Knowledge Base Category -

Did You Know?

The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:

• For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
• CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.

Why it Matters?

Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.

Current Projects

As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.

Completed Projects

To date, in CY 2022, the SMRC has posted project results for the following five projects:

• 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
• 01-036: Hospice Portfolio: Error Rates 29% and 47%,
• 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
• 01-044: Therapy Reviews: Error Rate 31%, and
• 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.

What Can You Do?

First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).

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.

In the early days of the COVID-19 Public Health Emergency (PHE) guidance and information was coming at us fast and furious by the likes of the CMS, CDC, OIG, and the AMA. Early on, MMP provided weekly COVID-19 updates. We later transitioned to including highlights in our end of the month Medicare updates article.

However, with new codes related to COVID-19 becoming effective April 1, 2022, the recent launch of an OIG telehealth webpage, and CMS announcing the end of specific COVID-19 waivers for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities, and end-stage renal disease facilities, updating our readers couldn’t wait until the end of April.

April 1, 2022: Reminder, New COVID-19 Codes Effective April 1, 2022

As a reminder, effective April 1, 2022, there are new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status as well as new ICD-10-PCS procedure codes describing the introduction or infusion of therapeutics, including vaccines for COVID-19 treatments.

In a related MLN Matters Article MM12578 (link), “CMS notes that for hospitalized patients, Medicare pays for COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. Medicare expects that the appropriate CPT codes will be used when a Medicare patient is administered a vaccine while a hospital inpatient. For details on billing Medicare for the COVID-19 vaccine appropriately, please see this page in our provider toolkit.”

Information about a new Pfizer BioNTech COVDI-19 vaccine code and changes for COVID-19 monoclonal antibody therapy product and administration codes can be found in MLN Matters Article MM12666 (link).

April 4, 2022: New Way for Medicare Beneficiaries to Get Free Over the Counter COVID-19 Tests

In an April 4, 2022, Special Edition of MLN Connects (link), CMS announced that Medicare beneficiaries, including Medicare Advantage enrollees, can now get free COVID-19 tests with a few caveats:

• They must be FDA approved, authorized, or cleared over the counter COVID-19 tests,
• You are limited to up to 8 tests per calendar month from participating pharmacies and health care providers, and
• Free testing is available for the duration of the COVID-19 public health emergency (PHE).

CMS also provided a list of national pharmacy chains participating in this initiative that includes Albertsons Companies, Inc., Costco Pharmacy, CVS, Food Lion, Giant Food, The Giant Company, Hannaford Pharmacies, H-E-B Pharmacy, Hy-Vee Pharmacy, Kroger Family of Pharmacies, Rite Aid Corp., Shop & Stop, Walgreens, and Walmart.

This new option for receiving COVID-19 tests is an addition to the following options outlined in the Special Edition MLN Connects:

• Requesting free over-the-counter tests for home delivery at covidtests.gov. Every home in the U.S. is eligible to order 2 sets of 4 at-home COVID-19 tests.
• Access to no-cost COVID-19 tests through health care providers at over 20,000 testing sites nationwide. A list of community-based testing sites can be found here.
• Access to lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost through Medicare.
• In addition to accessing a COVID-19 laboratory test ordered by a health care professional, people with Medicare can also access one lab-performed test without an order and cost-sharing during the public health emergency.

April 4, 2022: OIG Launches Telehealth Webpage

The OIG announced the launch of a new telehealth webpage (link). In the announcement they note that they are “conducting oversight work assessing telehealth services, including the impact of the public health emergency flexibilities. Once complete, these reviews will provide objective findings and recommendations that can further inform policymakers and other stakeholders considering changes to telehealth policies. This work can help ensure the potential benefits of telehealth are realized for patients, providers, and HHS programs.”

April 6, 2022: CMS to Pay for Second COVID-19 Booster without Cost Sharing

CMS announced (link) that they will pay for a second COVID-19 booster at no cost for people with Medicare or Medicaid coverage. They go on to note that the CDC recently updated their recommendation regarding COVID-19 vaccinations. Specifically, “Certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least 4 months ago are eligible for another booster to increase their protection against severe disease from COVID-19. Additionally, the CDC recommends that adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago can receive a second booster dose of a Pfizer-BioNTech or Moderna COVID-19 vaccine.”

April 7, 2022: CMS Returns to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities

In a CMS Press Release (link), they note that they have seen steadily increasing vaccination rates for nursing home residents and staff, and improvements in nursing homes’ abilities to respond to COVID-19 outbreaks. This provided the impetus for CMS to announce they will be phasing out certain flexibilities related to the COVID-19 PHE to re-establish certain minimum standards. Some of the same waivers are also being terminated for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and end-stage renal disease (ESRD) facilities.

Specifically, CMS is ending specific waivers in two groups: one group of waivers will terminate 30 days from the issuance of this new guidance, and the other group will terminate 60 days from issuance. CMS notes in the related memorandum Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers (link), that at this time “applicable waivers will remain in effect for hospitals and critical access hospitals (CAH).”

Note, CMS has updated their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (link) document to reflect the dates for when the waivers are to terminated.

Did You Know?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.

Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.

In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.

Esophageal Cancer Prevalence in the United States in 2021

• New Cases: 19,260
• Deaths: 15,530

Esophageal Cancer Risk Factors

• Tobacco Use,
• Heavy alcohol use,
• Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
• Men are about three times more likely than women to develop esophageal cancer,
• Older age,
• White men develop esophageal cancer at higher rates than Black men in all age groups

Signs and Symptoms of Esophageal Cancer

• Painful or difficult swallowing,
• Weight loss,
• Pain behind the breastbone,
• Hoarseness and cough
• Indigestion and heartburn
• A lump under the skin

Tests Used to Diagnose Esophageal Cancer

• Physical exam and health history,
• Chest x-ray,
• Esophagoscopy
• Biopsy

Why this Matters?

In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.

Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.

Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.

Resources:

• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
• PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]

Medicare MLN Articles & Transmittals

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2020 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs)

• Article Release Date: February 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12628: (link)

April 2022 Update to the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)

• Article Release Date: March 7, 2022
• What You Need to Know: This article provides information about coding needs and coding criteria for reprocessing inpatient claims involving Pfizer’s PAXLOVID™ or Merk’s Molnupiravir. Both drugs were granted FDA emergency use authorization in December 2021.
• MLN MM12631: (link)

One-Time Notification: Correction to Processing When Osteoporosis Drugs are Billed for Other Indications

• Transmittal Release Date: March 9, 2022
• What You Need to Know: This Change Request (CR) 12551 permanently removes an edit requiring osteoporosis drugs be billed only by home health agencies.
• Transmittal 11290 (CR 12551): (link)

April Quarterly Update for 2022 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: March 11, 2022
• What You Need to Know: This article provides information about the April 2022 quarterly update for the DMEPOS fee schedule and fee schedule amounts for new and existing codes.
• MLN MM12654: (link)

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

• Article Release Date: March 18, 2022
• What You Need to Know: Make sure your billing staff knows about how to code for difelikefalin injection and modifier use for code J0879.
• MLN MM12583: (link)

April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 11305/Change Request 12666 Release Date: March 24, 2022
• What You Need to Know: The effective date for the updates is April 1, 2022. Examples of items included in this update are:
• o New COVID-19 CPT vaccines and administration codes,
• o Changes for COVID-19 monoclonal antibody therapy product and administration codes,
• o A new HCPCS code describing the InSpace Subacromial Tissue Spacer System procedure to treat irreparably torn rotator cuff tendons, and
• o New separately payable procedure codes for medical procedures.
• Link to CR 12666: (link)

April 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: March 24, 2022
• What You Need to Know: Changes to make your billing staff aware of (updates to payment rates for separately payable procedures, services, drugs, and biologicals and descriptors for newly created CPT and Level II HCPCS codes) are detailed in this MLN article.
• MLN MM12679: (link)

Revised Medicare MLN Articles & Transmittals

Internet-Only Manual Updated for Critical Care Evaluation and Management Services

• Article Release Date: Initial article January 22, 2022 – Revised March 2, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR). All other information is the same. As a reminder, CMS has added language to the definition of a Global Surgical Package to direct you to critical care updates in section 30.6.12.7 of the Medicare Claims Processing Manual, Chapter 12.
• MLN MM12550: (link)

Coverage Updates

Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache)

• Article Release Date: February 16, 2022
• What You Need to Know: You will learn about revisions to NCD 240.2 and 240.2.2. For example, CMS notes that “Medical documentation requirements aren’t contained within the revised NCDs. The absence of medical documentation in these revised NCDs doesn’t otherwise remove or modify Medicare requirements of the Certificate of Medical Necessity (CMN) Form 484 itself or other medical documentation requirements under other existing authorities.”
• MLN MM12607: (link)

March 1, 2022: CMS Posts New Tracking Sheet for the Cochlear Implantation NCD (50.3)

According to a new Tracking Sheet link), “this NCD analysis will align with the scope of the request and focus on individuals with hearing test scores of > 40% and ≤ 60%, for whom coverage is available only when the provider is participating in, and patients are enrolled in a clinical study.” The initial public comment period is from March 1, 2022, to March 31, 2022.

Medicare Educational Resources

MLN Education Tool: Medicare Payment Systems

CMS alerted readers in the Thursday, March 3, 2022 edition of MLN Connects (link) that the MLN education tool Medicare Payment Systems has been updated to include 2022 regulation changes to payment, quality, and policy across several settings (i.e., acute care hospital, skilled nursing facility, and home health).

MLN Booklet: SBIRT Services Updated

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, early intervention approach for people with non-dependent substance use before they need more extensive or specialized treatment. CMS SBIRT Booklet MLN904084 (link) was recently updated to inform providers that beginning January 1, 2022, CMS covers Naloxone HCPCS Code G1028.

COVID-19 Updates

February 28, 2022: CMS COVID-19 FAQs on Medicare Fee-for-Service Billing Documented Updated

This CMS document (link) includes FAQs for providers and suppliers that bill Medicare (i.e., labs, hospitals, ambulance services, physician services) and was last updated on February 28, 2022. Specifically, on February 16th, CMS updated the answer to the following question:

• Question: The FDA has expanded the approved indication for the antiviral drug Veklury (remdesivir), and it is now authorized for the treatment of COVID-19 in certain adults and pediatric patients who are not hospitalized in addition to those that are hospitalized. How will CMS pay for remdesivir if it is administered in the outpatient setting?

March 3, 2022: Preliminary Medicare COVID-19 Data Snapshot

Medicare most recently updated their Preliminary Medicare COVID-19 Data Snapshot webpage (link) on March 3rd. The data snapshot reports COVID-19 cases and hospitalization data for Medicare beneficiaries diagnosed with COVID-19. Following are highlights from this data release:

• There have been 1,636,501 total Medicare COVID-19 hospitalizations,
• Of those hospitalized, most beneficiaries (38%) were discharged home. The other top three discharge dispositions include home health (17%), skilled nursing facility (17%), and expired (17%),
• The top five chronic conditions among hospitalized beneficiaries includes hypertension (81%), hyperlipidemia (65%), chronic kidney disease (58%), ischemic heart disease (49%) and diabetes (48%),
• Total Medicare Fee-for-Service payment to date for COVID-19 hospitalizations is $23.4B, and
• The average payment per beneficiary hospitalization with COVID-19 is $24,304.

March 10, 2022: MLN Matters Notice Revised Emergency Use Authorization (EUA) for EVUSHELD

CMS published the following information about a revised EUA for the COVID-19 monoclonal antibody cilgavimab (EVUSHELD) in the March 10, 2022, edition of MLN Matters (link):

“On February 24, the FDA revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as pre-exposure prophylaxis of COVID-19 in certain adults and pediatric patients. For more information about dosage and administration, including information about dosing for patients who got the original lower dose, review the fact sheet (ZIP) (link).

• Long Descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
• Short Descriptor: Tixagev and cilgav, 600mg

Visit the COVID-19 Monoclonal Antibodies webpage for more information (link). Note: you may need to refresh your browser if you recently visited this webpage.”

March 22, 2022: 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)

On March 23rd, CMS updated their COVID-19 Current Emergencies webpage (link) by adding a COVID-19 Medicare Provider Enrollment Relief FAQs document (link). The first question in this document answers the question of how CMS is using its 1135 blanket waiver authority to offer flexibilities with Medicare provider enrollment to support the COVID-19 national emergency.

Other Updates

March 16, 2022: Annual Civil Monetary Penalties Inflation Adjustment Published

The Office of the Assistant Secretary for Financial Resources, Department of Health and Human Services (HHS) published the Annual Civil Monetary Penalties Inflation Adjustment Final Rule (link) on March 17, 2022. Examples of actions that can come under a civil monetary penalty includes:

• Penalty for knowing of an overpayment and failing to report and return.
• Penalty for failure to grant timely access to HHS OIG for audits, investigations, evaluations, and other statutory functions of HHS OIG.
• Penalty for a Medicare Advantage organization that substantially fails to provide medically necessary, required items and services.
• Penalty for improper billing by Hospitals, Critical Access Hospitals, or Skilled Nursing Facilities.

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 bariatric surgery.

Did You Know?

There has been a National Coverage Determination (NCD) for bariatric surgery (100.1) since 1979. Originally titled Gastric Bypass Surgery for Obesity, the NCD is now titled Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (link). This name change reflects the fact that treatment for obesity alone remains a non-covered indication for bariatric surgery.

Why Does This Matter?

Bariatric surgery has come under scrutiny by more than one review contractor, for example:

Supplemental Medical Review Contractor (SMRC): Strategic Health Solutions, the first SMRC contractor, completed a review of claims for bariatric service codes for dates of service from January 1, 2014, through December 31, 2014. In their review results, they cited a 35% error rate. The main reason for denials was due to insufficient documentation, for example: documentation did not include information supporting prior unsuccessful medical attempts at weight loss prior to surgical intervention.

Recovery Auditors (RACs): Complex medical reviews of inpatient and outpatient bariatric procedures has been an approved RAC Issue (link) since February 1, 2017.

Office of Inspector General (OIG): More recently, the Office of Inspector General published the report Hospitals Did Now Always Meet Differing Contractor Specifications for Bariatric Surgery (link). The OIG undertook this audit due to findings from a prior review of claims in 2015 and 2016 where they found claims did not fully meet a MAC’s eligibility specifications as well as the variance in eligibility specifications by different MACs. The audit included hospital inpatient claims for bariatric surgery performed from January 2017 through July 2018.

The OIG found thirty-two claims that met the NCD requirements, however the claims did not meet the MACs local specifications in their Local Coverage Determination (LCD) or Local Billing and Coding Article (LCA). Noridian had the most restrictive eligibility specifications in their LCA. The top specification not met was a lack of documentation indicating the beneficiary had participated in a weight management program. Novitas and First Coast had the least restrictive LCDs. The OIG estimated that “Medicare could have saved $47.8 million during our audit period if Medicare contractors had disallowed claims that did not meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.”

OIG Audit Recommendations

Based on the audit findings, the OIG recommended that CMS:

• Determine if any of the MACs eligibility specifications in their LCDs or LCAs should be added to the NCD and if so, take steps to update the NCD,
• Work with the MACs to determine if any of the LCD or LCA eligibility specifications should be requirements rather than guidance, and
• If the NCD is updated, provide education to hospitals on the NCD requirements for bariatric surgery.

CMS Response

CMS did not agree with the OIGs recommendations. Two CMS responses were highlighted in the Report Brief:

• CMS will continue to monitor scientific evidence related to bariatric surgery and evaluate if an update to the NCD is needed, and
• “The Social Security Act does not mandate that LCDs be uniform across all jurisdictions and there are valid reasons that variations at the local Medicare contractor level is appropriate.”

What Can You Do?

If your hospital provides bariatric surgery services, I encourage you to read this OIG Report and perform a record review to ensure documentation supports the NCD requirements and when applicable your MAC LCDs and/or LCAs.

Collaboration is a process of working together to complete a task or achieve a goal.

For the Clinical Documentation Integrity Specialist, the goal of ensuring a patient’s story can be accurately reflected in codes (ICD-10-CM/PCS, HCPCS, CPT), requires collaborating with a team that can include physicians, nursing, dietitians, physical therapists, case managers, social workers, and coding professionals.

For the Case Manager, to ensure a patient’s story supports medical necessity of the services being provided and the patient has an appropriate discharge plan in place, this process, in addition to the above professions, requires open communication with the patient and his or her “people.”

Physicians must also collaborate with a team. In fact, CMS recently updated their MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership (link). This Fact Sheet opens with the following guidance:

“As a physician, supplier, or other health care provider, you may need to collaborate with other providers when providing care to your Medicare patients. For example, you may:

• Write orders
• Make referrals
• Request health care services or items for your patient

It’s important to understand Medicare coverage criteria and documentation requirements that apply for those services or items. This helps to ensure:

• Quality care for your patient
• Accurate and timely processing and payment of:
• Your claims, and
• The claims of other providers or suppliers who provide services or items for your patient

Note: This fact sheet is limited to information and documentation you need to support medical necessity when you partner with other providers. Other coverage and payment rules may also apply.”

Medicare Coverage Criteria and Documentation Requirements

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states “No payment may be made under Part A or Part B for expenses incurred for items or services which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…”

At the national level, CMS publishes National Coverage Determinations (NCDs) and at the local level, Medicare Administrative Contractors (MACs) publish Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs). Coverage documents provide guidance for when a service is covered or not covered, and include indications for coverage, limitations of coverage, documentation requirements and billing and coding guidance.

It is important to become familiar with where to find these documents (Medicare Coverage Database (link) and identify any NCDs, LCDs, and/or LCAs that apply to services that you provide. For example, at the national level, there is a NCD for Implantable Automatic Defibrillators (20.4) (link). In addition to the NCD, several MACs have published a related Billing and Coding article.

Ensuring the Story is Correct

Understanding Medicare coverage criteria and documentation requirements is important. So much so, CMS utilizes Contractors (i.e., Recovery Auditors, Supplemental Medical Review Contractor, and MACs) to audit claims.

CMS notes in the MLN Fact Sheet, “Medicare audits frequently show that provider-submitted documentation doesn’t provide enough information to establish medical necessity. To ensure proper claims processing and payment, you must follow documentation requirements and meet Medicare coverage criteria.”

They also underscore the importance of documenting everything needed to meet Medicare payment requirements when collaborating with other Providers. For example, let us once again focus on implantable automatic defibrillators and the Shared Decision Making (SDM) encounter requirement. The SDM encounter is:

• A requirement for all patients receiving a defibrillator for primary prevention,
• Must occur between the patient and a Physician or Non-Physician Practitioner (i.e., Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist),
• An Evidenced-Based Decision Tool must be used to ensure topics like patient health goals and preferences are discussed,
• The encounter must occur prior to the initial implantation, and
• The encounter may occur at a separate visit.

Given the timing of when the SDM encounter should occur, it is likely that this would be done in the Physician’s office. Therefore, the physician would need to include in documentation provided to the hospital that an SDM encounter had occurred and what tool had been used.

CMS advises that a providers documentation needs to be thorough and accurate to support the medical necessity of services provided and should:

• Provide a thorough picture of what happened during the patient’s visit, and
• Tell why services or items you ordered or gave are medically necessary.

I opened this article by noting that collaboration is a process of working together to complete a task or achieve a goal. I end this article by noting that a successful collaboration requires the physician to tell each patient’s story in a way that supports the medical necessity of services provided and allows for coding professionals to translate the story into code for accurate billing and payment of the claim.

Did You Know?

45 is the new 50 for colorectal cancer screening.

Why It Matters?

The U.S. Preventive Services Task Force’s indicated in their May 18, 2021 Final Recommendation statement for colorectal cancer screening that (link):

• It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years,
• Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016,
• In 2016, 25.6% of eligible adults in the US had never been screened for colorectal cancer, and
• In 2018, 31.2% were not up to date with screening.

What Can You Do?

There are five types of tests used to screen for colorectal cancer:

• Fecal occult blood test,
• Sigmoidoscopy,
• Colonoscopy,
• Virtual colonoscopy, and
• DNA stool test.

As a healthcare provider, be aware of Medicare’s colorectal screening coverage. According to the MLN Educational Tool Medicare Preventive Services (link), Medicare covers:

• Colorectal cancer screening using MT-sDNA and blood-based biomarker tests for patients with Medicare Part B who meet these criteria:
  • Aged 50-85 years,
  • Asymptomatic, and
  • At average risk of colorectal cancer risk.
• Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas for patients with Medicare Part B who meet at least one criterion:
• Aged 50 or older at normal colorectal cancer risk (there’s no minimum age requirement for screening colonoscopies), or
• Are at high colorectal cancer risk.

Also, Medicare has published a National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests (link). The most current iteration of this NCD became effective on January 19, 2021, to include blood-based biomarker testing as an appropriate colorectal cancer screening test based on specific criteria.

My first screening colonoscopy was performed when I was 45 years old. During the procedure a pre-cancerous polyp was removed. As a healthcare consumer, I encourage everyone to talk with your doctor to discuss your risk for colorectal cancer and the need for screening tests.

Coverage Updates

National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: September 15, 2021 – Latest Revision January 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12403: (link)

CWF Editing – NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: February 16, 2022
• What You Need to Know: This article provides information about new edits for autologous Platelet-Rich Plasma (PRP) claims for diabetes and chronic ulcers.
• MLN MM12611: (link)

Final Decision Memo: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

CMS posted a Final Decision Memo ((link) for Lung Cancer Screening with LDCT on February 10, 2022. The eligibility age for screening has decreased from 55 years to 50 years. The tobacco smoking history has decreased from thirty packs per year to at least twenty packs per year. Counseling and shared decision-making are required prior to a beneficiary’s first screening test. Shared Decision Making (SDM) shall “include the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

COVID-19 Updates

January 31, 2022: FDA Approves Second COVID-19 Vaccine

The FDA announced the approval of a second COVID-19 vaccine ((link). The vaccine under emergency use authorization has been known as the Moderna COVID-19 vaccine. The approved vaccine will be marketed as Spikevax. Spikevax has the same formulation as the EUA Moderna COVID-19 Vaccine and is administered as a primary series of two doses, one month apart.

February 18, 2022: FDA Authorized Monoclonal Antibody Bebtelovimab

CMS announced in a special edition of MLN Connects ((link) that the FDA has approved the monoclonal antibody Bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when specific criteria apply. CMS has created three new codes for administering this drug. You can find information about this and other monoclonal antibody drugs on the CMS COVID-19 Monoclonal Antibodies webpage (link).

Other Updates

February 1, 2022: DOJ News: False Claims Act Settlements and Judgements Exceed $5.6 Billion in Fiscal Year 2021

In this DOJ announcement ((link) the DOJ reports that over $5 billion of the more than $5.6 billion in settlements in the past fiscal year related to matters involving the health care industry, “including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians.”