Knowledge Base Category -

According to the Payment Accuracy.gov website “The Improper Payments and Elimination and Recovery Act of 2010 defines an “improper payment” as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.”

The Comprehensive Error Rate Testing (CERT) Program calculates improper payment rates for the Medicare Fee-for-Service program. This article focuses on the CERT Program and Review Process and findings from the 2018 CERT Report.

 

CERT Program & Review Process

Medical Record Request

For each reporting period, the CERT Program selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs). This sample include claims that were paid or denied by the MAC.

When the CERT requests medical records from a provider if no documentation is received within 75 days of the initial request, the claim is classified as a “no documentation” claim and counted as an error. However, the CERT will still review documentation received after 75 days as long as it’s before the end of the report period deadline.

Review of Claims

Medical review professionals perform complex medical reviews to determine whether a claim was paid properly under Medicare coverage, coding and billing rules. Claim reviewers includes nurses, medical doctors and certified coders. This group of Medical review professionals assign improper payment error categories.

Improper Payment Error Categories, Definitions, and Examples

In a CMS Introduction to CERT download on the CMS CERT webpage, the following examples are provided specific to each improper payment category.

‍Calculation of the Improper Payment Rate.

CMS calculates a national improper payment rate and contractor specific and service specific improper rates from this stratified random sample of claims. As noted on the CMS CERT webpage, “The improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.”

CMS notes “that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.”

 

2018 CERT Report by the Numbers:

Annually, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report. CMS later publishes more detailed improper payment rate information in the form of the annual Medicare FFS Improper Payments Report and Appendices.  CMS published the

2018 Medicare Fee-for-Service Supplemental Improper Payment Data Report on November 30, 2018. This report includes a review of claims submitted from July 1, 2016 through June 30, 2017.  

Overall

Overall Percent Accuracy Rate – 91.9% - Improper Payment Rate $357.7B

Percent Improper Payment Rate – 8.1% - Improper Payment Rate $31.6B

Common Causes of Improper Payments

Below is a table comparing the common causes of improper payments are broken out by the type of error. It appears that providers are doing better at submitting medical records. However, Medical Necessity errors are on the rise.

‍“0 or 1 Day” LOS Claims Continued Outlier

The CERT Program has reported Projected Improper Payments by Length of Stay (LOS) since the 2014 Report. While the Improper Payment Rate has dropped for “0 or 1 day” LOS claims, this group of claims continues to have the highest improper payment rate.

‍Compliance with Short Stays

Have you tracked your short stay volume overall, by MS-DRG or Physician over time? Do you know if your hospital is an outlier? Where can you look to find these answers?   

 

PEPPER

One resource available to hospitals is the Short-Term Acute Care PEPPER (Program for Evaluating Payment Patterns Electronic Report). The PEPPER is made available to hospitals on a quarterly basis and compares your hospital to your state, MAC Jurisdiction and the nation. One-day Stays for Medical and Surgical MS-DRGs are two of the “Target Areas” at risk for improper payments included in this report.

The PEPPER provides the following suggested interventions for high One-day Stays Hospitals:  

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

 

RealTime Medicare Data

Another source that can help assist you is our sister company, RealTime Medicare Data (RTMD). RTMD collects over 800 million Medicare Fee-for-Service paid claims annually from 23 states and the District of Columbia, and allows for searching of over 7 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. To give you a true picture of your “at risk” volume, this report excludes claims with a discharge status for Expired (20), left against medical advice (07), hospice (50 & 51) and /or were transferred to another Acute care facility (02). This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

 

To learn more about the CERT visit AdvanceMed’s CERT Provider Documentation Information website at https://certprovider.admedcorp.com/Home/About.

It’s hard to believe that Thanksgiving is almost two weeks ago now and there are only nineteen shopping days left until Christmas. CMS provided what one could potentially call a gift depending on your point of view when they finally published Change Request (CR) 10865 on November 21st related to the ICD Final Decision Memo published early this year.  

Background

CMS posted a Final Decision Memo on February 15, 2018 for the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4). The Decision Memo finalized what CMS described as “minimal changes” to the ICD NCD from the 2005 reconsideration.

Decision Memo: Summary of the Changes

Patient Criteria

• Add cardiac magnetic resonance imaging (MRI) to the list of diagnostic imaging studies that can evaluate left ventricular ejection fraction (LVEF).
• Note: Prior approved diagnostic imaging studies included echocardiography, radionuclide (nuclear medicine) imaging, and catheter angiography.
• Require patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation to have been on optimal medical therapy (OMT) for at least 3 months.
• Require a patient shared decision making (SDM) interaction prior to ICD implementation for certain patients.
• Note: This includes all patient’s receiving an ICD for primary prevention.

Additional Patient Criteria

• Remove the Class IV heart failure requirement for cardiac resynchronization therapy (CRT)

Exceptions to Waiting Periods

• Add an exception for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
• Add an exception for patients with an existing ICD and qualifying replacement
• End the data collection requirement

November 21, 2018: CMS Releases Change Request (CR) 10865

Chapter 13, section 13.1.1 of the Medicare Program Integrity Manual indicates “the decision outlined in the Coverage Decision Memo will be implemented in a CMS- issued program guidance instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.” The end of September came and went with no program guidance.

CMS finally published CR 10865 on November 21, 2018. This CR includes updates made to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1 for NCD 20.4 Implantable Cardioverter Defibrillators (ICDs).

It is important to note that “a subsequent CR will be released at a later date that contains a Pub.100-04 Claims Processing Manual update with accompanying instructions. Until that time, the Medicare Administrative Contractors (MACs) shall be responsible for implementing NCD 20.4.”

Shared Decision Making, a Deeper Dive

A significant portion of the February Decision Memo was dedicated to detailing public comments received and CMS responses. The following table highlights comments and responses specific to the new SDM criteria.   

In addition to the example SDM tool for ICDs, CMS made note of a website for patients with heart failure designed to lead them through information on ICDs to increase knowledge of their medical condition, the risks and benefits of available treatments and to empower the patient to become more involved in the decision-making process. https://patientdecisionaid.org/icd/.

Considerations Moving Forward

All patients receiving an ICD for primary prevention must be provided SDM. “For these patients…a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)) using an evidence-based decision tool on ICDs prior to initial ICD implantation.  The shared decision making encounter may occur at a separate visit.”

Questions to Consider:

• Who will be the healthcare provider to provide the SDM encounter?
• What tool will you utilize?
• When will this SDM be done? For example, the patient meeting Pacemaker and ICD indications that has been admitted for an AMI, Stent or CABG and placement is advised prior to the patient’s discharge.
• Since the SDM encounter can occur at a separate visit, what will be your process to make sure this information makes it into the medical record for the patient undergoing an ICD placement?

Optimal Medical Therapy, a Deeper Dive

Patients who have severe non-ischemic dilated cardiomyopathy but no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation must have been on optimal medical therapy (OMT) for at least 3 months prior to ICD placement. The following table highlights comments and responses specific to the new OMT criteria. 

‍Questions to Consider:

• Who is the healthcare provider providing optimal medical therapy? Is it a patient’s Internal Medicine Doctor, Cardiologist, Electrophysiologist?
• Similar to SDM, what will be your process to make sure this information makes it into the medical record when the patient receives an ICD?

CR Implementation Date: February 26, 2019

It is up to you to decide if the 2019 implementation date is an early gift from CMS or a potential lump of coal for those that have not begun to prepare for the changes. Either way, MMP will be on the lookout for the subsequent Change Request specific to the Medicare Claims Processing Manual and accompanying instructions and encourages key stakeholders to put processes in place now to meet the new NCD requirements.  

CMS utilizes five criteria to determine whether or not a procedure should be removed from the Inpatient Only (IPO) List and assigned to an Ambulatory Payment Category (APC) group for payment under the OPPS when provided in the hospital outpatient setting. They do not require that all five criteria be met to remove a procedure from the IPO list. The five criteria includes the following: 

1. Most outpatient departments are equipped to provide the services to the Medicare population.
2. The simplest procedure described by the code may be performed in most outpatient departments.
3. The procedure is related to codes that we have already removed from the IPO list.
4. A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis.
5. A determination is made that the procedure can be appropriately and safely performed in an ASC, and is on the list of approved ASC procedures or has been proposed by us for addition to the ASC list.

Procedures Proposed for Removal

CMS proposed removing CPT code 31241 (Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery) and CPT code 01402 (Anesthesia for open or surgical arthroscopic procedures of knee joint; total knee arthroplasty). In general, commenters supported the proposals and CMS adopted as final without modification the removal of both codes from the IPO list for CY 2019.

Procedure Proposed for Adding to the IPO List

CMS proposed to add HCPCS code C9606 to the IPO list.  They “believe that the procedure should be added to the IPO list because this procedure is performed during acute myocardial infarction and it is similar to the procedure described by CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel), which was added to the IPO list for CY 2018 (82 FR 52526).” Commenters supported this proposal and CMS adopted as final without modification the addition of this code to the IPO list for CY 2019.

Solicitation of Comments for Potential Removal of Procedure from IPO List

In the Proposed Rule, CMS sought comments on whether or not CPT code 0266T meets any criteria for removal from the IPO list and the APC assignment and Status Indicator for this code. This code describes the implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed).

Commenters referenced personal experience with this procedure, advancements and safety of the procedure, and patients’ experience after undergoing the procedure. They argued that procedures related to CPT 0266T are “commonly being performed safely in the hospital outpatient department.”

CMS determined that this procedure is similar to another procedure already being performed in numerous hospitals on an outpatient basis and therefor finalized the removal of this code from the CY 2019 IPO list.

Public Requests for Removal of Procedures on the IPO List

Commenters recommend the removal of several procedures not proposed by CMS but were related to other procedures recently removed from the IPO list. “In addition, several commenters recommended the removal of all orthopaedic, arthroplasty, and joint replacement procedures from the IPO list.” Specific procedure codes requested to be removed are listed in the table below.   

CMS agreed with commenters that CPT Code 00670 is appropriate for removal and are removing this procedure. CMS notes “because this spine procedure code is an add-on code, in accordance with the regulations at 42 CFR 419.2(b)(18), under the OPPS, this procedure is packaged with the associated procedure and assigned status indicator “N” (Items and Services Packaged into APC Rates) for CY 2019.”

As for the remaining four laminectomy procedure codes (63265, 63266, 63267, and 63268), CMS plans to continue to review the appropriateness of potential removal from the IPO list for subsequent rulemaking.

CMS does not believe they have sufficient data to support removing all orthopaedic, arthroplasty, and joint replacement procedures from the IPO list. They “encourage stakeholders to submit specific procedures, along with evidence, to support their requests for removal from the IPO list.”

Codes Finalized for “Removal from” or “Addition to” the IPO List for CY 2091

The following table details the finalized changes to the CY 2019 IPO List.

‍Where to Find the CY 2019 Inpatient Only Procedure List

The complete list of procedures codes that Medicare will pay as inpatient only procedures in CY 2019 can be found in Addendum E to the CY 2019 OPPS/ASC final rule at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html.

Ambulatory Surgical Center (ASC) – CMS’s definition of “Surgery” Revised

“Covered surgical procedures in an ASC are surgical procedures that are separately paid under the OPPS, that would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and for which standard medical practice dictates that the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure (“overnight stay”).”

Annually, CMS updates the ASC list and payment rates for covered surgical procedures and covered ancillary services in ASCs. This process includes a review of excluded surgical procedures (including all procedures newly proposed for removal from the OPPS inpatient list), new codes, and codes with revised descriptors, to identify any believed to meet criteria for designation as an ASC covered procedure or covered ancillary service.

Historically, CMS’s definition of a covered surgical procedure has excluded from ASC payment “certain invasive, “surgery-like” procedures, such as cardiac catheterization.” In the CY 2018 OPPS/ASC final rule CMS noted that some stakeholders suggested that certain procedures outside the CPT surgical range but that are similar to surgical procedures currently covered in an ASC setting should be ASC covered surgical procedures. Certain cardiovascular procedures were recommended due to their similarity to currently-covered peripheral endovascular procedures in the surgical code range for surgery and cardiovascular system.

In the CY 2019 OPPS Final Rule, CMS finalized the “proposal to define a surgical procedure under the ASC payment system as any procedure described within the range of Category I CPT codes that the CPT Editorial Panel of the American Medical Association (AMA) defines as “surgery” (CPT codes 10000 through 69999) (72 FR 42478), as well as procedures that are described by Level II HCPCS codes or by Category I CPT codes or by Category III CPT codes that directly crosswalk or are clinically similar to procedures in the CPT surgical range that we have determined are not expected to pose a significant risk to beneficiary safety when performed in an ASC, for which standard medical practice dictates that the beneficiary would not typically be expected to require an overnight stay following the procedure, and are separately paid under the OPPS.”

Finalized Updates to the ASC Covered Surgical Procedures List

With the change in the definition of “surgery” to account for “surgery-like” procedures CMS proposed and finalized the addition of twelve cardiac catheterization procedures to the list for CY 2019. Based on public comments, CMS also finalized the addition of five procedures performed during cardiac catheterization procedures to the list of ASC covered surgical procedures (CPT codes 93566, 93567, 93568, 93571, and 93572). The following table includes the HCPCS code, long code descriptors and payment indicators as displayed in Table 60 of the Final Rule.

‍Resources

CMS-1695-FC: Hospital Outpatient Prospective Payment – Notice of Final Rulemaking with Comment for CY 2019: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Link to CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

In a fit of spring-cleaning this week (well, I guess that would be fall-cleaning technically since it is October), I cleaned out my grandchildren’s toy closet. Those toys beyond repair were trashed and those in good shape but no longer played with I donated. I kept their favorite toys, including those toys that seem timeless even in our current electronic world such as water color paints, building blocks, and magnets. Even as an adult, I am fascinated by the pull of a magnetic field on metal objects. One really big magnet is a Magnetic Resonance Imaging (MRI) machine which has an enormous magnetic pull. This is a cause for concern and extreme caution when a patient is put into an MRI machine. Medicare recently released transmittals expanding coverage of MRI services to patients who have cardiac pacemakers or defibrillators, but only under specific conditions.

MLN Matters Article MM10877 explains that for dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D) according to changes to National Coverage Determination (NCD) 220.2. The MRI must be used according to FDA labeling. For devices that do not have FDA labeling specific to use in an MRI environment, the following conditions must be met:

• MRI field strength is 1.5 Tesla using Normal Operating Mode;
• The implanted pacemaker, ICD, CRT-P, or CRT-D system has no fractured, epicardial, or abandoned leads;
• The facility has implemented a checklist which includes the following:
• patient assessment is performed to identify the presence of an implanted pacemaker, ICD, CRT-P, or CRT-D;
• before the scan benefits and harms of the MRI scan are communicated with the patient or the patient’s delegated decision-maker;
• prior to the MRI scan, the implanted pacemaker, ICD, CRT-P, or CRT-D is interrogated and programmed into the appropriate MRI scanning mode;
• a qualified physician, nurse practitioner, or physician assistant with expertise with implanted pacemakers, ICDs, CRT-Ps, or CRT-Ds must directly supervise the MRI scan as defined in 42 CFR § §410.28 and 410.32;
• patients are observed throughout the MRI scan via visual and voice contact and monitored with equipment to assess vital signs and cardiac rhythm;
• an advanced cardiac life support provider must be present for the duration of the MRI scan;
• a discharge plan that includes before being discharged from the hospital/facility, the patient is evaluated and the implanted pacemaker, ICD, CRT-P, or CRT-D is reinterrogated immediately after the MRI scan to detect and correct any abnormalities that might have developed.

For Medicare patients with implanted PMs, ICDs, CRT-Ps, or CRT-Ds undergoing MRIs both on and off FDA label, providers should report the appropriate MRI code and ICD-10 diagnosis code Z95.0 for cardiac pacemakers and CRT-Ps or code Z95.810 for ICDs and CRT-Ds.

Since the changes to the NCD also include removal of the Coverage with Evidence Development (CED) requirement, the -Q0 and -KX modifiers on claims for MRIs for patients with an implanted pacemaker are no longer required effective April 10, 2018.

These NCD changes expand the benefits of diagnostic MRI studies to Medicare patients with certain cardiac devices. Radiology personnel must still be mindful of potential complications from metallic objects and MRIs. For example, the NCD lists a contraindication for patients with metallic clips on vascular aneurysms. Toy magnets are fun to play with and big magnets have many valuable uses – as long as we remain aware of the dangers.

MEDICARE TRANSMITTALS – RECURRING UPDATES

 Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2019

The January 2019 quarterly release of the edit module for clinical diagnostic laboratory services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10941.pdf

Quarterly Influenza Virus Vaccine Code Update - January 2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4141CP.pdf

2019 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

Updates to edits to allow only those services that are excluded from SNF CB to be paid separately.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10981.pdf

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.125 percent effective October 17, 2018 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R307FM.pdf

OTHER MEDICARE TRANSMITTALS

Implementation of the Award for the Jurisdiction F (J-F) Part A and Part B Medicare Administrative Contractor (JF A/B MAC)

The Jurisdiction JF A/B MAC recompetition procurement was recently awarded to Noridian Healthcare Solutions, LLC (Noridian), the incumbent contractor for this workload.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2143OTN.pdf

Guidance Regarding the Use of Statistical Sampling for Overpayment Estimation

Updates instructions for Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), the Supplemental Medical Review Contractor (SMRC), and Medicare Administrative Contractors (MAC) regarding the use of statistical sampling in their reviews and estimation of overpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R828PI.pdf

Local Coverage Determinations (LCDs)

CMS is updating the Medicare Program Integrity Manual with detailed changes to the Local

Coverage Determination (LCD) process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes

Implements Fiscal Year (FY) 2019 policy changes for the Inpatient Prospective Payment System (IPPS) and LTCH PPS.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10869.pdf

Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates

This MLN Matters Article is intended for organizations enrolled as Medicare Diabetes Prevention Program (MDPP) suppliers billing Medicare Administrative Contractors (MACs) for MDPP services provided to Medicare beneficiaries.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10970.pdf

Medical Review of Diagnostic Laboratory Tests

Clarifies how medical review contractors should review orders for diagnostic laboratory test claims.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R836PI.pdf

MEDICARE SPECIAL EDITION ARTICLES

Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations

Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location based on the information submitted on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18023.pdf

2018-2019 Influenza (Flu) Resources for Health Care Professionals

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18015.pdf

MEDICARE COVERAGE UPDATES

 Magnetic Resonance Imaging (MRI)

Effective for claims with dates of service on and after April 10, 2018, Medicare will allow for MRI coverage for beneficiaries with an Implanted Pacemaker (PM), Implantable Cardioverter Defibrillator (ICD), Cardiac Resynchronization Therapy Pacemaker (CRT-P), or Cardiac Resynchronization Therapy Defibrillator (CRT-D).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10877.pdf

MEDICARE PRESS RELEASES

 2019 Medicare Parts A & B Premiums and Deductibles

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019. The annual deductible for Medicare Part B beneficiaries is $185 in 2019. The Medicare Part A inpatient deductible that beneficiaries will pay when admitted to the hospital is $1,364 in 2019.

https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles

MEDICARE EDUCATIONAL RESOURCES

October 2018 Medicare Quarterly Provider Compliance Newsletter

Assists health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations such as the Office of the Inspector General (OIG).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN8893947.pdf

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

September 2018 Patients Over Paperwork Newsletter

An update on CMS’s ongoing work to reduce administrative burden and improve the customer experience while putting patients first.

https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/POPSeptember2018Newsletter.pdf

What’s the difference between nice and kind? Nice is treating others respectfully while kindness involves a deeper caring for others. A recent television commercial presents that it is related to a particular type of snack bar. If you go for the snack bar analogy, what about healthcare coverage? One might say that Medicare coverage for the elderly is a nice program, and that Medicaid for those with limited income and resources is a kind program. I suppose that makes dual eligibility programs both nice and kind.

Some hospital patients will have both Medicare and Medicaid medical coverage. Certain qualified Medicare beneficiaries (known as dual eligible or QMB patients) meet criteria to get help with their Medicare premiums and cost-sharing. According to CMS’s QMB Program webpage, “In 2016, 7.5 million people (more than one out of eight people with Medicare) were in the QMB program.” Because of this program, providers, including hospitals, must bill the state Medicaid program for the patient’s Medicare deductible and co-pays. Patients in the QMB program are not legally obligated to pay providers for any Medicare cost-sharing, even if Medicaid does not pay the entire amount. The webpage noted above also reports that historically there has been confusion and billing errors related to the QMB program. I can certainly understand – dealing with Medicare rules by themselves is challenging enough – the challenge doubles when there are two government payers. I recommend billers mark the QMB webpage for future reference. It offers numerous resources and information about the QMB program, such as a list of QMB Frequently Asked Questions.

One new question and answer in the QMB FAQs deals with billing limitations and special instructions when an Advance Beneficiary Notice (ABN) is given to a dual eligible patient. An ABN is given to a Medicare patient when the item or service being provided is expected to be denied by Medicare as not reasonable and necessary (medical necessity denial). The ABN notifies patients they will be financially liable for the service and allows them the option to elect to have the service or not. When presenting an ABN to a dually eligible Medicare/Medicaid patient, the provider:

• Directs the patient to select Option 1, which requires a claim be submitted to Medicare for an official decision on payment. (Note: This is the only time a provider may direct a patient as to which option to select.)
• CANNOT require payment from the patient at the time of the service. In fact, the provider cannot bill the patient until the claim is adjudicated by both Medicare and Medicaid.
• Submits a cross-over claim to Medicaid if Medicare denies payment.
• Can shift liability to the patient based on Medicare policy and state laws if the claim is denied by Medicare as not medically necessary and if coverage is denied by Medicaid (or not paid for other reasons).

Dual eligible patients are also liable for Medicare statutorily excluded services if the patient or the services are not covered by Medicaid. Although an ABN is not required to be given for statutorily excluded services, it is a nice courtesy to ensure patients are aware of their potential financial liability. Or maybe even kind. The world certainly needs more niceness and kindness.

There is not a lot of activity on the Medicare Administrative Contractor (MAC) medical review front this month. The various MACs are proceeding at different rates and providing information in different formats concerning the new Targeted Probe and Educate (TPE) program. One of the main aspects of the program is to individualize education and present it to providers one-on-one. This has resulted in different interpretations by the MACs on what information to place on their websites:

Palmetto (JJ and JM), CGS (J15) and Novitas (JH and JL): These MACs have listings of active topics and results of some reviews posted on their websites. Results generally include the major errors and suggestions for avoiding denials. Some of this information is confusing, since results include both numbers of compliant/non-compliant providers and error rates by state, but the suggestions for avoiding errors is helpful information for all providers. I, for one, really appreciate this type of detail on the MAC websites.

First Coast (JN) and WPS (J5 and J8): TPE topics listed on their websites, but no review results yet. WPS does offer a number of articles on documentation guidance for their review topics which is also helpful information for all providers.

NGS (J6 and JK) and Noridian (JE and JF): There is general TPE information on their websites, but no specific review topics have been posted.

This week I would like to focus on WPS’s review topic of Facilities Billing Emergency Room Services CPT Codes 99281-99285. I was surprised to see this TPE topic because there are no national visit guidelines for the selection of a specific ER facility level of care CPT code. For years, many thought CMS would eventually publish such criteria, but they have not. CMS instructs individual hospitals to develop internal criteria for charging E&M levels based on the following guidelines that appeared in the 2008 Outpatient Prospective Payment System (OPPS) Final Rule:

• Reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
• Be based on hospital facility resources, not on physician resources.
• Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
• Meet the HIPAA requirements.
• Only require documentation that is clinically necessary for patient care.
• Not facilitate upcoding or gaming.
• Be written or recorded, well-documented, and provide the basis for selection of a specific code.
• Be applied consistently across patients in the emergency department to which they apply.
• Not change with great frequency.
• Be readily available for MAC review.
• Result in coding decisions that could be verified by other hospital staff, as well as outside sources.

To summarize, the levels should be related to the hospital resources used, be clear and verifiable by outside reviewers, not promote up-coding, be supported by the usual ER documentation, and be consistent.

Also discussed in the 2008 OPPS Final Rule (FR) was the consideration of separately payable services in selecting the ER facility level of care. At one time, assigning your ER level based on procedures for which you also received separate payment was considered “double-dipping” and was discouraged. In the 2008 FR, CMS stated, “In the absence of national visit guidelines, hospitals have the flexibility to determine whether or not to include separately payable services as a proxy to measure hospital resource use that is not associated with those separately payable services. The costs of hospital resource use associated with those separately payable services would be paid through separate OPPS payment for the other services.” The discussion goes on to suggest hospitals contact their local MAC for additional guidance.

Hospitals use different definitions and systems to define their ER visit levels. A number of hospitals use American College of ED Physicians (ACEP) criteria; some use the modified AHA / AHIMA criteria; some hospitals use computer-generated or manually calculated systems based on an intervention point system; other options are patient acuity or time-based. Medicare does not prescribe that a particular system be used as long as the above principles are followed. However your facility chooses to select ER visit facility level codes, how do you and outside reviewers (such as a MAC) evaluate your coding to ensure it is accurate, appropriate, and compliant?

One consideration in evaluating your ER levels is the distribution of the CPT codes. In the 2008 FR, CMS evaluated the use of hospital-specific criteria for ER level selection based on a bell curve for the codes submitted. See a prior Wednesday@One article for more information about the code distribution. CMS stated in that rule, “We would not expect individual hospitals to necessarily experience a normal distribution of visit levels across their claims, although we would expect a normal distribution across all hospitals as currently observed…We understand that, based on different patterns of care, we could expect that a small community hospital might provide a greater percentage of low-level services than high-level services, while an academic medical center or trauma center might provide a greater percentage of high level services than low-level services.” An individual hospital’s ER level distribution does not have to be a bell-curve, but would be expected to be a reasonable graph that fits with the acuity of the facility’s ER patients and services.

Here are some examples of the variation in distribution of ER levels seen in similar types of hospitals. Numbers 1-5 correlate respectively with ER level codes 99281-99285. These volumes were obtained from Medicare data from our sister company RealTime Medicare Data (RTMD). I am not saying any of these distributions are right or wrong – this is something each hospital should evaluate internally. You understand the types of patients coming through your emergency room – practically, does your ER level distribution look appropriate to you?

Along this same line, PEPPER reports (Program for Evaluating Payment Patterns Electronic Report) for short-term acute care hospitals added a new measure related to ED facility levels beginning with the July – September 2017 quarter reports. This Emergency Department Evaluation and Management Visits (ED E&M) measure provides the ratio of Level 5 ED visits to all ED visits reported by a hospital and compares your data to that of other hospitals at your state, MAC jurisdiction and national levels. This will allow you to evaluate if you are reporting a higher or lower percentage of Level 5 ED visits (CPT 99285) than your peers. In some cases, there may be valid reasons for being an outlier, but this is another way to assess the appropriateness of your ED levels. If you cannot think of a reason for being higher or lower than other hospitals, a deeper evaluation of your system for assigning ED levels is warranted. See a prior Wednesday@One article for more information about this PEPPER target.

Think about whether your ER levels correlate with the acuity of a patient’s condition. An ER visit for a minor upper respiratory infection should be a lower visit level than that of a broken bone, which should be less than a possible heart attack. Also, does your internal criteria make sense and flow appropriately from the lowest to the highest levels?

Other considerations for evaluating your ER levels can be found on the WPS website. Hopefully, WPS will publish some results information as they move forward with this review. In the meantime, they have provided some documentation guidance for a successful review of CPT codes 99281-99285. According to their article, documentation should include:

• 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
• The internal guidelines used to determine the HCPCS equivalent CPT code (99281-99285) for the hospital resources being billed (HCPCS to CPT conversion guidelines)

It will be interesting (or possibly frightening if your hospital is targeted) to see how the WPS audit plays out.

• Will WPS deny claims they believe are coded at an inappropriate level or adjust the payment to a code they think is more appropriate?
• Will WPS accept hospitals’ criteria at face value or will they question the appropriateness of the criteria itself?
• Will other MACs follow WPS and audit ER facility levels in the future?
• Some commercial insurers have targeted ER facility levels – will they continue, back off like Anthem did, or will this practice expand?
• And most importantly, how should hospitals prepare for these audits?

My suggestions are to make sure you have clear and reasonable ER facility level of care criteria, that you “feel good” about your ER facility levels overall, documentation clearly supports the levels selected, and you think you could defend your level selections to an outside auditor.

MAC medical review activity since last month is listed below.

For many years, many people (providers, patients, and even Medicare contractors and reviewers) believed that one basis for Medicare coverage of therapy services was an expectation of improvement in the patient’s function. In 2013, a court case settlement known as the Jimmo Settlement Agreement clarified that “the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).” However, this was taking a while to sink in so the case went back to court in 2017 and the court again confirmed there is no improvement standard for therapy services. The 2017 decision resulted in a CMS webpage dedicated to Jimmo including a corrective statement disavowing the improvement standard and further clarification with a listing of frequently asked questions (FAQs) and other resources. There were also national calls and training for contractors making coverage decisions.

It is interesting and amusing to note that all the Medicare “clarifications” insist this is not a policy change, but is consistent with Medicare’s longstanding policy. They do admit however, “the Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”

Section 220 (Coverage of Outpatient Rehabilitative Therapy Services) of Chapter 15 of the Medicare Benefit Policy manual was revised in response to the Jimmo settlement and includes this statement, “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” The manual now specifically includes separate sections for Rehabilitative Services and Maintenance Programs. Rehabilitative therapy addresses recovery or improvement in function with restoration to a previous level of health and well-being when possible. Maintenance programs are to maintain functional status or to prevent or slow further deterioration in function. The key to coverage for both types of services is that they must require the specialized skill, knowledge and judgment of a qualified therapist and meet all other Medicare therapy coverage requirements.

Last month, Noridian JE published a new coverage article for Maintenance Programs effective August 31, 2018 that is again a clarification regarding outpatient therapy services and maintenance programs. The article states, “Maintenance programs are developed to:

1. Maximize the patient's rehabilitation potential;
2. Assure patient safety;
3. Train the patient, family member and/or unskilled staff in home maintenance activities;
4. Prevent further decline in the patient's condition.”

The article also makes it clear that once services in a maintenance program can be safely and effectively furnished by non-skilled personnel without the supervision of a qualified professional, the need for coverage of skilled therapy is over. At that point, the patient should be discharged from therapy.

The Jimmo FAQs discuss that specific documentation is not an element of coverage, but documentation is the means to support that skilled services were indeed necessary. The Noridian article requires clear documentation of:

• Focus on establishing or revising an individualized maintenance program,
• The change in the patient’s status/condition that justifies skilled intervention, and
• Services requiring a skilled level of care.

Documentation should include specific goals for the patient that make it clear what benefit to the patient is expected from the therapy, especially since it is not an improvement in function. Documentation should explain why a therapist is needed – this may relate to specifics of the patient’s condition or patient safety that could not be addressed by non-skilled personnel. When documenting, therapists should think about the story they want to tell about their patient’s limitations, that patient’s need for their specific skills, and the benefit those skills will bring to the patient.

My elderly father was a perfect candidate for this type of therapy services. He has multiple conditions that limit his mobility and function for which a maintenance exercise program would benefit him. Because of his conditions, the skills of a therapist were required to establish a program and to initially ensure proper performance of the program. Once the program was established and taught, my dad and his caregiver were able to continue the program safely and effectively without the supervision of the therapist. I did not see the home health therapist’s documentation, but hopefully it explained the goals were to establish a home exercise program to prevent or slow further decline in function and mobility. The skills of a therapist were required because of multiple conditions affecting strength, function, and cognition; a high fall risk; and the need for specific strengthening exercises performed properly. Patient would be discharged once he could safely and properly perform the program alone or with non-skilled assistance.

To clarify (yet again), therapy services can be covered by Medicare even if there is no expectation of improvement in the patient’s function. The services must require the skills of a therapist to safely and effectively develop and/or perform the maintenance program. Once the patient or non-skilled personnel can perform the maintenance program, the services are no longer covered.

A positive outlook affects our health, happiness, and even longevity. So, on the positive side, there are some advantages to getting older. Grandchildren, clearer priorities, not caring so much what others think, and retirement – to name a few. Realistically, aging also brings a whole new set of challenges. To maintain a positive position however, I will not enumerate those other than the one relevant to the subject of this article. As people age, they are very likely to develop cataracts, a clouding of the lens in the eye that affects vision. The good news is that cataracts are easily correctable and Medicare covers cataract surgery as well as the replacement intraocular lens. Even more good news, is that although Medicare does not normally cover eyeglasses or contact lenses, they cover one pair furnished subsequent to each cataract surgery with insertion of intraocular lens.

As with all services, but especially those that are high volume such as cataract surgeries, Medicare wants to ensure they are appropriately paying for these services. This means the provision of the services and the medical record documentation must meet Medicare coverage guidelines. All four of the Recovery Auditors (RACs) and CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, are currently performing medical reviews for cataract surgery. In fact, the RACs have several issues related to cataract surgery – automated reviews to prevent billing of more than one cataract surgery per eye in a lifetime and to prevent excessive units, and a complex review of records to ensure Cataract Surgery meets Medicare coverage criteria, applicable coding guidelines, and/or is medically reasonable and necessary. The CGS targeted probe and educate (TPE) review also examines records to make sure Medicare guidelines are met. CGS has a Local Coverage Determination, as do several other MACs, describing the specific indications and limitations of coverage for the procedure.

As stated above, there are RAC review issues related to limits and excessive units.  Cataract removal can only occur once per eye during a lifetime. The RACs are looking for overpayments from providers who have billed more than one unit of cataract removal for the same eye.  Also, cataract removal cannot be performed more than once on the same eye on the same date of service. The RACs are identifying overpayments where providers have billed excessive units. This is usually the result of reporting more than one of the cataract CPT codes for the same surgery. As explained in Chapter 8 of the National Correct Coding Initiative manual, “CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another. Only one code from this CPT code range may be reported for an eye.”

Both the RACs and CGS are performing complex reviews (review of the medical record) for compliance with Medicare regulations and medical necessity of services. An example of the requirements for coverage of cataract surgery as detailed in an LCD are:

“The patient has impairment of visual function due to cataract(s) and the following criteria are met and clearly documented:

• Decreased ability to carry out activities of daily living including (but not limited to): reading, watching television, driving, or meeting occupational or vocational expectations; and
• The patient has a best corrected visual acuity of 20/50 or worse at distant or near; or additional testing shows one of the following:
• Consensual light testing decreases visual acuity by two lines, or
• Glare testing decreases visual acuity by two lines
• The patient has determined that he/she is no longer able to function adequately with the current visual function; and
• Other eye disease(s) including, but not limited to macular degeneration or diabetic retinopathy, have been ruled out as the primary cause of decreased visual function; and
• Significant improvement in visual function can be expected as a result of cataract extraction; and
• The patient has been educated about the risks and benefits of cataract surgery and the alternative(s) to surgery (e.g., avoidance of glare, optimal eyeglass prescription, etc.); and
• The patient has undergone an appropriate preoperative ophthalmologic evaluation that generally includes a comprehensive ophthalmologic exam and ophthalmic biometry.”

(from the CGS LCD L33594 Cataract Extraction)

CGS actually began auditing for cataract surgery in 2014 with a probe review. There were significant denial rates from the probe review so CGS progressed to targeted reviews over the next few years and then continued the review of cataract procedures into their TPE process. Initial denial rates from the probe reviews were greater than 85%, but as the providers in the CGS jurisdiction have learned the Medicare requirements and necessary supporting documentation, the denial rates have fallen to around 20% in the recent Round One TPE review results.

Although decreasing in numbers, the major denial reasons have remained basically the same. Most denials are due to missing documentation of:

• Biometry results
• Visual acuity exams
• Description of impairment of ADLs, and
• Documentation to support that cataracts are the primary cause of the patient’s decreased visual acuity.

Hospital providers need to remember that often the documentation that best supports the medical necessity of cataract removal is found in the ophthalmologist’s office notes. Copies of these notes should be included in the documentation submitted when responding to an additional documentation request (ADR) for the cataract surgery review.

One last thing to note is that Medicare only covers the insertion of a conventional intraocular lens (IOL). Special IOLs to correct presbyopia (P-C IOLs) and astigmatism (A-C IOLs) are not covered by Medicare. If a Medicare patient elects to receive either of these special lens, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting or astigmatism-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. Medicare guidance states:

• Payment for the IOL following removal of a cataract is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital or the ASC for an IOL inserted following removal of a cataract.
• For a P-C or A-C IOL inserted following removal of a cataract, the hospital or ASC will bill for removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional or special IOL is inserted. The hospital or ASC shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
• The facility and physician cannot require a patient to obtain a special lens and must only perform implantation of special lens at the specific request of the patient.
• Prior to the procedure to remove a cataractous lens and insert a P-C or A-C IOL, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment, or other subsequent treatments related to the presbyopia or astigmatism-correcting functionality of the IOL. CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to identify clearly the non-payable aspects of a special IOL insertion.
• In determining the beneficiary’s liability, the facility and physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P-C IOL or A-C IOL that exceeds the work and resources attributable to insertion of a conventional IOL.

Providers need to be aware of Medicare’s requirements for cataract removal and IOL implantation to ensure appropriate performance, documentation and billing for these services. A great Medicare resource to help with this understanding is the Medicare Vision Services Fact Sheet. For more information about Medicare cataract services, including the annual Medicare treatment costs for select states, see the infographic on Cataracts from our sister company, Realtime Medicare Data (RTMD), in this week’s Wednesday@One.

Enjoy the vision of youth while you can, but when things get cloudy, it may be time for some cataract surgery.

I did not realize the extent of peripheral nerve stimulation procedures until I started reading all of the related Medicare coverage policies – there was so much information, it almost got on my last nerve. All peripheral nerve stimulation is not the same. This is evidenced by several new coverage, or more accurately, non-coverage articles this month from the Medicare Administrative Contractors (MACs). Below is a listing of the MAC local coverage determinations (LCDs) and coverage articles that address peripheral nerve stimulation. Some of the policies listed may have a future effective date due to recent changes in coverage. You can easily view these policies by going to the Medicare Coverage Database and entering the Policy number in the Quick Search ‘Document ID’ field. 

There are different indications for different types of peripheral nerve stimulation.

Peripheral Nerve Stimulation (PNS) for Chronic Pain

Quoting from the Noridian JE Peripheral Nerve Stimulation article:

“Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interventional treatments….PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the known anatomic location of a peripheral nerve.”

Coverage of PNS requires the patients have all of the following:

• Documented chronic and severe pain for at least 3 months,
• Documented failure of less invasive treatment modalities and medications,
• Lack of surgical contraindications including infections and medical risks,
• Appropriate proper patient education, discussion and disclosure of risks and benefits,
• No active substance abuse issues,
• Formal psychological screening by a mental health professional, and
• Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent implantation.

CPT codes for PNS addressed by the Noridian policy include: 61885, 64550, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, and 64595. Also see National Coverage Determination (NCD) 160.7 for other coverage information on Implanted Peripheral Nerve Stimulators.

Peripheral Nerve Stimulation for Urinary and/or Fecal Incontinence

Sacral nerve stimulation coverage for urinary and fecal incontinence is addressed by several MAC policies. Covered indications include:

• Urinary urge incontinence.
• Urgency-frequency syndrome.
• Urinary retention.
• Fecal incontinence.

There are limitations to coverage such as refractory or documented failure or intolerance to conventional therapy; only after a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms; and the exclusion of certain causes of the incontinence. Limitations vary slightly per policy so providers should read carefully the policy which applies to their MAC jurisdiction. CPT codes 64561, 64581, and sometimes 64585 or 64590 are addressed by the Sacral nerve stimulation policies.

Posterior tibial nerve stimulation (CPT code 64566) is generally covered in a physician office setting for urinary urgency, urinary frequency, and urge incontinence. Patients receive one 30-minute weekly treatment in the office for 12 weeks, but most MACs allow treatments for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms. Most MACs require documentation of failed standard anticholinergic drug therapy or intolerance to the anticholinergic drug therapy. Again, requirements vary from MAC to MAC, so providers need to be aware of their MAC’s requirements.

Non-Covered Peripheral Nerve Stimulation

As stated at the beginning of this article, new coverage articles this month detail the correct coding and non-coverage of certain types of peripheral nerve stimulation. Remember, coverage for services not addressed by a national coverage determination or Medicare manuals is determined by the individual MACs. Not all MACs make the same coverage determinations. If coverage of a particular service is not addressed by an LCD or coverage article for your MAC, you will need to contact your MAC to determine if they cover the service or not.

The WPS article for Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) explains that “PENS and PNT therapies combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS)…. PENS is performed with a few needle electrodes (not implanted) while PNT uses very fine needle-like electrode arrays (not implanted) that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.”

Per the WPS article, therapeutic use of these services is non-covered and should be reported with CPT code 64999 and the respective procedure name. They should not be reported with:

• CPT codes 64553-64566 as these apply to percutaneous implantation of neurostimulator electrodes and not appropriate, as PENS and PNT use percutaneously inserted needles, OR
• CPT code 64590 as this applies to insertion or replacement of neurostimulator pulse generator or receiver and not appropriate, as PENS and PNT stimulation devices are not implanted, OR
• HCPCS code range L8680-L8689.
• It would also not be appropriate for providers to use any neurostimulator pulse generator or receiver implantation CPT codes such as CPT 63663, 63685, 63688, 64585, 64590.

Specifically, Biowave’s Deepwave percutaneous neuromodulation pain therapy system is one PENS system that is non-covered. (See NCD 160.7.1.B for discussion of coverage of PENS for diagnostic purposes.)

The two new Noridian coverage articles clarify that Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) is not covered for any condition. PNFS refers to use of a lead placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This service should also be billed with the unlisted CPT code 64999 for both the trial and permanent insertion of the electrode array.

One last peripheral nerve stimulation service for which Novitas JH and JL has a non-coverage policy is Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device).  As with the other non-covered peripheral nerve stimulation procedures, Novitas reports that auricular peripheral nerve stimulation has been inappropriately billed to Medicare using an incorrect CPT code (CPT 64555).  Per the Novitas policy, “The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system….The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.

The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.

While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.” The WPS policy that addresses PENS and PNT also states that any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

With all the different types of peripheral nerve stimulation and the different coverage requirements, make sure your facility is assigning the correct code and that documentation supports the coverage indications. Denied claims can get on your last nerve.