization Hospital Outpatient Department Services (OPD) FAQs
Novitas posted this FAQ document in their June 12th eNews indicating the document had been developed to include questions and answers posed during their webinar about the PA program for certain hospital OPD services.
June 15, 2020: WPS GHA Medicare eNews: Appropriate Application of Modifier for Injections to Manage Age-Related Macular Degeneration (AMC)
WPS included the following information in their June 15th Medicare eNews:
“Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss that affects millions of Americans. Medicare Part B covers age-related macular degeneration (AMD) treatments, which include:
- Aflibercept (Eyelea)
- Ranibizumab (Lucentis)
- Brolucizumab (Beovu)
- Bevacizumab (Avastin)
Recent claim review data showed that claims submitted with anti-vascular endothelial growth factor (anti-VEGF) drug codes did not include an appropriate modifier identifying the eye being treated resulting in claim denials. For more information, see the full article on our website.”
One Medicare contractor that we do not talk a lot about, especially concerning outpatient services, is the Comprehensive Error Rate Testing (CERT) contractor. The purpose of the CERT program is to calculate the Medicare Fee-for-Service (FFS) improper payment rate. Improper Payments statutory requirements compel federal agencies to annually review programs they administer in order to reduce and recover improper payments. CERT measures the payment compliance of the Medicare Administrative Contractors (MACs) by evaluating a statistically valid stratified random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. It is sort of a “report card” for the MACs. The random sampling makes CERT very different from other Medicare reviewers who select targets at potential “high risk” of noncompliance based on data analysis and findings from other reviews. In fact, the MACs often target their medical reviews based on the findings of the random CERT audits.
The reasons we do not discuss CERT findings much are the random nature of the audits and the more general types of findings that are published from CERT outpatient reviews. For outpatients, we often see errors such as missing signatures, lack of a signed order, or a missing report. CERT findings for an individual hospital are shared with that hospital and afford an opportunity to identify any potential system issues. However, a recent article by Palmetto GBA, the MAC for Jurisdictions J and M, about the top CERT errors for Jurisdiction J included some detailed examples of errors that are good lessons for all providers beyond missing signatures, orders and reports. You can find the article here. I encourage providers to check their MAC’s website for information on CERT findings for your jurisdiction.
You can read about all the common errors at the link above, but a few of them particularly caught my attention.
The common CERT error for psych admissions was medical records missing the physician-signed multidisciplinary treatment plan. This caught my attention because psychosis DRG 885 is a Targeted Probe and Educate review topic for Palmetto (JJ and JM) and First Coast (JN). As a result, I have written about the documentation requirements for psychiatric admissions before and one of my co-workers has recently performed an audit of psych records. Here is information about psych documentation requirements from a prior Wednesday@One article.
Psychiatric admission documentation should include:
- A psychiatric treatment plan developed within the first 3 days of admission that contains
- a substantiated diagnosis;
- short-term and long-range measurable, functional, time-framed goals;
- specific treatment modalities; and
- responsibilities of each treatment team member.
- Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.
- Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.
- An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.
- Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.
Defibrillators/AICD—National Coverage Determination (NCD) 20.4
The common errors for Automatic Implantable Cardiac Defibrillators (AICDs) included:
- “Providers are not submitting physician progress notes to support the medical necessity of the device
- Missing formal shared decision making encounter between the patient and a physician using an evidence-based decision tool on ICDs prior to initial ICD implantation”
This is note-worthy because implantation of AICDs has a large reimbursement rate, generally over $25,000 so it would be a significant financial loss for a hospital for this service to be denied. NCD 20.4 has very detailed coverage requirements so if you perform these services, make sure you are familiar with and follow the requirements. To support the medical necessity of the service, you will need documentation from the physician’s office, such as history and physical and/or progress notes that describe the patient’s condition and the reasons the procedure is needed. You also need to include in the current medical record reports of relevant diagnostic testing and notes describing prior treatments and interventions including the patient’s response.
A term we are seeing more and more these days is “shared decision making.” The AICD NCD has the most descriptive requirements of what documentation is expected, requiring the use of an evidence-based decision tool to document the physician’s discussion with the patient about the risks versus the benefits of proceeding with the procedure. This requirement was added to NCD 20.4 in the February 2018 NCD revision, but the MACs did not implement the new NCD until March 2019. Remember however, that the effective date of the NCD revisions is February 15, 2018. For all claims your hospital submits after the implementation date, the formal SDM tool is required for dates of service on and after February 15, 2018.
Other coverage policies, both national and local, are beginning to include requirements for shared decision making. For example, it is part of NCD 20.34 for Percutaneous Left Atrial Appendage Closure (LAAC) (also known as the Watchman procedure). This NCD requires, “A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision making interaction must be documented in the medical record.”
And in Palmetto’s new Local Coverage Determination (LCD) for Lumbar Spinal Fusion, we find the following:
“Where possible, there must be documented shared decision making with the patient or the individual who is serving as the proxy decision maker for the patient with the appropriate discussion of anticipated risks and benefits of the procedure…. Outcomes for fusion in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment option only when all other treatment options have failed. This information must be communicated to the patient prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical record must reflect that this counseling was done and that the patient wished to undergo surgery with the appropriately informed consent.”
I think a well-informed patient is a good thing and I applaud CMS for beginning to make this a documented requirement. This documentation of shared decision making goes beyond a surgical consent – it should include the risks and benefits that were discussed with the patient. The tools CMS recommends for AICD and the Watchman procedure SDM make it easy to know what to include – in Palmetto’s Spinal Fusion LCD the SDM requirements are left up to the physician as to what should be included and how it should be documented. Providers should not skim over this however, as I expect Medicare reviewers will be looking for this documentation for all services that require it. I appreciate the challenge this may present for physicians especially with elderly patients who have declining cognitive abilities. In this case, the physician may need to document a discussion with a family member or friend or whoever is serving as the proxy decision maker for the patient.
Physicians and other providers can find information on the Agency for Healthcare Research and Quality (AHRQ) website about AHRQ’s SHARE Approach, “a five-step process for shared decision-making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.”
Speaking of the challenges of elderly patients, the CERT common error for cataract surgery caught my eye (unintended pun) because my mother has recently had cataract surgery on one eye and will undergo the second eye surgery soon. The error was the lack of documentation “to support the beneficiary’s own assessment of his/her functional status (usually in the form of a patient questionnaire).” I do not recall that I or my mother completed such a form, but had she filled it out she would have said she could see “fine.” However, we did have that discussion with the doctor, with my mother saying she could see just fine, and me insisting that lack of clear vision was causing issues with her activities of daily living. Hopefully the physician documented that conversation for justification of his and the facility’s Medicare payment.
Another common error listed for cataract surgery was that providers are only submitting documentation for the affected date of service. As you can tell from the above discussions about including diagnostic test results, prior treatments and physician office notes, documentation from only the procedure date of service would be lacking much critical information to support the services were medically necessary.
These are good lessons that contain some excellent learning points from CERT findings. Check the MAC websites (especially your own MAC’s) and review your hospital’s CERT report for more potential lessons from the CERT reviews. By being proactive, the CERT can be another education opportunity instead of just another means to deny your Medicare claims.
When I was growing up, there were lots of television commercials about cigarettes (remember the Marlboro man?), but none about prescription drugs. Things change. Today television commercials featuring tobacco products are banned, but the airwaves are inundated with advertisements for prescription medications. I am not sure that is any wiser choice than the cigarette commercials, but that is the way it is. You may also notice that the generic name of a large number of the medicines advertised end with the letters “mab.” This means the drug is a monoclonal antibody. Even if there had been television advertisements for drugs when I was growing up, they would not have been MABs, because those drugs were not even developed back then. I am sure there are a lot of things that can be said about monoclonal antibodies, but two such statements could be - first, they offer new hope to many with certain conditions and second, “cha-ching!” meaning of course they are expensive drugs.
As a payor of healthcare services, specifically drugs in this case, Medicare wants to ensure the drugs they are paying for are appropriate (medically necessary), administered to the patient, and follow Medicare and evidence-based guidelines. Add this to the high costs of some of these drugs and it is not surprising that a number of Medicare Administrative Contractors (MACs) are auditing certain drugs under their Targeted Probe and Educate (TPE) audits. Specifically, Palmetto GBA (Jurisdictions J and M) and Novitas (Jurisdictions H and L) include the review of several drugs in their TPE Medical Reviews. As the name indicates, TPE reviews focus on individualized provider education. The MACs also offer educational resources that are available to all through their websites. Palmetto has recently added the following “checklists” for drugs to their website as well as an article about Prolia (Denosumab).
These checklists include the basic requirements for the billing of any drug administered to outpatients –
- A signed and dated physician’s order that includes the dosage, frequency, and route of administration
- Documentation supporting the need for the drug and the patient’s diagnosis – this may require the hospital to obtain the physician’s office notes discussing the patient’s condition and treatment
- The units billed, the units ordered, and the units administered to the patient must all match
- A protocol was followed as specified in the package insert (FDA approved) or in accepted drug compendia for off-label uses
- Medicare and MAC-specific coverage requirements for the drug are met
- The medical record includes documentation of the administration of the drug with date, time, route, dose, and patient response
Some drugs require additional documentation such as the patient’s weight or body surface area to calculate dosage or other documentation based on coverage requirements. For example, the drug Prolia (denosumab) requires documentation the patient is taking calcium and vitamin D supplements or the reasons why not and documentation the patient has had an x-ray or DEXA scan.
The benefit of these checklists is that if you use them and make sure you submit all of the required documentation upon request for records for Medicare review, your chances of being paid by Medicare are much better than if you didn’t follow a checklist. Is this a Medicare contractor being nice to providers?!? Well, things change.
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