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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

Palmetto Offers Drug Audit Checklists
Published on Apr 16, 2019

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).

Neulasta Checklist

Prolia Checklist 

Rituxan Checklist 

Remicade Checklist 

Avastin Checklist 

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.

Debbie Rubio

Medical Review Updates from SMRC, RAC, and MACs
Published on Mar 19, 2019

My co-worker and I, as part of our duties at MMP, monitor Medicare’s medical review activities. We are often amused that the same old issues seem to come around again and again and again. I guess there are certain Medicare services that are harder to perform, document, code, and/or bill appropriately. And despite the repeated reviews and ongoing education, providers still struggle to get it right. Therefore, Medicare contractors often review the same issues again and again and again. This month is no different; this article contains some new “old” updates of medical review activity.

Dental Services

The new Supplemental Medical Review Contractor (SMRC), Noridian Healthcare Solutions, added several new current projects this month, but the one affecting acute-care hospitals is the medical review of hospital outpatient dental services. As is often the case with SMRC reviews, this one is based on the findings of an Office of Inspector General (OIG) audit. As a reminder, Medicare generally does not cover dental services such as tooth extraction except in very limited circumstances.

From the OIG report, “Under the general exclusion provisions of the Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures) are not covered (§ 1862(a)(12)). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

For hospital outpatient dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare. For example, Medicare covers extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw, but a tooth extraction performed because of tooth decay is not covered.”

The OIG found that 542 of 600 dental services (90.3%) did not comply with Medicare’s requirements resulting in overpayments for the six Medicare contractors reviewed of $9,783,023 for a three-year time frame. No wonder this topic keeps being reviewed.

Cardiac and Pulmonary Rehabilitation

The Recovery Auditors (RACs) recently announced newly approved reviews of cardiac and pulmonary rehabilitation services.

Cardiac and pulmonary rehab are Medicare-covered physician-supervised programs that provide exercise, education, and assessments for specific cardiac and pulmonary conditions to improve patients’ physical and social function. Medicare has specific guidelines for the covered conditions eligible for each program, the required components that must be included in each program, and other requirements such as physician supervision and program duration. The Medicare requirements for cardiac and pulmonary rehab can be found in Chapter 15 of the Medicare Benefit Policy Manual, sections 232 and 231 respectively. The required components for both services include:

  • Physician-prescribed exercise
  • Education or training (in the form of cardiac risk factor modification for cardiac rehab)
  • Psychosocial assessment
  • Outcomes assessment
  • Individualized treatment plan

For the RAC reviews, “Medical Documentation will be reviewed to determine if pulmonary or cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.” Some recommendations on how your documentation could meet the Medicare requirements are discussed in this prior Wednesday@One article about Cardiac Rehab, but also can apply to Pulmonary Rehab documentation.

At the time of the writing of this article, all RAC regions had posted an approved audit issue for cardiac rehab and all but one RAC (Performant Region 1) had posted an approved audit issue for pulmonary rehab.

Facility ED Levels of Care

WPS, the Medicare contractor for Jurisdictions 5 and 8, had previously posted a Targeted Probe and Educate (TPE) review of CPT Codes 99281-99285 Emergency Department Visits. That topic temporarily disappeared from the listing of TPE topics for both J5 and J8 but now it is back. There have not been many, if any, other reviews of facility ED levels by Medicare reviewers, although some commercial insurers have attempted to curb high-level ER payments through review. This is a tricky subject because there are no national guidelines for assigning facility levels of care for Emergency Department services. Each hospital is instructed to develop their own level definitions based on the following guidance from the 2008 OPPS Final Rule.

  • The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate to the intensity of hospital resources to the different levels of effort represented by the code.
  • The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources.
  • The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits.
  • The coding guidelines should meet the HIPAA requirements.
  • The coding guidelines should only require documentation that is clinically necessary for patient care.
  • The coding guidelines should not facilitate up-coding or gaming.
  • The coding guidelines should be written or recorded, well-documented and provided the basis for selection of a specific code.
  • The coding guidelines should be applied consistently across patients in the Clinic or emergency department to which they apply.
  • The coding guidelines should not change with great frequency. CMS would not generally expect hospitals to adjust guidelines less frequently than every few months, but would be reasonable to adjust annually.
  • The coding guidelines should be readily available for fiscal intermediary or MAC review.
  • The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.

WPS’s checklist for the audit recommends submitting documentation of:

  • The number and type of interventions under the facility charge,
  • The visit record showing the signs/symptoms that support the medical necessity for the interventions, and
  • The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines).

If a hospital’s codes meet their own definitions, who is to say if that is right or wrong. It does make me cringe to see a Facility ED Level graph that is significantly skewed one way or the other. Medicare has been clear that an individual hospital does not have to have a perfect bell curve, but hospitals should still consider a reasonable distribution of levels for their patient population.

It is likely this topic will not go away. As reported by various healthcare newsletter, MedPAC (the Medicare Payment Advisory Commission) addressed the topic of national guidelines for coding hospital emergency department visits in a recent meeting. This call for guidelines appears to be in response to a commission report showing hospitals are reporting increased volumes of the higher ED levels.  If the recommendation passes in the April MedPAC meeting, it would likely require CMS to revisit national guidelines by 2022 which would result in CMS having a foundation for assessing and auditing coding behavior.

DRG Validation Reviews

One other interesting item to note is an announcement by HMS, the RAC for Region 4, clarifying that MS-DRG reviews are comprehensive coding reviews and are not limited to only code changes that impact the DRG code billed and paid. You can find the March 8, 2019 provider update here.

The good news about reviewing the same topics is that, as a provider, it gives you specific risk areas on which to concentrate. You may find your internal audits, like those of outside contractors, reviewing the same issues again and again and again.

Debbie Rubio

New RAC Activity
Published on Feb 18, 2019

There is a book and movie about World War I from around 1930 titled “All Quiet on the Western Front.” The title means there was no enemy activity occurring on the western boundary of the homeland troops. The problem in war, and sometimes in other areas of life, is that you have to be aware of all fronts. The enemy may sneak around and come at you from the North, the South, or even from behind. This reminds me of this month’s report on Medicare medical review activity. Though Medicare is not always the enemy, their medical reviews can sometimes feel like an attack and providers definitely have monies at risk.

The year is starting off mostly quiet on the Medicare Administrative Contractor (MAC) Targeted Probe and Educate (TPE) front. The only new activity for the first of the year comes from Novitas, the MAC for Jurisdictions H and L. You will find those issues listed in the table at the end of this article. In contrast, the Recovery Auditors (RACs) appear to be starting off the New Year with a bang, posting four new complex reviews for hospital services since the first of the year. Here is a listing of the new RAC approved issues and some details of what the RACs will be looking for in your documentation.

Hyperbaric Oxygen Therapy (HBOT) for Diabetic Wounds

This is a review to ensure HBOT meets Medicare medical necessity requirements. The coverage of HBO is defined in National Coverage Determination (NCD) 20.29. Medicare coverage for diabetic wounds requires the following:

  • Patient must have type I or II diabetes and wound(s) of the lower extremities due to diabetes,
  • The wound must be a Wagner Grade 3 or higher,
  • The patient must have failed an adequate course of standard wound therapy – specifically, there must be no measurable signs of healing for at least 30 –days of treatment with standard wound therapy (such as, vascular status assessment and correction if possible, optimization of nutritional status and glucose control, debridement and dressings, off-loading and infection treatment),
  • HBO must be used in addition to continuing standard wound therapy.

The medical record must contain documentation supporting all of the above requirements, including documentation the patient is diabetic, the Wagner grade of the wound, details of the standard wound therapy that was tried and failed, and evidence that there were no measurable signs of healing for at least 30 days.

In addition to the NCD, three MACs (First Coast JN, and Novitas JH and JL) have Local Coverage Determinations (LCDs) for HBO.

Complex Medical Necessity Panniculectomy

The following verbiage comes from the Noridian JE LCD L35163 and is one of the resources of additional information for this issue:

“Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.”

If the panniculectomy is for cosmetic reasons, it is not medically necessary and therefore not covered by Medicare. Also, a panniculectomy performed in conjunction with an open abdominal surgery or incidental to another procedure is not separately coded per Coding Guidelines. In addition to the Noridian JE LCD quoted above, Novitas (JH/JL), Palmetto (JJ/JM), WPS (J5/J8), and Noridian JF also have cosmetic surgery LCDs.

Cryosurgery of the Prostate Medical Necessity

Per NCD 230.9 and section 180 of Chapter 32 of the Medicare Claims Processing Manual (100-04), Medicare covers cryosurgery of the prostate gland for:

  1. Primary treatment of patients with clinically localized prostate cancer, Stages T1 – T3 (diagnosis code is 185 or C61– malignant neoplasm of prostate).
  2. Salvage therapy for patients:
  3. Having recurrent, localized prostate cancer;
  4. Failing a trial of radiation therapy as their primary treatment; and
  5. Meeting one of these conditions: State T2B or below; Gleason score less than 9 or; PSA less than 8 ng/ml.

The RACs will looking for records that do not meet Medicare’s medical necessity guidelines.

Medical Necessity Vertebroplasty and Kyphoplasty

This review will be looking at correct coding as well as medical necessity. Most MACs have an LCD for vertebroplasty and kyphoplasty.

According to the Palmetto LCD, “The decision for treatment should be multidisciplinary and consider such factors as the extent of disease, the underlying etiology, the severity of the pain, the nature of any neurologic dysfunction, the outcome of any previous non-invasive treatment attempts, and the general state of the patient’s health.”

So, while the MAC TPE front is quiet, there is a lot of review activity on the RAC front.

Debbie Rubio

OIG Finds Overpayments for HBO Services
Published on Jan 23, 2019

In all the years I have been writing articles for this newsletter, I am sure that I have at least once referenced the saying, “the devil is in the details” because this saying so perfectly fits in the Medicare world. It is often all about the details. A perfect example of this is from the recent OIG report on payments for hyperbaric oxygen (HBO) therapy that did not comply with Medicare requirements. Specifically, the OIG looked at HBO therapy services paid by the Medicare Administrative Contractor (MAC), First Coast, during calendar years 2012 through 2015. The OIG selected First Coast, the MAC for Jurisdiction N, because it paid the second largest amount for HBO therapy in 2013 and 2014; the highest MAC payor, WPS, had already been audited by the OIG (OIG Review of WPS HBO Payments). The OIG found that First Coast made payments for HBO that did not comply with Medicare requirements for 110 of 115 claims – a denial rate of 92%. Based on these findings, the OIG estimates First Coast has “overpaid providers in Jurisdiction N $39.7 million during the audit period for HBO therapy that did not comply with Medicare requirements.”

The OIG Report of First Coast HBO Overpayments gives three examples of ways providers did not comply with Medicare requirements. These examples mirror issues I often see when reviewing HBO records. Also interesting is the fact that the errors are associated with the most common Medicare coverage conditions for HBO therapy. Medicare’s requirements for HBO therapy can be found in the National Coverage Determination (NCD) 20.29 for Hyperbaric Oxygen Therapy. Below is a summary of what the OIG found, along with additional information from other Medicare resources.

HBO Covered Condition – Chronic Refractory Osteomyelitis, unresponsive to conventional medical and surgical management:

The OIG example about osteomyelitis was for ‘Medicare Payment for HBO Therapy Without Failing Conventional Treatment,’ and it specifically noted “HBO therapy treatment began before the conventional

treatment had been completed.”

The First Coast HBO LCD (Local Coverage Determination) states concerning osteomyelitis, “(it) must be chronic and refractory to usual standard of care management (i.e., prolonged antibiotics therapy preferably directed by appropriate culture and sensitivity information, drainage of the abscesses, immobilization of the affected extremity, and surgical debridement with removal of infected bone). HBO for osteomyelitis that is not documented to be chronic and refractory to conventional treatment, and HBO not provided in an adjunctive fashion, is not covered.”

The medical record must also contain documentation that supports the diagnosis of chronic refractory osteomyelitis. For example, Palmetto GBA in findings and education from their reviews of HBO, requires the diagnosis be supported by imaging studies or bone description and positive cultures. When reviewing such records, I notice it is often difficult to determine how long the patient has had osteomyelitis, how the diagnosis of OM was confirmed, and exactly what treatments have been tried.

HBO Covered Condition – Preparation and preservation of compromised skin grafts (not for primary management of wounds):

In the OIG report, “there was no evidence that the beneficiary ever received a flap procedure. She had surgery that resulted in a wound that became infected and did not heal, but there was no evidence that she ever received a flap.” The OIG listed this as ‘HBO therapy That Was Not Medically Necessary.’

Additional guidance concerning HBO for skin grafts/flaps can again be found in the First Coast LCD and from Palmetto GBA education. From the FC LCD, “Preparation and preservation of compromised skin grafts utilizes HBO therapy for graft salvage in cases where hypoxia or decreased perfusion has compromised viability.” The LCD reiterates that per the NCD, coverage under this indication is “not for primary management of wounds.” The LCD also points out HBO for this indication requires the presence of a compromised skin graft, and does not include HBO treatment that is empiric treatment or prophylactic maintenance of grafts or solely for preparation of a wound bed for receiving a graft.

In a Palmetto Ask the Contractor teleconference from May 2018, Dr. Leland Garrett, Medical Director, responded to questions concerning HBO coverage and documentation requirements. Per Dr. Garrett, for Medicare coverage, skin grafts and flaps treated with HBO should not be a chronic wound that had a flap performed several months ago and has reopened as a new (non) healing wound. It is for more acute situations where the flap or graft area has dehisced or is lost partially or fully. Preservation would be to use HBO to prevent (or repair) the dehisced side, and preparation would be the use of HBO to a site where the previous graft or flap was completely lost and is being oxygenated with HBO as an attempt to promote granulation tissue for the site for a new graft or flap …”.  The physician’s documentation should include information about the original graft or flap procedure including the date of the procedure, or preferably, a copy of the operative note. The documentation should also describe what has happened to the graft/flap site since the procedure that would cause the patient to need HBO.

HBO Covered Condition – Diabetic Wounds of the Lower Extremities in patients who meet the following three criteria:

  1. “Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
  2. Patient has a wound classified as Wagner grade III or higher; and
  3. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.” (NCD 20.29)

These plentiful NCD requirements seem to be a challenge to providers. The OIG’s 3rd and final example is ‘HBO Therapy With Insufficient Documentation.’ In this case, the medical records did not contain sufficient documentation to support that there were at least 30 days of standard wound care therapy provided prior to HBO therapy. Since the NCD provides so many details for diabetic wounds, there is not a lot to add from the First Coast LCD or Palmetto findings. I recommend making a check list for diabetic wounds from the NCD requirements looking at each requirement from two perspectives – 1) does the patient meet the criterium and 2) is there documentation to support it. For example, your checklist would be:

  • Is the patient diabetic? Is there documentation of such in the medical record?
  • Does the patient have a lower extremity wound due to diabetes? Is the record clear that the wound is a diabetic wound?
  • Is the wound a Wagner Grade III or higher and is that clearly documented in the record? Check for consistency in the documentation of the Wagner grade in physician’s progress notes and nursing assessments.
  • Has the patient been receiving conservative wound care for treatment of the wound for at least 30 days? Does the medical record describe the different types of assessments and interventions that have been done to promote wound healing?
  • Has there been no measurable signs of healing for at least 30 consecutive days? For example, the wound may fail to decrease in size as one indication of lack of healing, or there may be other wound characteristics signifying lack of healing. The First Coast LCD contains this statement – “Documentation of all aspects of optimization defined by the NCD (clarified by this LCD) and the absence of improvement in the wound characteristics constitutes stalled wound healing and suggests that it may benefit from adjunctive HBOT.”

The conditions addressed above are frequent reasons for a need for HBO therapy and providers need to ensure the coverage criteria and documentation requirements are met to receive appropriate reimbursement. Also remember to include other required elements in your HBO therapy – make sure you have:

  • A physician’s (or practitioner’s) order for the HBO therapy,
  • The physician/NPP’s explanation of the reason for HBO therapy (diagnosis or condition warranting the HBO treatment),
  • The expected benefits of HBO treatment – these are the HBO treatment goals, and
  • An evaluation of the patient’s progress from HBO therapy at least every 30 days.

This sounds like a lot of documentation but it is really just the basics of what is wrong with the patient, what is being done to help the patient, what is the expected outcome, and what is the actual outcome. The difficulty is, the devil is in the details.

Debbie Rubio

MAC Medical Review of Therapy Services
Published on Jan 15, 2019

When I first started working in healthcare compliance many moons ago, physical and occupational therapy were hot topics for Medicare review. The focus on therapy services for medical review has waxed and waned over the years since then, but here we are again with several Medicare Administrative Contractors (MACs) focusing on the review of therapy services. Palmetto JJ and JM are reviewing therapeutic exercise (CPT 97110) and manual therapy (97140 (JM only for now)); First Coast JN is reviewing physical, occupational, and speech services based on revenue codes (042x, 043x, and 044x), Novitas JH and JL are reviewing therapy services CPT codes describing therapeutic exercise and therapeutic activity (97110 and 97530), and recently WPS J8 added a review of therapeutic exercise (97110).

The good news is that documentation requirements for therapy services have not changed much over the years. The bad news is that despite consistent requirements, providers still often fail to get it right, resulting in denials for lack of medical necessity upon complex review.

Palmetto GBA offers a module that discusses the medical necessity and documentation requirements for therapeutic exercise, but this would apply equally to all therapy services and the requirements of all Medicare contractors. When I review therapy records, I instruct the therapists to “tell a good story” that describes what is wrong with the patient, what you plan to do about it, how this will benefit the patient, and then what you did and how the patient responded. This may sound over-simplified, so let’s examine these steps in more “clinical” terms.

  1. What is wrong with the patient – The patient must have a disabling condition that results in a functional impairment that causes a significant change or loss in body function. There must be activity limitations and participation restrictions affecting the patient’s activities of daily living (ADLs).
  2. The limitation is assessed during the therapy evaluation.
  3. Examples of limiting conditions are weakness, stiffness, decreased range of motion, gait problem, balance deficit, pain resulting in one of these conditions, etc. Providers should refer to their MAC’s LCD addressing therapy requirements for more details concerning covered indications.
  4. The therapist should describe the limitation in the evaluation, including body part and type of limitation, objective measurements, subjective observations, and description of the impaired ADLs.
  5. When applicable include the onset date and cause, and any other conditions and complexities that may impact the patient’s treatment.
  6. What you plan to do about it – This is the plan of care (POC) for the patient’s treatment. The therapist must select individualized exercises related to the patient’s impairment that address the goals for the patient (see number 3 below for a discussion of goals).
  7. The treatment must require the skills of a therapist and documentation must justify why the services are skilled. This may involve teaching the patient the proper way to perform exercises, monitoring the patient medically, providing cues and instruction on exercise performance, assisting the patient for safety reasons, etc.
  8. The plan must also include the expected amount, frequency, and duration of treatment required to reach the patient’s goals.
  9. The POC must be certified and re-certified by the patient’s physician/practitioner initially and every 90 days if therapy continues.
  10. How this will benefit the patient –There must be an expectation the patient will benefit from the therapy services. The expected benefit or outcomes are documented in the POC as therapy goals.
  11. Notice the patient must “benefit” from therapy, not necessarily “improve.” Medicare covers restorative therapy when prior functional levels are partially or completely restored. Medicare also covers maintenance therapy to prevent or slow decline in patient function. For maintenance therapy, there must be documentation of a reasonable concern of deterioration in function without therapy.
  12. Goals must be specific, measurable, and relate to the patient’s functional limitation(s).
  13. What you did – This is the documentation of the daily treatment notes –exercises that were performed, patient needs (e.g. instruction, cueing) and response, and the treatment time.
  14. The treatment note must include the date of treatment and a list of services provided.
  15. Timed-code treatment minutes and total treatment minutes must be documented. Timed-code treatment minutes will be used to support services rendered and number of units billed.
  16. All of the CPT codes targeted for MAC review are constant attendance codes. This means the therapy provider must have direct one-on-one contact with the patient.
  17. Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service determines the number of timed units billed. When reporting units of timed-codes to Medicare, providers follow the eight-minute rule. This means you do not bill if less than 8 minutes of timed-code therapy was provided in a day, you bill 1 unit for 8-22 minutes, 2 units for 23-37 minutes, etc. The complete time table can be found in the Medicare Claims Processing Manual, Chapter 5, section 20.2.
  18. The daily treatment note must be signed by the clinician who provided the services that day, including notation of their credentials.
  19. How the patient responded - Through on-going assessments, therapists determine how the patient is progressing toward the therapy goals. This may include comments in the daily notes, but must include a progress report at least every 10 treatment days and a discharge summary at the end of treatment.
  20. The progress report/discharge summary must be prepared by a physician or therapist who has actively participated in the patient’s care at least once during the reporting period. Therapy assistants (PTAs and OTAs) can provide treatments but the progress reports and discharge summaries must be written by a therapist, the same as evaluations and plans of care.
  21. These reports include an assessment of the patient’s progress or lack of progress towards the therapy goals based on objective measures, self-reported statements from the patient, and the therapist’s observations of function. If the patient is not progressing as expected, the therapist may need to modify goals and/or treatments.
  22. Like all therapy documentation, these reports must be dated and signed by the author with their credentials noted.

Also remember that the patient must be under the care of a physician/practitioner during therapy. This is evidenced by the physician/practitioner’s signature certifying the Plan of Care. And although therapy caps went away, providers are still required to append the KX modifier to services beyond the KX modifier threshold to verify these services are medically necessary in order to receive payment. One bit of good news for 2019 is that Medicare no longer requires reporting of the functional limitation G-Codes and severity modifiers.

The bottom line for therapy reviews is that, as a therapy provider, if you follow Medicare’s rules for medically necessary treatments, certifications, calculating units, documentation, and “tell a good story,” you should be able to receive appropriate reimbursement from Medicare for the services you provide. Along with positive patient outcomes, what more could you ask for?

Debbie Rubio

New Palmetto JJ Part A Medical Reviews
Published on Dec 11, 2018

People do not seem to be as trusting as they once were. I believe this is in part due to the fact our lives are more complicated and complex than those of our forefathers. Technology, for example, offers numerous ways to deceive, cheat, and steal from others that did not exist 50 years ago. To be good stewards of our resources, we must be diligent against theft and deception – maybe “trust, but verify.” Medicare receives and pays billions of dollars in claims each year and for the majority of those claims, they “trust” them to be correct. But CMS also has numerous agencies and contractors who oversee the integrity of the Medicare program to ensure proper payments are being made. These contractors “verify” appropriate Medicare payments through automated claim edits and complex medical reviews.

On December 3, 2018, Medicare Administrative Contractor (MAC) Palmetto Jurisdiction J updated their list of Targeted Probe and Educate (TPE) Active Medical Reviews. They added Part A (hospital) reviews for several drugs: Rituximab (J9310), Infliximab (J1745), and Bevacizumab (J9035). These new drug reviews are in addition to still active medical reviews for drugs Pegfilgrastim (J2505) and Denosumab (J0897). Palmetto is also reviewing all of these drugs in their other MAC jurisdiction, JM.

For coverage of drugs, there first has to be a signed physician’s order for the medication. The order should specify the drug, the dosage, the route of administration, frequency, and the diagnosis or condition for which the drug is being given. Years ago, Medicare accepted the diagnosis to support medical necessity if it was simply documented on the order. They are not so trusting these days and now expect to see documentation, such as physician progress notes or a relevant history and physical, that includes a clear indication of the diagnosis, clinical signs and symptoms, prior treatments and response, and the stage of treatment if applicable. For hospitals, this often requires requesting office notes from the ordering physician to include with records submitted to Palmetto for review. Another option is to require this type of documentation up front from physicians’ offices scheduling outpatient drug infusions and maintain it in the patient’s medical record.

Another thing to consider up front is the drug protocol. Does the dose and indication for use meet the FDA-approved usage which is described in the manufacturer’s insert? Or if the drug is being used off-label, is it in accordance with Medicare approved drug compendia? This is a lot for the hospital to consider, but not knowing puts the hospital at risk of not being paid. The “recommended protocol was not ordered or followed” is a common denial reason in the published findings of prior Palmetto drug reviews. For example, here are some granular denial reasons from November 2017 findings of a Pegfilgrastim review in which 48% of the denials were for this reason:

  • For the prophylactic treatment of febrile neutropenia in patients with non-myeloid malignancies receiving myelosuppressive chemotherapy,
  • the recommended dose of Pegfilgrastim was administered before 24 hours after administration of cytotoxic chemotherapy.
  • the recommended dose of Pegfilgrastim of less than or equal to 1-6 mg administered subcutaneously once per chemotherapy cycle was not ordered or followed.
  • the recommended dose of Pegfilgrastim is administered between 14 days before and 24 hours after administration of cytotoxic chemotherapy.
  • Pegfilgrastim was administered with contraindicated non-myelosuppressive chemotherapy.

To provide Palmetto Medical Review with more information on drug usage, a recent Palmetto article on Billing and Coding for Chemotherapy requires the inclusion of remarks on the claim to describe specifics of usage, such as drug combination therapy and the condition being treated. 

Next there must be documentation of the actual administration of the drug. The drug administration record must include the drug name, the date administered, the dosage, the route of administration, start and stop times when applicable, patient response to treatment and the signature of the clinician who administered the drug. Also remember that if the drug dosage is dependent on the patient’s weight or body surface area, that information must also be documented in the record.

Providers also need to verify they are reporting the appropriate number of units. Units are reported based on the HCPCS code description. This means if the drug descriptor is per 100 mg and 536 mg are administered to the patient, 6 units would be reported on the claim. Here is some information from a prior Wednesday@One article about the challenges of reporting drug units.

  • Drug HCPCS codes must be billed based on the amount, such as milligrams (mgs) in the HCPCS code description, not on standard usage or packaging amounts.
  • Most hospitals accomplish this by using a “multiplier” in their charge description master (CDM), which presents the challenges of making sure all drugs that need a multiplier have one, there are no errors or typos in the multiplier amounts, and the multipliers are kept updated with code description changes.
  • CMS often changes drug HCPCS codes and/or the HCPCS description. This is especially challenging when the amount in the description changes.
  • Medical record documentation should include the dosage amount in the physician’s order and in the administration record.
  • If the dose administered does not match the dosage amount the physician ordered, a corrected order should be obtained from the ordering physician.
  • If the drug dose is based on the patient’s weight, there should be documentation in the medical record of the patient’s weight.
  • Medicare has published Medically Unlikely Edits (MUEs) applicable to drug quantities for over 550 drug codes. Limits are based on anatomic or clinical considerations, prescribing information, CMS policy, or code descriptor/instructions.
  • Medicare does not allow providers to bill for wastage of multi-dose vials.
  • When billing for wastage associated with single-dose vials, there should be documentation in the medical record of the dose given and the amount wasted.

For more information on drug wastage, please see Palmetto's article on Drug Wastage Billing and Coverage Guidelines.

Hospital providers should be diligent to verify the accuracy of their claims before a Medicare reviewer does so. It is more often not an intent to deceive, but lack of knowledge or simple errors that cause inaccurate claims. Hospitals, like Medicare, should “trust, but verify.”

Debbie Rubio

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