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When to Expect Your 340B Drug Remedy Payment
Published on Jan 10, 2024

During the first week of 2024, the following information was posted on several of the Medicare Administrative Contractors (MACs) websites.

“On June 15, 2022, the Supreme Court held in American Hospital Association v. Becerra that because CMS had not conducted a survey of hospitals’ acquisition costs, it could not vary the payment rates for outpatient prescription drugs by hospital group. On remand, the U.S. District Court for the District of Columbia prospectively vacated-beginning September 28, 2022- adjustments CMS had made to payments under the Hospital Outpatient Prospective Payment System for drugs acquired through the 340B program.

On January 10, 2023, the U.S. District Court for the District of Columbia issued a remand without vacatur to give the Centers for Medicare & Medicaid Services (CMS) the opportunity to determine the proper remedy for the reduced payment amounts to 340B hospitals under the payment rates in the final OPPS rules beginning in CY 2018 and continuing through September 27, 2022.

Accordingly, on November 8, 2023, CMS published the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022.

Under this final rule, affected hospitals will be paid a one-time lump-sum amount based on the difference between what they were paid for 340B-acquired rugs from CY 2018 through September 27, 2022, and what they would have been paid during this time-period had the 340B Drug Payment Policy never existed. These payment amounts are listed in Addendum AAA to the final rule. This final rule ensures affected hospitals will receive the approximate payment they would have received if the original CY 2018-2022 340B payment policy had never existed.

Beginning January 8, 2024, Medicare Administrative Contractors (MACs) will begin making these one-time lump-sum remedy payments to affected providers via HIGLAS. There payments are scheduled to be completed by February 7, 2024.

The MACs will not included these lump sum payments on any cost report.

All remedy payments are subject to the MAC’s normal accounting procedures and may in effect be combined with other payment released on the same date and/or include any applicable outstanding Medicare offsets that are the result of provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process, any of which may impact the provider’s net payment amount.”

MAC Specific Announcements

Palmetto GBA Jurisdiction J

Palmetto GBA Jurisdiction M

NGS Jurisdiction 6

NGS Jurisdiction K

CGS Jurisdiction 15

WPS Jurisdictions 5 & 8

Beth Cobb

October 2022 PAR Pro Tips
Published on Oct 16, 2022

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on seven of the recent review results posted by the Supplemental Medicare Review Contractor (SMRC).

Project 01-034 Transforaminal Epidural Injections

Background: 2018 CERT Improper Payment Report noted a 29.1% error rate for this service. Also, a previous SMRC contractor found a claim error rate of 40% with 30% of the claims error being due to no response to documentation request.

  • Dates of Service (DOS) Reviewed: July 1, 2018 - June 30, 2019.
  • Claims Error Rate: 65%

Common Denial Reasons: Incomplete/insufficient documentation, no response to documentation request, and documentation submitted did not support identification and administration of medication and or dosage limitations.

Project 01-058: Traditional Telehealth

Background: Under COVID-19 waivers and flexibilities, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including the patient’s place of residence starting March 6, 2020.

  • DOS Reviewed: March 6, 2020 - May 13, 2021
  • Claims Error Rate: 88%

Common Denial Reasons: documentation did not support the use of appropriate real-time telecommunication technology and documentation did not support the signs and symptoms to warrant billing an E&M visit.

Project 01-302 Cataract Surgery

Background: This surgery had been a topic of the OIG for many years. They have reviewed surgery in both the outpatient facility and ambulatory surgery center setting. CMS data reflects a potential vulnerability.

  • DOS Reviewed: CY 2019
  • Claims Error Rate: 51%

Common Denial Reasons: No response to the documentation request, documentation submitted did not support the required documentation needed for cataract surgery, and the documentation did not include a signed physician order or documentation to support intent to order.

Project 01-304 Facet Joint Injections

Background: The OIG has found significant billing errors in this area in the past and an October 2020 OIG report found that due to coverage limitations Medicare improperly paid out $748,555.

  • DOS Reviewed: CY 2019
  • Claim Error Rate: 92%

Common Denial Reasons: Documentation submitted was insufficient or incomplete. Documentation submitted did not support medical necessity as listed in National and Local Coverage determinations. No response to the documentation request.

Project 01-305 Inpatient Psychiatric Facility

Background: The OIG found on 87% error rate on claims reviewed dated fiscal years 2014 – 2015. A CERT report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service with the highest improper payment rate.

  • DOS Reviewed: January 16, 2019 through December 31, 2019
  • Claim Error Rate: 26%

Common Denial Reasons: documentation submitted lacked evidence that category requirements were met. No response to the documentation request. Documentation submitted did not include the required certifications or recertifications for the inpatient psychiatric stay.

Project 01-308 Outpatient Therapy

Background: The Bipartisan Budget Act (BBA) of 2018 created a medical review (MR) expense threshold of $3,000 or physical therapy (PT) and speech-language pathology (SLP) combined and $3,000 for occupational therapy (OT). The SMRC was directed to perform data analysis on outpatient therapy claims below the 2019 therapy threshold and recommend codes to be selected for review, recommend a sampling strategy, and identify MR strategy for the project.

  • DOS Reviewed: CY 2019
  • Claim Error Rate: 39%

Common Denial Reasons: No response to the documentation request. Certifications for the Plan of Care (POC) not present. Documentation did not support the initial POC was certified by the physician / NPP. Lack of evidence of delayed certification attempts to obtain the certification. Documentation did not support the units billed.

Project 01-310 Endomyocardial Biopsy with Right Heart Catheterization

Background: Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure. Potential misuse of this modifier represents a potential vulnerability and has been featured in work done by the OIG.

  • Dates of Service Reviewed: CY 2019
  • Claim Error Rate: 60%

Common Denial Reasons: No response to the documentation request. Documentation was not sufficient to support the medical necessity of the procedure performed. Documentation did not support that the procedure was performed.

Moving Forward What Can You Do?
  • First, make sure your hospital has a process in place to respond to documentation request from the SMRC,
  • Read the entire review results that can be found on the SMRC website (link), and
  • Identify services that have a related National or Local Coverage Determination (NCD/LCD) that you are providing at your hospital and share this information with key stakeholders.

Beth Cobb

September 2022 PAR Pro Tips
Published on Sep 21, 2022

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide medical review updates and educate resources from the Medicare Administrative Contractors (MACs)

CGS Administrators, LLC J15 MAC

Review of Implantable Automatic Defibrillator CERT Errors Education Session

CGS is offering this education session on Monday September 26, 2022, from 10:00 AM – 11:00 AM CDT (link). During this session they will discuss an increase in CERT errors related to the “formal shared decision-making encounter using an evidence-based decision tool prior to implantation” as outlined in National Coverage Determination (NCD) 20.4.

First Coast Service Options, Inc. JN MAC

TPE Rehabilitation Services (Outpatient) Review Results

First Coast recently published review results for outpatient rehabilitation services (CPT® 97110, 97112 and 97140) (link). In addition to CPT specific review results, First Coast provides a link to a documentation checklist to help providers when responding to medical documentation requests for therapy and rehabilitation services.

National Government Services (NGS), Inc. J6/JK MAC

Prior Authorization Exemption Status Inquiry Tool Alert

This month NGS announced (link) that they have developed this tool as a way to unnecessary prior authorization requests by exempt providers.

Noridian Healthcare Solutions, LLC JE/JF MAC

Noridian JE Medical Record Review Results

On August 31st, TPE medical record review results were posted on the Noridian JE (link) and Noridian JF (link) websites.

Noridian JE Medical Record Review Results

  • Cataract Removal (CPT® 66984): Error rate 48.78%,
  • Lumbar Epidural Injection (CPT® 64483): Error rate 34.43%, and
  • Dual-energy X-ray absorptiometry (DXA) (CPT®77080): Error rate 26.43%.

Noridian JF Medical Record Review Results

  • Cataract Removal (CPT® 66984): Error rate 55.64%, and
  • Total Knee Arthroplasty (CPT® 27447): Error rate 44.83%.

Review Results for both jurisdictions were for dates of service April 1, 2022, through June 30, 2022. Articles for review topics includes top denial reasons, links to educational resources, and education specific to documentation requirements and medical necessity.

Novitas Solutions, Inc. JH/JL MAC

Forms Catalog for Medicare Part A

Novitas Solutions has recently modified their Forms Catalog for Medicare Part A webpage (link). Examples of forms you will find on this webpage includes:

  • Link to the Advanced Beneficiary Notice (ABN) Form (CMS-R-131),
  • Hospital-Issued Notices of Noncoverage (HINNs), and
  • Prior authorization request for certain hospital outpatient department services.

Palmetto GBA JJ/JM MAC


Annually, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, hosts their provider education event MACtoberfest. This virtual three-day conference includes a Medicare Part A and Part B track. Registration is now open and you can learn more about this event on their website (link).

New Local Coverage Determination (LCD)

Palmetto published LCD L39270 Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin’s and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (link). This policy is effective for services performed on or after September 4, 2022. There is a National Coverage Determination (NCD) 110.23 Stem Cell Transplantation. Palmetto notes in their LCD, “This policy describes additional locally covered indications for allo-HSCT for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin that are medically necessary in patients for whom there are no other curative intent options.”


WPS recently published Quarter 2 Targeted Probe and Educate (TPE) review results for WPS J5 (link) and WPS J8 (link).

WPS J5 TPE Review Results

  • Infusion Services (CPT® 96413 or 96415): Trending error rate 99%. The top reason for denial cited by WPS was the documentation did not support frequent monitoring.
  • Routine Foot Care: Trending error rate 24%. The top reason for denial being documentation did not support the presence of severe systemic conditions.
  • Outpatient Therapy (CPT® 97110): Trending error rate 52%. The top denial reason was documentation did not support the skills of a licensed professional therapist.
  • Group Psychotherapy (CPT® 90853): Trending error rate 49%. The top denial reason was claim billing did not meet the National Correct Coding Initiative (NCCI) guidelines.

WPS J8 TPE Review Results

  • Wound Care (CPT® 11042): Trending error rate 43%. The top denial reason was that documentation did not contain initial wound measurements.
  • Infusion Services (CPT® 96361): Trending error rate 53%. Denials occurred due to documentation supporting intravenous fluids for the purpose of keeping a vein open. “According to CPT coding guidelines providers should not bill codes 96360 and 96361, when the purpose of the fluids is to keep open a vein.”
  • Basic Life Support (BLS) Ambulance transports (HCPCS A0429): Trending error rate 29%. Denials occurred cue to the Assignment of Benefits (AOB) being incomplete or missing.

Beth Cobb

June 2022 PAR Pro Tips
Published on Jun 15, 2022

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). In general, this article spotlights current review activities. This month’s focus is on medical review activity accomplishments touted in recently released Government Accountability Office (GAO) and Office of Inspector General (OIG) reports, a new OIG Work Plan Item and a new Supplemental Medical Review Contractor (SMRC) project.

GAO Report: Priority Open Recommendations: Department of Health and Human Services


(GAO-22-105646) published May 26, 2022, and publicly released June 2, 2022.

In May 2022, the GAO added five new priority recommendations for HHS bringing the total to fifty-six open priority recommendations. According to the GAO, priority open recommendations warrant priority attention from heads of key departments or agencies because implementation could save substantial amounts of money; improve congressional or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and that funds are legally spent. The fifty-six recommendations fall into one of eight areas:

  • COVID-19 response and other public health emergency preparedness,
  • Public health and human services program oversight,
  • FDA oversight,
  • Improper payments in Medicare and Medicaid,
  • Medicaid program,
  • Medicare programs,
  • Health information technology and cybersecurity, and
  • Health insurance premium tax credit payment integrity.

Specific to improper payments, the GAO notes estimates of improper payments in the Medicare and Medicaid programs continue to be unacceptably high totaling about $148 billion in fiscal year 2021. They identified the following six priority recommendations that they believe if implemented could reduce improper payments by assessing documentation requirements, minimizing program risks, and conducting prepayment claim reviews, among other things:

  1. Recommendation: The Administrator of CMS should institute a process to routinely assess, and take steps to ensure, as appropriate, that Medicare and Medicaid documentation requirements are necessary and effective at demonstrating compliance with coverage policies while appropriately addressing program risks.
  2. Recommendation: The Administrator of CMS should complete a comprehensive, national risk assessment and take steps, as needed, to assure that resources to oversee expenditures reported by states are adequate and allocated based on areas of highest risk.
  3. Recommendation: The Administrator of CMS should eliminate impediments to collaborative audits in managed care conducted by audit contractors and states, by ensuring that managed care audits are conducted regardless of which entity—the state or the managed care organization (MCO)—recoups any identified overpayments.
  4. Recommendation: The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the Payment Error Rate Measurement (PERM), such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care.
  5. Recommendation: To better ensure proper Medicare payments and protect Medicare funds, CMS should seek legislative authority to allow the recovery auditors (RA) to conduct prepayment claim reviews.
  6. Recommendation: As CMS continues to implement and refine the contract-level risk adjustment data validation (RADV) audit process to improve the efficiency and effectiveness of reducing and recovering improper payments, the Administrator should enhance the timeliness of CMS’s contract-level RADV process.

I encourage you to read the report to see HHS’ response to these recommendations.

OIG Spring 2022 Semiannual Report to Congress (SAR):

This OIG’s Semiannual Report to Congress (link) details work performed to identify significant risks, problems, abuses, deficient, remedies, and investigative outcomes related to the administration of HHS programs during the reporting period October 1, 2021 through March 31, 2022. Following are examples of three completed audits:

  • An estimate that during 2016 and 2017, providers received $636 million in unallowable Medicare payments associated with neurostimulator implantation surgeries, and beneficiaries paid $54 million in related unnecessary copays and deductibles.
  • The OIG found that Medicare could have saved approximately $993 million in 2017 and 2018 if the transfer payment policy to early discharges to home health care was expanded to inpatient rehabilitation facilities (IRFs).
  • The OIG published four reports where they identified Medicare Advantage plans submitting diagnosis codes for use in CMS’s risk adjustment program that did not comply with Federal requirements. Collectively, the OIG estimated that the four Medicare Advantage plans audited received just over $15.8 million net overpayments for high-risk diagnosis codes.

May 2022 OIG Work Plan Item: Follow-up Review of Inpatient Claims Under the Post-Acute Care Transfer Policy (PACT)

For certain MS-DRGs under the PACT policy, Medicare pays hospitals a per diem rate when an inpatient is transferred to specific post-acute care settings. You can read more about this policy in a related MMP article (link). The OIG notes that in a prior review they identified overpayments to hospitals that did not comply with the policy. This follow-up audit is to determine whether CMS’s Common Working File (CWF) edits are working properly in detecting inpatient claims under the PACT policy and are automatically recovering overpayments, and whether MACs are receiving the automatic notifications and acting to recover overpayments.

New SMRC Reviews: SNF 3 Day Stay Waiver PHE Notification of Medical Review

On June 7, 2022, the SMRC added Project 01-056 (link) to their list of Current Projects (link). In response to the COVID-19 Public Health Emergency (PHE), CMS enacted 1135 blanket waivers, one of which waived the long-standing requirement for a beneficiary to have a medically necessary 3-day hospital stay prior to admission to Skilled Nursing Facility (SNF).

Data analysis done by the SMRC, and CMS has identified this to be an area of potential vulnerability. The SMRC has been tasked with performing medical review on SNF claims with zero hospital days prior to admission for SNF claims from March 1, 2020, through December 31, 2021. As a reminder, in general, COVID-19 blanket waivers are in effect until the end of the PHE.

Beth Cobb

May 2022 PAR Pro Tips
Published on May 18, 2022

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on the April 2022 release of CMS’ Medicare Provider Compliance newsletter.


In the Tax Relief and Health Care Act of 2006, the U.S. Congress authorized the expansion of the Recovery Audit Program nationwide by January 2010 to further assist the CMS in identifying improper payments.

The first Medicare Quarterly Compliance Newsletter was issued in October 2010 as a Medicare Learning Network® (MLN) educational product, “to help providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations such as the Office of Inspector General.”

In the second edition of this newsletter CMS indicated that it is “designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities, such as failure to submit timely medical record documentation, when dealing with the Medicare FFS program.”

Twelve years later, much has changed since the release of the first quarterly newsletter.

  • Instead of a network of contractors (i.e., Carriers and Fiscal Intermediaries) processing more than 1 billion claims each year, there are twelve Medicare Administrative Contractor (MAC) regions where the MACs process the claims,
  • In addition to the Recovery Auditors and the OIG, there are new contractors auditing claims, for example the Supplemental Medicare Review Contractor (SMRC) and the Unified Program Integrity Contractors (UPICs) who assumed the responsibilities of the former ZPIC contractor,
  • The OIG no longer publishes an annual workplan, instead the Work Plan is updated monthly to be able “to anticipate and respond to emerging issues with resources available,” and
  • As of the April 2022 edition, this newsletter is now released twice a year instead of quarterly.

What has not changed is the ongoing challenge for providers to meet Medicare rules and regulations required to accurately order, schedule, perform, code and bill medically necessary services.

April 2022 Medicare Provider Compliance Newsletter

In the April 2022 edition of the newsletter (link), you will find information about:

  • The Comprehensive Error Rate Testing (CERT) review of hospice certification and recertification of terminal illness,
  • The CERT review of refills of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items provided on a recurring basis, and
  • The Recovery Auditor review of Issue 0184: total hip arthroplasty (THA) medical necessity and documentation requirements.

This article focuses on the RAC’s review of total hip arthroplasty (link).

RAC Issue 0184: Total Hip Arthroplasty: Medical Necessity and Documentation Requirements

Total hip arthroplasty procedures were removed from the Medicare Inpatient Only (IPO) procedure list effective January 1, 2020. RAC issue 0184 was approved in August 2020. This RAC Issue entails a review of medical records (complex review) for provider types of inpatient hospital, outpatient hospital and professional services.

The review only focuses on total (involving the entire joint) hip arthroplasties to determine if documentation supports that a THA was medically necessary according to the guidelines outlined in the Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) of the following MACS:

  • Jurisdiction N MAC: First Coast Service Options, Inc.,
  • Jurisdictions H and L MAC: Novitas Solutions, Inc.,
  • Jurisdictions 6 and K MAC: National Government Services, Inc.,
  • Jurisdictions J and M MAC: Palmetto GBA LLC, and
  • Jurisdictions E and F MAC: Noridian Healthcare Solutions, LLC.

Unlike the CERT reviews included in this newsletter, the RAC review does not include an improper payment amount. What you will find are the CPT codes for review, the reminder to respond to review requests promptly and ensure records include documentation supporting the medical necessity of the THA, and links to the MAC’s LCDs and LCAs.

Total Hip Arthroplasty Removal from the Medicare Inpatient Only (IPO) Procedure List

As mentioned above THA procedures were removed from the Medicare IPO List effective January 1, 2020. CMS reminded providers in the CY 2020 Outpatient Prospective Payment System (OPPS) Final Rule that “the removal of any procedure from the IPO list, including THA, does not require the procedure to be performed only on an outpatient basis. That is, when a procedure is removed from the IPO, it simply means that Medicare will pay for it in either the hospital inpatient or outpatient setting; it does not mean that the procedure must be performed on an outpatient basis.”

CMS also finalized a two-year exemption from site-of-service claims denials, Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization referrals to Recovery Auditors, and Recovery Auditor reviews for “patient status” (that is, site-of-service) for procedures removed from the IPO list under the OPPS beginning January 1, 2020.

It is important for providers to be mindful that this exemption does not include medical necessity based on a National or Local Coverage Determination meaning irrespective of site-of-service, a short stay claim can still be denied for lack of documentation supporting medical necessity of the procedure.

THA Site of Service in CY 2020 and 2021

In keeping with the late Paul Harvey’s, The Rest of the Story segments, I turned to RTMD to see where THA’s are being performed since being removed from the IPO list. The following claims data represents Medicare Fee-for-Service paid claims data available in RTMD’s footprint which includes all U.S. states and territories except Kentucky and Ohio. The reader should be reminded that THA was added to the Ambulatory Surgery Center (ASC) Covered Procedure List (CPL) January 1, 2021.

Calendar Year 2020 THA Claims Data in RTMD Database

Inpatient Claims

  • Claims Volume: 116,804
  • Percent of All 2020 THA Claims: 56.8%
  • Sum of Paid Claims: $1,620,651,115.06

Outpatient Claims

  • Claims Volume: 88,828
  • Percent of All 2020 THA Claims: 43.2%
  • Sum of Paid Claims: $893,162,528.27
  • Calendar Year 2021 Claims Data in RTMD Database

    Inpatient Claims

    • Claims Volume: 48,330
    • Percent of All 2021 THA Claims: 24.37%
    • Sum of Paid Claims: $659,846,754.97

    Outpatient Claims

    • Claims Volume: 128,385
    • Percent of All 2021 THA Claims: 62.41%
    • Sum of Paid Claims: $1,311,707,091.83

    Ambulatory Surgery Center (ASC)

    • Claims Volume: 26,218
    • Percent of All 2021 THA Claims: 13.22%
    • Sum of Paid Claims: $64,580,122.48

    There has been a significant shift in site-of-service for THA procedures away from the inpatient hospital setting. While the patient setting should be based on each individual patient, it is also important to be aware of the difference in payment for THA based on the setting.

    • In the inpatient setting THA procedures group to MS-DRG 469 with an MCC or MS-DRG 470 without an MCC. In general, most inpatient THA procedures group to MS-DRG 470. The 2021 national average payment for MS-DRG 470 was $11,192.94.
    • 2021 ambulatory payment category (APC) national payment rate for THA: $12,314.76.
    • 2021 ASC CPL national payment rate for THA: $8,818.37.

    Whether hospital inpatient, outpatient or ASC is the most appropriate setting for your patient, you must ensure documentation in the medical record supports indications outlined in your MAC’s LCDs.

    Beth Cobb

    April 2022 PAR Pro Tips
    Published on Apr 20, 2022

    MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide updates and educate resources from the CERT, two MACs and Livanta, the National Medicare Review Contractor.

    CMS Q1 2022 Program Scorecard

    The U.S. government website PaymentAccuracy (link) publishes program scorecards “to assist the public in understanding what agencies are doing to overcome unique challenges and obstacles to ensure federal funds reach the right recipient.” More specifically, program scorecards are published for high-priority programs such as the Department of Health and Human Services Medicare Fee-for-Service (FFS) program.

    The most recent Medicare FFS Program Scorecard published is for Q1 of the CMS fiscal year (FY) 2022 (link). Of note, actions being taken to recover overpayments includes:

    • Recovery Audit Contractors reviewing inpatient claims for medical necessity and coding purposes,
    • HHS implementation of the Review Choice Demonstration for Home Health Services in the last two states of North Carolina and Florida, and
    • HHS providing additional funding to the MACs and the Supplemental Medicare Review Contractor (SMRC) to allow for additional claims review to determine if they had been billed appropriately. You can read more about current SMRC activities in a related article in this week’s newsletter.
      • Comprehensive Error Rate Testing (CERT) Announcement

        The CERT Review Contractor has posted (link) their review year 2022 completion status. As of April 4, 2020, they have completed initial review of 34,400 claims out of 41,974 claims in the 2022 Annual Report (claims submitted to the MAC between July 1, 2020, and June 30, 2021).

        Palmetto GBA JJ/JM MAC

        New Address Information for CERT Review Contractor

        Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published an article (link) to alert providers about the CERT Review Contractor’s move to a new location. The new address will be on letters beginning April 11, 2022. You will find the CERT Review Contractor’s new address, fax number, customer service toll free number and email in Palmetto’s article.

        Cervical Discectomy Module

        Palmetto GBA, has published a Cervical Discectomy module (link) focused on the roles of cervical spine, the differences between discectomy and fusion, and documentation requirements.

        Spinal Cord Stimulatory Therapy Module

        Palmetto GBA has also recently published a Spinal Cord Stimulator module (link) focused on the purpose of the spinal cord stimulator, coverage requirements for spinal cord stimulatory (SCS) therapy, and documentation requirements.

        CERT: Inpatient Psychiatric Facility Checklist

        Palmetto GBA posted a checklist (link) for providers to use when your claim(s) are selected for review by the CERT contractor. In this notice, they also provide links to their Psychiatric Inpatient Hospitalization Local Coverage Determination and related Billing and Coding article.

        WPS J5/J8 MAC

        New YouTube Video

        WPS has released a new YouTube Video titled Transcatheter Aortic Valve Replacement (TAVR) CERT Findings (link). This video describes reasons for improper payments identified by the CERT Contractor for WPS claims and provides information on how to avoid these errors.

        Therapy Assistants: What They Cannot Do

        WPS published an article (link) noting they have identified that physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) have been providing services outside CMS guidelines. The article details what activities that Medicare does not allow PTAs or OTAs to complete.

        Livanta National Medicare Review Contractor

        Livanta’s focus as the National Medicare Review Contractor is on performing Short Stay Review (SSR) and Higher Weighted DRG (HWDRG) reviews. Monthly, they release a publication titled The Livanta Claims Review Advisor. The March 2022 edition (link) focuses on Exploring Short-Stay Claim Review Guidelines and provides information about:

        • The history and background of short stay claim reviews,
        • Short stay medical review,
        • Step-by-Step guideline for short-stay determinations,
        • Example scenarios for short-stay Part A denials, and
        • Documentation features.
          • For those interested in receiving this publication, Livanta provides a link to subscribe at the bottom of the newsletter.

    Beth Cobb

    August 2020 MAC Talk
    Published on Aug 25, 2020

    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:

    • Blepharoplasty
    • Botulinum Toxin Injections - use for chronic migraine treatment
    • Panniculectomy
    • Rhinoplasty
    • 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.

    New: 8/7/20”


    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.

    Beth Cobb

    July 2020 MAC Talk
    Published on Jul 21, 2020

    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:


    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:


    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: 

    Link to Noridian JF webpage:


    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:

    • Blepharoplasty
    • Botulinum toxin injections
    • Panniculectomy
    • Rhinoplasty
    • 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.

    To help introduce Providers to the new format of PEPPER, the PEPPER Team prepared a recorded webinar demonstration of the new PEPPER, which is available on the PEPPER website.


    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:

    • 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.

    Beth Cobb

    May 2020 MAC Talk
    Published on Jun 16, 2020

    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.”

    Beth Cobb

    Top CERT Errors for Jurisdiction J
    Published on May 14, 2019

    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.

    Psychiatric Admission

    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.”

    Cataract Surgery

    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. 

    Debbie Rubio

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