Knowledge Base Category -

I regret the paper pages of newspapers and books are becoming obsolete in today’s digital age. There was some comfort in holding the pages, smelling the print, and hearing the sound of crinkling paper as you read. Newsprint was important – movies set in the 20’s and 30’s often show the newsboy running through the streets shouting, “Special edition! Special edition! Read all about it!” Now we receive most of our “printed” news on-line or on our smart phones. But thanks to Medicare there are still “special editions.” Most of CMS’s MLN Matters Articles are based on recent transmittals (change request) – these are named based on the change request number beginning with the alpha characters “MM.” CMS also publishes Special Edition (SE) articles, generally to clarify existing regulations.

Two recent SE articles address prolonged drug infusions using an external pump and coverage of substance abuse services.

Prolonged Drug Infusions Via External Pump

On April 25, 2016, CMS released MLN Matters Article SE1609 clarifying Medicare’s policy for prolonged drug and biological infusions started incident to a physician's service using an external pump. There are times when hospitals or physicians’ offices may start an infusion using an external pump in the hospital outpatient or office setting of a drug they purchased, then send the patient home for a portion of the infusion and have the patient return to the clinic/office at the end of the infusion.   In these situations, the drug or biological and the drug/biological administration are billable to the Medicare Administrative Contractor (MAC). Also, payment for the external pump is included in the drug administration payment. The external pump may not be billed separately as Durable Medical Equipment to the DME MAC.   The MAC may direct use of a CPT or HCPCS code for the drug administration service that also accounts for the cost of external pump. This may be an unlisted code if no specific CPT or HCPCS code exists.

Medicare Coverage of Substance Abuse Services

There is not a distinct benefit category for substance abuse services but Medicare will cover medically necessary services for substance abuse as explained in the April 28th MLN Matters Article SE1604. The almost epidemic national opioid abuse make these services extremely important for Medicare beneficiaries. Medicare covers:

• Inpatient Treatment
• Medically necessary inpatient services, associated professional services, and medications (bundled into the inpatient payment).
• Outpatient Treatment
• Professional services such as counseling by an enrolled licensed clinical social worker, psychologist, or psychiatrist.
• Incident-to services of auxiliary personnel in certain settings (such as an outpatient hospital)
• Medications used in an outpatient setting that are not usually self-administered may be covered under Part B if they meet all Part B requirements.
• Note that substance abuse treatment facilities are not recognized by Medicare as an independent provider type. There is no integrated payment for the bundle of services these providers provide (either directly, or incident to a physician’s service).
• Partial Hospitalization Programs (PHP)
• Available in hospital outpatient department or Medicare certified Community Mental Health Center (CMHCs)
• Includes psychotherapy, occupational therapy, some activity therapies, family counseling, patient education/training, diagnostic services, and covered Part B medications.
• Supplier Services
• Suppliers such as physicians (medical doctor or doctor of osteopathy), clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives may furnish substance abuse treatment services providing the services are reasonable and necessary and fall under their State scope of practice.
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
• Early intervention strategies for individuals with nondependent substance use prior to the need for more extensive or specialized treatment
• Easily used in primary care settings
• Consists of 1) Structured Assessment, 2) Brief Intervention, and 3) Referral to Treatment
• See Medicare's fact sheet, “Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services”
• Drugs Used to Treat Opioid Dependence
• Part D drugs medically necessary for the treatment of opioid dependence
• Medicare also covers laboratory drug testing services when necessary

Providers need to watch for Medicare MLN Matters Special Edition articles in order to stay informed about the latest changes to CMS Programs. Read all about it!

When I was first introduced to the concept of Case Mix Index (CMI) in the late 90’s, documentation in the medical record was handwritten. And I can remember understanding that CMI depends on the physician’s pen.

Flash forward to 2016 and the electronic health record. It is now fair to say that it all begins with the click of a button. I am not sure if it is due to the fact that I wrote my college term papers on a Brother Typewriter or from auditing electronic records remotely, the “click of the button,” has not improved the telling of the patient’s story which is at the heart of what needs to happen.

In fact, it seems to me that it is harder than ever to find proof that your “patients are sicker.” Understanding CMI is a good way to answer the question of “how do I know my patients are sicker.” However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:

In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.  

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.  

Assigning a DRG:

Principal Diagnosis:

The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):

These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication.  When the DRG system transitioned to MS-DRGs the comorbidities and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities (CC) are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting.
• For example: A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications (CC) are those conditions that occur during the inpatient hospitalization.
  For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions. 
• Major Comorbidities and Complications (MCCs): DRGs with MCCs reflect the highest level of severity. For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.
  

As many times as we have heard it said it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record.   Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.  

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated that “we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG.

Case Mix Index (CMI) is defined by CMS as representing “the average diagnosis-related group (DRG) relative weight for the hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.”

GPA Example:

(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA

30 ÷ 10 = 3.0 GPA

Case Mix Index Example A:

Formula for Case Mix Index: Sum of Relative Weights ÷ Total Number of DRGs Coded = CMIExample A CMI: 3.7688 ÷ 4 = 0.9422 Case Mix IndexExample B: The Potential Impact Physician Queries can have on DRG Assignment

Example B CMI: 4.5823 ÷ 4 = 1.1456 Case Mix Index

“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.” (Source: Optum 360 2016 DRG Expert)

Challenges for Hospitals:

Understanding what can make your hospitals CMI fluctuate?

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.
• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.  
• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

In 2013, the American Health Information Management Association (AHIMA) published the practice brief Guidelines for Achieving a Compliant Query Practice. The AHIMA brief states that “A query is a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

ICD-10-CM/PCS and CMI

We are now six months post ICD-10-CM/PCS implementation. Has this transition impacted CMI? To answer this question I analyzed paid claims data from our sister company RealTime Medicare Data (RTMD). The following tables compare CMI data from October through December of 2014 compared to 2015.

Figure 1: Alabama CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 2: South Carolina CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 3: Texas CMI Compare Pre and Post ICD-10-CM/PCS Implementation

So far, it appears that the transition has not had a negative impact on CMI but it is still early and MMP, Inc. will continue to keep an eye on the trends and report key findings to our readers. In the meantime, remember that a successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.

“I don’t know why my brain has kept all the words to the Gilligan’s Island theme song and has deleted everything about triangles.”- Jeff Foxworthy

This month CMS appears to have stuck with their “theme” from past transmittals as a lot of the newly released transmittals are periodic updates of different CMS edits and systems. In contrast, this month, we are broadening our “theme” of bringing you monthly transmittal updates by making this an “all inclusive” Medicare Updates article (i.e., Transmittals, Conditions of Participation, Code of Federal Regulations).

Transmittals

April 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.1

• Transmittal 3477, Change Request 9553, MLN Matters MM9553
• Issued March 22, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries
• Updates Chapter 4, section 40.1; Medicare Claims Processing Manual

Summary of Changes: This notification providers the Integrated OCE instructions and specifications for the Integrated OCE that will be effective April 1, 2016.

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.2, Effective July 1, 2016

• Transmittal 3482, Change Request 9516, MLN Matters MM9516
• Issued March 18, 2016; Effective: July 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries
• Updates Chapter 23, section 20.9; Medicare Claims Processing Manual

Summary of Changes: This is the normal update to the CCI procedure to procedure edits.

April 2016 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal 3478, Change Request 9557, MLN Matters MM9577
• Issued March 11, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects Ambulatory Surgical Centers (ASCs) who submit claims to MACs
• Updates Chapter 14, section 10; Medicare Claims Processing Manual

Summary of Changes: This Recurring Update Notification describes changes to billing instructions for various payment policies implemented in the April 2016 ASC payment system update. As appropriate, this notification also includes updates to the Healthcare Common Procedure Coding System (HCPCS).

Telehealth Services

• Transmittal 221, Change Request 9428, MLN Matters MM9428
• Issued March 11, 2016; Effective: January 1, 2015; Implementation date April 11, 2016
• Affects providers submitting claims to MACs for telehealth services provided to Medicare beneficiaries
• Updates telehealth language has been removed from the Medicare Benefit Policy Manual, Chapter 15, Section 270 and a reference added in text to see the Medicare Claims Processing Manual, Chapter 12, section 190 for further information regarding telehealth services (see related Transmittal 3476)

Summary of Changes: The purpose of this change request is to display the list of telehealth services that were once available through the manual updates to now be displayed via a web-link going forward. CMS is also adding CRNAs to the list of Medicare practitioners who may bill for covered telehealth services.

July Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

• Transmittal 3473, Change Request 9561, MLN Matters MM9561
• Issued March 4, 2016; Effective: January 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries during a SNF stay.
• Changes to CPT/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in Chapter 6, section 20.6; Medicare Claims Processing Manual

Summary: This notification provides updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

April 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3471, Change Request 9549, MLN Matters MM9549
• Issued February 26, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to MACs for services provided to Medicare beneficiaries paid under the OPPS.
• Updates Chapter 4, section 50.8; Medicare Claims Processing Manual

Summary: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the April 2016 OPPS update.

Coding Revisions to National Coverage Determinations

• Transmittal 1630, Change Request 9540
• Issued February 26, 2016; Effective: July 1, 2016; Implementation date July 5, 2016

Summary of Changes: This is the 6th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. Some are the result of revisions required to other NCD-related CRs released separately.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.

Conditions of Participation (CoPs)    

Advance Copy – Interpretive Guidelines for the Organ Transplant CoPs at 42 Code of Federal Regulations (CFR) §§ 482.68 through 482.104

• Memo # 16-10-Transplant
• Posting Date March 11, 2016

Summary: CMS has updated the Organ Transplant Interpretive Guidelines to incorporate previously-published changes, clarify certain areas, and address feedback received based on previously-released drafts. New Appendix X Interpretive Guidelines supersede all previous versions and will be published in a new Appendix X of the State Operations Manual (SOM).

The month of March is National Nutrition Month and March 9, 2016 was Registered Dietitian Nutritionist Day.   According to the Academy of Nutrition and Dietetics website - “As the nation’s food and nutrition experts, registered dietitian nutritionists are committed to improving the health of their patients and community.” We at MMP, Inc. would like to acknowledge dietitians, nutritionists, and all those who work in the field of nutrition and thank them for their commitment to helping hospital patients. We also want to take this opportunity to look at some guidelines and information related to hospital dietitian services allowed and covered by Medicare.

Ordering Therapeutic Diets

Several years ago, a deficiency report released by CMS identified 147 deficiencies for hospitals related to dietary standards. In response to these deficiencies and to minimize regulatory requirements for hospitals, CMS revised the Hospital Conditions of Participation at section 482.28(b)(2) effective July 11, 2014 as follows:

§482.28(b)(2) -All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

The final rule can be read at Federal Register Final Rule May 12, 2014

The revision allows registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner, if allowed by State law and hospital privileging.

CMS made the following comments related to this change:

“[T]he addition of ordering privileges enhances the ability that RDNs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”

“We believe that the greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed will allow them to meet the needs of their patients most efficiently and effectively.”

The problem many hospitals may face with the revised rule relates to State law. Another

link from the Academy of Nutrition and Dietetics website shows the status of State laws for allowing therapeutic diet orders by dietitians, including a color-coded map. Therefore hospitals and dietitians must be familiar with the laws for their particular State before seeking hospital privileging for RDNs to order patient diets. For example, Alabama State law states in section 420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients." The Academy of Nutrition and Dietetics will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Medical Nutrition Therapy (MNT) Services

Medicare covers medical nutrition therapy (MNT) upon physician referral for beneficiaries with diabetes or renal disease when furnished by a registered dietitian or nutrition professional meeting certain requirements. Basic coverage includes initial assessment visit, follow-up visits for interventions, and reassessments within the year for a total of 3 hours for the first calendar year of a diagnosis of diabetes or renal disease and 2 hours for subsequent years for a renal disease diagnosis.

Important points about MNT services include:

• The treating physician must make a referral and indicate a diagnosis of diabetes or renal disease.
• Renal disease means chronic renal insufficiency (not severe enough to require dialysis or a transplant; GFR of 13-50) or successful renal transplant within the last 36 months.
• Diabetes Self Management Training (DSMT) and MNT can be provided within the same time period, but not on the same day.
• The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician.
• Additional covered hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary.
• Hours may not be carried over into the following calendar year.
• MNT can be provided individually (one-to-one) or in a group setting.

Dietitians and nutritionists must meet the profession standards as described in Section 300.3 of the Medicare Claims Processing Manual, Chapter 4 and be enrolled as a provider in the Medicare program.

The following codes can be paid if submitted by a registered dietitian or nutrition professional who meets the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. Payment is only made for MNT services actually attended by the beneficiary and documented by the provider. MNT is not covered for inpatients of a hospital or skilled nursing facility.

• 97802 – MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (only for the initial visit)
• 97803 - Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
• 97804 - Group (2 or more individual(s)), each 30 minutes
• G0270 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
• G0271 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (2 or more individuals), each 30 minutes

So here’s to eating right for everyone, but especially hospital patients, diabetic patients, and patients with renal disease. The knowledgeable advice and direction of a dietitian/nutritionist can make a critical difference.

“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”- Mark Twain

On January 26th, 2015 Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” This was the first time that CMS had set the following explicit goals for Alternative Payment Models (APMs) and Value Based Payment goals.

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

On March 3, 2016 CMS announced in a Fact Sheet that it estimates that the first target of 30 percent of Medicare payments being tied to APMs has been met 11 months ahead of schedule. CMS indicates that “when it comes to improving the way providers are paid, we aim to reward value and care coordination – rather than volume and care duplication.”

Alternative Payment Models by the Numbers

• $411 million is the amount that Medicare Accountable Care Organizations (ACOs) saved the program in 2014 alone through markedly improved quality and patient experience over previous years.
• $3,000 saved per Medicare beneficiary on average is what was saved in just one year through the Independence at Home Demonstration.
• 17% is the reduction from 2010 to 2014 in the number of hospital acquired conditions (HACs). This represents over 87,000 lives saved and $20 billion in cost savings.
• 565,000 is the estimated number of readmissions prevented across all conditions between April 2010 and May 2015.
• Medicare spent $315.9 billion less on personal healthcare expenses between 2009 and 2013 than what would have been spent if the 2000-2008 average growth rate had continued through 2013.

Health Care Payment Learning and Action Network

CMS created the Health Care Payment Learning and Action Network (LAN) March of 2015 “to help align the important work being done across the private, public, and non-profit sectors.”

CMS notes that this network has accelerated the transition to APMs by “fostering collaboration between Department of Health and Human Services (HHS), private payers, large employers, providers, consumers, and state and federal partners.”

Ready or not, the shift in payment is happening. To learn more about LAN you can visit the LAN web page at the CMS Innovation Center as well as the LAN website where you can join the network, view their Work Products, participate in webinars and sign up for the LAN e-newsletter.

“Mortality rates from sepsis are higher than heart attack, stroke, or trauma. Sepsis needs to be viewed with the same urgency as these other life-threatening conditions because we know early treatment can decrease mortality.”- Craig M. Coopersmith, MD, FCCM, Task Force Member and Immediate Past President of the Society for Critical Care Medicine (SCCM)

On February 22, 2016 the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was released at SCCM’s 45th Critical Care Congress. The new recommendations are the result of extensive efforts by a Task Force of 19 leaders in the field of sepsis that was convened by the SCCM and the European Society of Intensive Care Medicine (ESICM). According to the SCCM announcement “the group’s recommendations have been endorsed by more than 30 medical societies from six continents, spanning disciplines from critical care and emergency medicine to infectious disease and family practice.”

Sepsis-3 Definitions

The Sepsis-3 definitions were published in the February 2016 issue of the Journal of American Medical Association (JAMA). “The task force recommended that its report be designated “Sepsis-3,” recognizing the two iterations to define sepsis (1991 and 2001) and signaling the need for future study.”  

Sepsis is now defined as “life threatening organ dysfunction due to a dysregulated host in response to infection.”

SOFA (Sequential [Sepsis-related] Organ Failure Assessment) is a tool to be used to clinically characterize the septic patient.

qSOFA (quick Sequential [Sepsis-Related] Organ Failure Assessment) is a new diagnostic tool that clinicians can conduct for patients outside a hospital, in an Emergency Department or General Hospital floor setting to identify patients at risk for sepsis. The three warning signs to assess for are:

• An alteration in mental status,
• A decrease in systolic blood pressure of less than 100mm Hg; and
• A respiration rate greater than 22 breaths/min.

Two or more of the warning signs increases the risk of a hospitalized patient having a longer length of stay in an ICU or to die in the hospital.

The task force stresses that SOFA and qSOFA are not intended to be used as a “stand alone definition of sepsis.”

Septic Shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.” The task force identified the following two new criteria for diagnosing septic shock:

• “Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg;” and
• “Blood lactate level ≥2 mmol/L despite adequate volume resuscitation.”

Sepsis (lay definition) the recently published definition that “sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues,” was endorsed by the task force as it is consistent with the new Sepsis-3 definition.

Severe Sepsis was deemed “redundant” by the task force, “as sepsis has a mortality rate of 10 percent or higher, making the condition already severe.”

Systemic Inflammatory Response Syndrome (SIRS) “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”

While SIRS due to a localized infection can no longer be coded as sepsis in ICD-10, Coding and CDI Professionals need to be mindful that at this time the code set definitions of sepsis and severe sepsis remain the same.

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

Medicare transmittals from February include four transmittals based on updates to National Coverage Determinations (NCDs). As a reminder, the NCD process is described in the Medicare Program Integrity Manual, chapter 13.

National Coverage Determinations (NCDs) are developed by CMS and outline the conditions for which an item or service is considered to be covered (or not covered) by Medicare nationally. Initially a decision memorandum is posted on the CMS Web site that describes the clinical position which CMS intends to implement. CMS implements the coverage decision through transmittals generally within 180 days of the end of the calendar quarter in which the memo was posted. Implementation often includes both an update to the NCD manual and the Claims Processing Manual to provide claims processing instructions related to the new coverage requirements.

Such is the case for the February updates with a new NCD for human Papillomavirus (HPV) and a revision to the NCD for Human Immunodeficiency Virus (HIV).

February 2016 Transmittals

Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing – National Coverage Determination (NCD)

• Numbers:Transmittal R189NCD, Transmittal R3460CP, Change Request 9434,MLN Matters MM9434
• Dates:Issued: February 5, 2016; Effective: July 9, 2015; MLN: February 18,2016;   Implementation: January 3, 2017
• Affects: Physicians and other providers who submit claims to Medicare Administrative Contractors
• Updates: National Coverage Determinations Manual, Chapter 1, Section 210.2.1; Medicare Claims Processing Manual, Chapter 18, Sections 30.2.1, 30.5, 30.6, 30.7, 30.8, and 30.9

Summary of Changes: The purpose of this Change Request (CR) is that CMS has determined that for dates of service on or after effective July 9, 2015, evidence is sufficient to add HPV testing under specified conditions.

Screening for the Human Immunodeficiency Virus (HIV) Infection

• Numbers: Transmittal R190NCD; Transmittal R3461CP, Change Request 9403, MLN Matters MM9403
• Dates: Issued: February 5, 2016; Effective: April 13, 2015; MLN: February 17, 2016; Implementation: January 3, 2017
• Affects: Physicians, other providers, and suppliers who submit claims to Medicare Administrative Contractors
• Updates: National Coverage Determinations Manual, Chapter 1, Section 210.7; Medicare Claims Processing Manual, Chapter 18, Sections 130.1, 130.2, 130.3, 130.4, 130.5 and 130.6

Summary of Changes: The purpose of this CR is to inform MACs that CMS has determined that the evidence is adequate to conclude that screening of HIV infection for all individuals between the ages of 15-65 years is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled in Part B.

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”- William A. Foster

The Office of Inspector General (OIG) began releasing Hospital Medicare Compliance Review (Compliance Reviews) Reports in early 2011. In Fiscal Year (FY) 2012 Compliance Reviews became part of the OIG’s Work Plan. Although the name of the project may have changed since 2012, Compliance Reviews remain a part of the Work Plan in FY 2016.

FY 2012 OIG Work Plan Project

• Medicare Inpatient and Outpatient Payments to Acute Care Hospitals (New)

We will review Medicare payments to hospitals to determine compliance with selected billing requirements. We will use the results of these reviews to recommend recovery of overpayments and identify providers that routinely submit improper claims. Prior OIG audits, investigations, and inspections have identified areas that are at risk for noncompliance with Medicare billing requirements. Based on computer matching and data mining techniques, we will select hospitals for focused reviews of claims that may be at risk for overpayments. Using the same data analysis techniques, we will identify hospitals that broadly rank as least risky across compliance areas and those that broadly rank as most risky. We will then review the hospitals’ policies and procedures to compare the compliance practices of these two groups of hospitals. We will also survey or interview hospitals’ leadership and compliance officers to provide contextual information related to hospitals’ compliance programs. (OAS; W-00-11-35538; various reviews; expected issue date: FY 2012; work in progress; and OEI; 00-00-00000; expected issue date: FY 2012; new start)

FY 2016 OIG Work Plan Project

• Selected inpatient and outpatient billing requirements

We will review Medicare payments to acute care hospitals to determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments. Prior OIG audits, investigations, and inspections have identified areas at risk for noncompliance with Medicare billing requirements. Our review will focus on those hospitals with claims that may be at risk for overpayments. (OAS; W-00-12-35538; W-00-13-35538; W-00-14-35538; W-00-15-35538; various reviews; expected issue date: FY 2016)

Compliance Reviews by the Numbers

As of February 2016, the OIG has released over 140 Compliance Reviews. According to these reviews, collectively this group of hospitals was overpaid $76,447,380.00. Adding insult to injury, in 2013 the OIG began extrapolating their findings. To date, 21 hospitals have been subject to extrapolation, including the most recent hospital Compliance Review released on February 3, 2016 for the University of Minnesota Medical Center for 2012 and 2013.

Extrapolating overpayments has exponentially increased the amount hospitals are to refund to the Contractor. Collectively, the $7,780,049.00 overpaid by 21 hospitals was extrapolated to $66,495,541.00. When you add this subset of hospitals to the overall amounts, the $76,447,380.00 that all hospitals were overpaid increased to $135,262,862.00 to be refunded to the Contractor. Now let’s take a closer look at the most recent Report released.

Medicare Compliance Review of University of Minnesota Medical Center for 2012 and 2013

The objective of this review was to “determine whether University of Minnesota Medical Center (the Hospital) complied with Medicare requirements for billing inpatient and outpatient services on selected types of claims.”

Audit Scope

This Compliance Review covered $24,360,864 in Medicare payments to the hospital for 3,351 claims potentially at risk for billing errors. The OIG selected a stratified random sample of 255 claims with payments totally $2,370,592. Claims consisted of 75 inpatient and 180 outpatient claims with dates of service in Calendar Year 2012 and 2013.

Risk Areas

Specific “risk areas” identified as being at risk for noncompliance with Medicare billing requirements included:

• Inpatient Rehabilitation Claims,
• Inpatient claims billed with high-severity-level DRG codes,
• Inpatient and Outpatient manufacturer credits for replaced medical devices,
• Outpatient dental claims,
• Outpatient claims billed with modifier -59,
• Outpatient claims billed for Doxorubicin Hydrochloride; and
• Outpatient claims billed for Herceptin.

Note that manufacturer credits for replaced medical devices and outpatient dental claims are also stand-alone projects within the FY 2016 Work Plan. This should be a red flag for hospitals to make sure you are in compliance with these two “risk areas.” A valuable resource is readily available in the specific findings in the report where the OIG provides references such as the Code of Federal Regulations (CFR) and the CMS Provider Reimbursement Manual (PRM) as guidance for compliance with billing requirements.

Audit Findings

The Hospital complied with Medicare billing requirements for 125 of the 255 inpatient and outpatient claims reviewed. The remaining 130 claims resulted in overpayments of $565,286, specifically:

• 29 Inpatient claims had billing errors, resulting in overpayments of $261,886, and
• 101 Outpatient claims had billing errors, resulting in overpayments of $303,400.

The OIG indicated that “these errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.” On the basis of this sample, the OIG extrapolated that the hospital received overpayments of at least $3,266,841 for the audit period and recommended that the Hospital refund this amount to the Medicare contractor.

Looking at the dollars to be refunded, it is easy to see why Compliance Reviews continue to be a part of the OIG’s annual Work Plan. While Compliance Reviews are a part of the OIG Work Plan, hospitals should consider closely monitoring “risk areas” in these reports as an additional tool in your annual and ongoing compliance assessment, plan and actions.

The Centers for Medicare and Medicaid Services (CMS) posted an update to the Therapy Cap webpage on February 9, 2016. CMS indicates that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015 impacted Therapy Caps by extending the “exception process” and making changes to the manual medical review process.

Therapy Cap Exception Process Extension

Therapy caps are a financial limitation on the amount Medicare allows for outpatient therapy services for a single Medicare patient in a given calendar year. The therapy cap amount for each patient starts over each January 1st. The therapy caps for Calendar Year 2016 are $1,960 for Physical Therapy (PT) and Speech-Language Pathology (SLP) combined and $1,960 for Occupational Therapy (OT).

An exception process to the therapy caps for reasonable and necessary services beyond the cap was initially required by section 5107 of the Deficit Reduction Act of 2005. Congress has continuously extended the exception process through legislation. The most recent extension can be found in section 202 of MACRA that extended the therapy caps exception through December 31, 2017.

Manual Medical Review of Therapy Claims

Along with the ability for a provider to receive money beyond the therapy caps came the manual medical review of the claims to ensure that Medicare dollars were being spent appropriately. Initially, the Medicare Administrative Contractors (MACs) conducted pre-payment reviews with dates of service January 1, 2013 to March 31, 2013. The Recovery Auditors assumed responsibility for reviews on April 1, 2013.

MACRA included key changes to this process. First, it shifted the review requirement from ALL records to a “targeted review process.” Second, it prohibits the continued use of Recovery Auditors to conduct the review.

“CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis.

CMS indicates that claims selection will be based on:

• Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA.
• Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers.”

This medical review process will be paying close attention to evaluating the number of units/hours of therapy provided in a day.”

Information about the number of units/hours of therapy provided in a day can be found in a related article Rehabilitation Therapy Documentation, Part 2.

Resources for More Information

Therapy Caps has been a “hot topic” for several years now. Additional articles on therapy caps/manual review can be accessed on our website – just use the subject search function with subject “therapy”.

In addition to the CMS Therapy Cap web page there is also a Therapy Services webpage, which includes links to the Medicare Manual sections that address rehabilitation therapy services as well as a link to the Beneficiary Fact Sheet Medicare Limits on Therapy Services.

Last, we strongly encourage you to visit the Strategic Health Solutions, LLC website at http://strategichs.com/smrc/ to view their prior reviews of Medicare Part B Outpatient Rehabilitation Therapy Services found on their Completed Projects webpage. Pay close attention to the “Denial Reasons” and “How to Prevent Denial” sections of the Project detail.