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COVID-19 in the News May 4th through May 10th, 2021
Published on May 12, 2021
20210512
 | Coding 
 | Quality 

This week we highlight key updates spanning from May 4th through May 10th, 2021.

May 3, 2021: New COVID-19 Coverage Assistance Fund: Paying for COVID-19 Vaccine Administration

HHS posted a Press Release (link) announcing the new COVID-19 Coverage Assistance Fund (CAF). This program will cover the cost of administering a COVID-19 vaccine for individuals enrolled in health plans that either do not cover vaccination fees or cover them with patient cost-sharing.

May 4, 2021: Funding to Increase COVID-19 Vaccinations in Underserved & Rural Communities

HHS announced (link) the availability of $250 million, through the American Rescue Plan, “to develop and support a community-based workforce who will serve as trusted voices sharing information about vaccines, increase COVID-19 vaccine confidence, and address any barriers to vaccination for individuals living in vulnerable and medically underserved communities.”

In addition to underserved communities, HHS announced (link) the availability of nearly $1 billion to increase vaccination efforts in rural communities.

May 5, 2021: FDA Issues Roadmap for FDA Inspectional Oversight

The FDA has issued a new report titled “Resiliency Roadmap for FDA Inspectional Oversight” (link). This report outlines their “inspectional activities during the COVID-19 pandemic and its detailed plan to move toward a more consistent state of operations, including the FDA’s priorities related to this work going forward.”

At the onset of the pandemic, FDA inspections began to be reserved for what they describe as “mission-critical issues” based on the following four factors:

  • Product received breakthrough therapy or regenerative medicine advanced therapy designation,
  • Product is used to treat a serious disease or medical condition and there is no substitute,
  • Product required follow-up due to recall, or there is evidence of serious adverse events or outbreaks of a foodborne illness, and
  • Product is related to FDA’s COVID-19 response (e.g., drug shortages).
May 6, 2021: Increased Payment for COVID-19 Monoclonal Antibody Infusions & Two New HCPCS Codes

CMS announced (link) an increase in the national average payment rate, for administering monoclonal antibodies to treat COVID-19, from $310 to $450 for most health care settings. Further, “in support of providers’ efforts to prevent the spread of COVID-19, CMS will also establish a higher national payment rate of $750 when monoclonal antibodies are administered in the beneficiary’s home, including the beneficiary’s permanent residence or temporary lodging (e.g., hotel/motel, cruise ship, hostel, or homeless shelter.)” CMS has updated the COVID-19 Vaccines and Monoclonal Antibodies webpage (link) to reflect the payment updates.

Along with CMS establishing a higher national payment rate for monoclonal antibodies in the beneficiary’s home, CMS has added two new HCPCS codes for the administration of the monoclonal antibodies infusion in the home (M0244 and M0246). Note, these will be paid in the same manner as HCPCS codes, M0243 and M0245.

May 7, 2021: CDC Updates SARS-CoV-2 Mode of Transmission

The CDC had updated their Scientific Brief: SARS-CoV-2 Transmission (link). Recent updates to this brief includes:

  • Updates have been made to reflect current knowledge about SARS-CoV-2 transmission,
  • “Modes of SARS-CoV-2 transmission are now categorized as inhalation of virus, deposition of virus on exposed mucous membranes, and touching mucous membranes with soiled hands contaminated with virus.
  • Although how we understand transmission occurs has shifted, the ways to prevent infection with this virus have not. All prevention measures that CDC recommends remain effective for these forms of transmission.”
May 10, 2021: EUA Expanded for Pfizer-BioNTech COVID-19 Vaccine

The FDA announced (link) the expansion of the emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine to include adolescents 12 through 15 years of age. “The most commonly reported side effects in the adolescent clinical trial participants, which typically lasted 1-3 days, were pain at the injection site, tiredness, headache, chills, muscle pain, fever and joint pain. With the exception of pain at the injection site, more adolescents reported these side effects after the second dose than after the first dose, so it is important for vaccination providers and recipients to expect that there may be some side effects after either dose, but even more so after the second dose.”

Beth Cobb

Highlights from April 27, 2021 Release of the FY 2022 IPPS Proposed Rule
Published on May 05, 2021
20210505
 | Billing 
 | Coding 
 | Quality 

CMS issued the FY 2022 IPPS Proposed Rule (CMS-1762-IFC) on Tuesday April 27, 2021. Following are highlights from the Proposed Rule.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use is approximately 2.8 percent.

Overall, CMS estimates hospitals payments will increase by $2.5 billion.

COVID-19 Impact on Inpatient Hospitalization Utilization Data

CMS notes, in a related Fact Sheet, that their goal when setting inpatient hospital payment rates is to use the best available data. Given the impact that the COVID-19 Public Health Emergency (PHE) had during FY 2020, CMS is proposing to use the FY 2019 data to approximate the expected FY 2022 inpatient hospital utilization.

New Technology Add-On Payment (NTAP) Policy

There is good news for hospitals regarding the proposal being made related to the New Technology Add-On Payment (NTAP) policy. As background, the NTAP policy provides additional payment beyond the MS-DRG for cases where a CMS designated new technology was used and coded on the claim. Note, this “is not budget neutral and is generally limited to the 2-to 3-year period following the date of the FDA approval or clearance for marketing.”

“CMS is proposing a one-year extension of new technology add-on payments for 14 technologies for which the new technology add-on payment would otherwise be discontinued beginning FY 2022.”

New COVID-19 Treatments Add-on Payment (NCTAP)

CMS established the NCTAP policy for eligible discharges during the PHE. This policy was “designed to mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments. CMS is proposing to extend this policy for eligible products through the end of the fiscal year in which the COVID-19 PHE ends.

The PHE was once again extended in April 2021 and is currently set to expire on July 20, 2021. (link to release) However, in January of this year, HHS sent a letter (link to letter) to governors indicating the likelihood that the PHE will remain in place for all of 2021. If this proposal is finalized, and the PHE ends on December 31, 2021, that would mean the NCTAP policy will be in place until September 30, 2022.

To learn more about the NCTAP policy visit the CMS NCTAP webpage by clicking here.

Quality Program Proposals

CMS is proposing a measure suppression policy that would allow CMS to suppress use of measure data if they determine that the COVID-19 PHE has affected quality measures and resulting quality scores significantly. This measure suppression policy is being proposed for:

  • The Hospital Readmission Reduction Program (HRRP),
  • The Hospital-Acquired Condition (HAC) Reduction Program, and
  • The Hospital Value-Based Purchasing (VBP) Program.

Also, with the Hospital Compare website now being the Care Compare website, CMS is proposing to update regulatory text for the HRRP and HAC Reduction Program to reflect the name change. The new Care Compare webpage ( link to site ) allows you to compare care by providers across the continuum of care (i.e. hospitals, nursing homes, home health, and hospice).

Specific to the HRRP, CMS is “seeking public comment on closing the gap in health equity through possible future stratification of results by race and ethnicity for condition/procedure-specific readmission measures and by expansion of standardized data collection to additional social factors, such as language preference and disability status.”

The Hospital VBP Program is funded by reducing participating hospitals base operating MS-DRG payments by 2%. The total estimated amount is then redistributed to hospitals based on their Total Performance Score (TPS). It is possible for your hospital to earn back a value-based incentive payment percentage that is less than, equal to, or more than the applicable reduction for that FY. The estimated amount available for incentive payments to hospitals in the current FY 2021 is $1.9 billion.

Due to the proposed measure suppression for the Hospital VBP Program, CMS is “proposing to not calculate a TPS for any hospitals based on one domain and to instead award to all hospitals value based payment amount for each discharge that is equal to the amount withheld.”

Graduate Medical Education (GME)

The Consolidated Appropriations Act (CAA), 2021, Section 126, “requires the distribution of an additional 1,000 new Medicare-funded medical residency positions to train physicians. CMS is proposing to distribute the slots to qualifying hospitals, as specified by the law, including those located in rural areas and those serving areas with a shortage of health care professionals.”

The 1,000 new slots would be phased in at no more than 200 per years beginning in FY 2023 (October 1, 2022). The estimated additional funding will total approximately $1.8 billion from FY 2023 through FY 2031.

Repeal of Hospital Negotiated Charges with Medicare Advantage Payers

Tom Nickels, Executive Vice President of the American Hospital Association, indicated in an April 27, 2021 AHA Statement on the release of the Proposed Rule that “based on our initial review, we are very pleased CMS is proposing to repeal the requirement that hospitals and health systems disclose privately negotiated contract terms with payers on the Medicare cost report. We have long said that privately negotiated rates take into account any number of unique circumstances between a private payer and a hospital and their disclosure will not further CMS's goal of paying market rates that reflect the cost of delivering care. We once again urge the agency to focus on transparency efforts that help patients access their specific financial information based on their coverage and care.” (Link to statement)

CMS is accepting comments on the proposed rule through 5 p.m. EDT on June 28, 2021.

Resources
  • CMS FY 2022 IPPS Proposed Rule CMS Fact Sheet: Link
  • CMS FY 2022 Proposed Rule web page: link

Beth Cobb

COVID-19 in the News April 27th through May 3rd, 2021
Published on May 04, 2021
20210504
 | Coding 
 | Quality 

This week we highlight key updates spanning from April 27th through May 3rd, 2021.

Spotlight: Noridian JF Ask the Contractor (ACT) Question and Answer: Targeted Probe & Educate during the Pandemic

Noridian JF recently posted Questions and Answers from their January ACT Call (link). Following is an excerpt from one of the Q&A’s regarding the Medicare Administrative Contractors (MACs) Targeted Probe and Educate (TPE) program:

“Q8: Our facility has not received a Targeted Probe and Education (TPE) audit or an Additional Documentation Request (ADR) since the pandemic started. Can Noridian please clarify whether these audits have been restarted?
A8: MACs have not received direction from CMS to resume TPE audits. Currently MACs are conducting service specific claim reviews. More information can be found on Noridian’s Medical Review webpage under Post-Pay Reviews. Individual providers will be notified if they have an open, pending TPE file when we have direction from CMS to resume TPE activities.”
April 26, 2021: QW Modifier Added to HCPCS 87636

CMS published MLN MM12269 (link) to inform providers of the addition of the QW modifier to HCPCS code 87636 [Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza type virus types A and B, multiplex amplified probe technique].

CMS ends this MLN article by noting that “claims for tests you perform in facilities having a CLIA certificate of waiver must include the QW modifier. MACs won’t search their files to either retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims you bring to their attention.”

April 27, 2021: CDC Clinical Outreach & Communication Activity Call: Johnson & Johnson/Janssen COVID-19 Vaccine and TTS Update for Clinicians

The CDC conducted an initial call related to the Johnson & Johnson vaccine and Cerebral Venous Sinus Thrombosis with Thrombocytopenia (CVST) on April 15, 2021. The April 27th call provided updates for clinicians about the Johnson & Johnson vaccine and Thrombosis with Thrombocytopenia Syndrome (TTS) (link). For those that missed this call, the CDC webpage for this call includes a video of the session and call materials.

April 27, 2021: Memorandum Update to Interim Final Rule – Additional Policy & Regulatory Revisions in Response to the COVID-19 PHD related to Long-Term care Facility Testing Requirements and Revised COVID-19 Focused Survey Tool e

CMS has updated this Memorandum (link) that was initially provided to State Survey Agency Directors in August of 2020. CMS has revised the COVID-19 Focused Survey Tool for surveyors. They “are also adding to the survey process the assessment of compliance with the requirements for facilities to designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's infection prevention and control program (IPCP) at 42 CFR § 483.80(b).” Additionally, they “are making a number of revisions to the survey tool to reflect other COVID-19 guidance updates.”

April 29, 2021: Expanding COVID-19 Training and Support for Health Centers

HHS announced (link) that 122 organizations, including Primary Care Associations (PCAs), National Training and Technical Assistance Partners (NTTAPs), and Health Center Controlled Networks (HCCNs), have been awarded $32 million to “use the funds to provide health centers with critical COVID-19 related training, technical assistance, and health information technology.” This was made possible through the American Rescue Plan.

Beth Cobb

COVID-19 in the News April 20th through April 26th, 2021
Published on Apr 28, 2021
20210428
 | Coding 
 | Quality 

This week we highlight key updates spanning from April 20th through April 26th, 2021.

Resource Spotlight: HHS’ COVID-19 Public Education Campaign & Community Corps

HHS has launched a public education campaign “to increase public confidence in and uptake of the COVID-19 vaccines while reinforcing basic prevention measures such as mask wearing and social distancing.” HHS is expanding the campaign through the creation of the COVID-19 Community Corps. Members of this group will receive resources to build vaccine confidence in your community, including:

  • Fact Sheets,
  • Social Media Content, and
  • Regular email updates with the latest vaccine news and resources to share.

You can sign up to be a member of the COVID-19 Community Corps at https://wecandothis.hhs.gov/covidcommunitycorps.

April 20, 2021: I Received the Johnson & Johnson Vaccine, Now What?

The CDC has created a Johnson & Johnson/Janssen COVID-19 vaccine update page (link). The April 20th update highlights the following “What you need to know” information:

  • “The use of Johnson & Johnson’s Janssen (J&J/Janssen) COVID-19 Vaccine is paused for now. This is because the safety systems that make sure vaccines are safe received a small number of reports of people who got this vaccine experiencing a rare and severe type of blood clot with low platelets.
  • Seek medical care right away if you develop any of the symptoms listed in the question and answer – what if I got the J&J/Janssen COVID-19 vaccine?
  • If you have any questions at all, call your doctor, nurse, or clinic.”
April 20, 2021: COVID-19 Update – FDA Revoked EUA for Bamlanivimab When Administered Alone

In last week’s article, I reported that on April 16th, the FDA revoked the Emergency Use Authorization (EUA) for Bamlanivimab when administered alone. CMS released a Special Edition MLN Connects related to this revocation (link). They note that they will cover and pay for Bamlanivimab, when administered alone, for dates of service from November 10, 2020 through April 16, 2021.

April 22, 2021: CDC & Dialysis Organizations Partner to Provide COVID-19 Vaccine

The CDC announced in the Thursday April 22nd MLN Connects newsletter (link) that they are partnering with dialysis organizations nationwide to make the COVID-19 vaccine available to patients and health care personnel in outpatient dialysis clinics. CMS reminds you that there is no copayment, coinsurance or deductible for receiving a COVID-19 vaccine.

April 22, 2021: New Acute Care Delivery at Home Tip Sheet

Also in the April 22nd MLN Connects, CMS provides a link to a new Acute Care Delivery at Home Tip Sheet (link). In addition to the Tip Sheet a link is provided to the CMS Acute Hospital Care at Home webpage where you will find an overview of this program, reporting measures participating hospitals are required to provide, additional resources, and access to past webinars.

April 22, 2021: HHS’ “We Can Do This: Live” Initiative

Building upon the “We Can Do This” public education campaign, HHS announced the launch of their “We Can Do This: Live” series “to pair medical experts with prominent influencers and organizations with large social followings to meet people where they are with the information they need to feel confident about receiving the vaccine. Events will include conversations to answer direct questions about COVID-19, Instagram Live Q&As, and social media account takeovers where doctors, scientists and health officials can provide the public with factual, scientific information about vaccines.” HHS notes in the Press Release (link) that this initiative follows the launch of the COVID-19 Community Corps initiative.

April 23, 2021: Johnson & Johnson (Janssen) COVID-19 Vaccine Pause Lifted

After a “thorough safety review,” the CDC and FDA announced that use of the Johnson & Johnson (Janssen) COVID-19 vaccine should resume. The Fact Sheets related to this vaccine have all been revised to include information about the risk of thrombosis-thrombocytopenia syndrome (TTS). The FDA goes on to note that as of April 23rd they can confirm 15 cases of TTS. All cases were women between 18 and 59 years old, with a median age of 37 years. Symptom onset was between 6 and 15 days after vaccination. (link)

COVID-19 in the News April 13th through April 19th, 2021
Published on Apr 21, 2021
20210421
 | Coding 
 | Quality 

This week we highlight key updates spanning from April 13th through April 19th, 2021.

April 13, 2021: CDC Health Alert: Cases of Cerebral Venous Sinus Thrombosis with Thrombocytopenia after Johnson & Johnson COVID-19 Vaccination

The CDC issued an official Health Alert relaying information about six cases of cerebral venous sinus thrombosis (CVST) in the U.S. after receiving the Johnson & Johnson COVID-19 vaccine. All six cases were women aged 18 – 48 years and the lag time from vaccination to onset of symptoms ranged from 6 – 13 days. Five of the six women had an initial presenting symptom of a headache. One woman died.

The CDC indicated they would convene an emergency meeting of the Advisory Committee on Immunization Practices (ACIP) on April 14th… “until this process is complete, CDC and FDA are recommending a pause in the J&J COVID-19 vaccine out of an abundance of caution.”

Recommendations for Clinicians, Public Health, and the general public are also included in this Alert.

April 13, 2021: New Legal Guidance & Resources to Ensure Expansion of Access to COVID-19 Vaccines

HHS issued a Press Release announcing new resources that have been published to assist in ensuring people with disabilities and older adults access to COVID-19 vaccines. HHS notes that “these resources clarify legal requirements, illustrate some of the barriers to vaccine access faced by people with disabilities and older people, and provide strategies – and examples of how the aging and disability network can help employ them to ensure accessibility.”

April 14, 2021: H.R. 1868 Becomes a Law – Sequestration Suspension Extended

The Coronavirus Aid, Relief, and Economic Security (CARES) act was enacted on March 27, 2020 and suspended the 2% sequestration payment adjustment applied to all Medicare FFS claims from May 1 through December 31, 2020. This payment adjustment was included in the Budget Control Act signed into law in August 2011 and became effective April 1, 2013. This Act required that $1.2 trillion in federal spending cuts be achieved over the course of nine years. With no action from Congress, sequestration would last until 2022. You can read more about the 2013 Sequestration in an American Medical Association FAQ document.

Additional legislation extended the suspension through March 31, 2021. A subsequent House Resolution (H.R.) finally made its way through the House and Senate. On April 14, 2021, an Act to Prevent Across-the-Board Direct Spending Cuts, and for Other Purposes was signed into law extending the Sequestration suspension through December 31, 2021.

CMS noted in the Friday April 16, 2021 edition of MLN Connects that Medicare Administrative Contractors will:

  • Release any previously held claims with dates of service on or after April 16, 2021, and
  • The emergency blanket waiver of the timeframe requirements for completing and transmitting resident assessment information (Minimum Data Set (MDS).

They ended the announcement by noting that you do not need to take any action.

April 15, 2021: CDC Clinical Outreach & Communication Call – Johnson & Johnson/Janssen COVID-19 Vaccine and Cerebral Venous Sinus Thrombosis with Thrombocytopenia – Update for Clinicians on Early Detection and Treatment

The CDC held this call to present the latest evidence on cerebral venous sinus thrombosis (CVST) with thrombocytopenia associated with the Johnson & Johnson/Janssen COVID-19 vaccine. If you missed this April 15th call, you can download the call materials from this CDC webpage.

April 15, 2021: OIG Message on COVID-19 Vaccination Program and Provider Compliancet

The OIG released a letter reminding vaccine providers and the public that the Federal Government is providing this vaccine and must be provided at no cost to recipients. They go on to note they are aware of patient complaints about charges by providers when getting their COVID-19 vaccines.

April 15, 2021: COVID-19 Public Health Emergency Extended

Secretary of Health and Human Services, Xavier Becerra, renewed the Public Health Emergency (PHE) due to the continued consequences of the COVID-19 pandemic. This most current extension will expire on July 20, 2021. In January of this year, HHS sent a letter to governors indicating the likelihood that the PHE will remain in place for all of 2021. They also indicated that states would be given a 60 days’ notice to the states prior to the termination of the PHE due to COVID-19.

April 16, 2021: COVID-19 Health Equity Task Force Virtual Meeting April 30, 2021

HHS posted a “Notice of Meeting” regarding the next COVID-19 Health Equity Task Force (Task Force) virtual meeting scheduled for April 30, 2021. As background, this Task Force was established by a January 21, 2021 Executive Order and the group is tasked with making recommendations for “mitigating the health inequities caused or exacerbated by the COVID-19 pandemic and for preventing such inequities in the future.” This meeting is open to the public and will be lived streamed at www.hhs.gov/live. The confirmed time and agenda will be posted on the Task Forces’ webpage at www.minorityhealth.hhs.gov/healthequitytaskforce/.

April 16, 2021: COVID-19 Health Equity Task Force Virtual Meeting April 30, 2021

CMS included the following information regarding COVID-19 Vaccine history in their Friday April 16, 2020 edition of MLN Connects:

“Starting April 16, in addition to screening your patients, you can check Medicare eligibility (PDF) for COVID-19 vaccine administration history from Fee-for-Service (FFS) claims paid for calendar years 2020 and 2021. This includes Medicare Advantage patients.

You can get the following eligibility information for each paid vaccine administration claim:

  • CPT or HCPCS codes
  • Date of service
  • National provider identifier for who administered the vaccine

We can only provide this information if the provider billed Medicare for administering the vaccine. If your patients got vaccinated and the provider didn’t submit a Medicare claim (like if they got vaccinated at a free event), ask your patients about their COVID-19 vaccination history.”

April 16, 2021: Medicare Telehealth Services List Updated

CMS indicated in the April 16, 2021 edition of MLN Connects that CMS had published an updated list of Medicare telehealth services on March 30th. They noted that due to the public health emergency, many audiology and speech-language pathology services have been added to the list effective March 1, 2021.

April 16, 2021: FDA Revokes EUA for Monoclonal Antibody Bamlanivimab

The FDA announced that they have revoked the Emergency Use Authorization (EUA) for Bamlanivimab, when administered alone, to treat mild-to-moderate COVID-19 in adults and certain pediatric patients. Patizia Cavazzoni, M.D., director of the FDA’s Center for Drug Evaluation and Research stated in this announcement that “while the risk-benefit assessment for using bamlanivimab alone is no longer favorable due to the increased frequency of resistant variants, other monoclonal antibody therapies authorized for emergency use remain appropriate treatment choices when used in accordance with the authorized labeling and can help keep high risk patients with COVID-19 out of the hospital.” .

COVID-19 in the News April 6th through April 12th, 2021
Published on Apr 14, 2021
20210414
 | Coding 
 | Quality 

This week we highlight key updates spanning from April 6th through April 12th, 2021.

Resource Spotlight: WPS YouTube Video: New COVID-19 Condition Codes for Billing Vaccines/Monoclonal Antibody Infusions

WPS, the Medicare Administrative Contractor (MAC) for Jurisdictions 5 and 8, has published a New COVID-19 Condition Codes YouTube video, which includes information on the new condition codes required when billing for COVID-19 vaccines and monoclonal antibody infusions.

April 6, 2021: FDA Issues Emergency Use Authorization (EUA) for COVID-19 Self-Collected Antibody Test System

The FDA announced that they issued a EUA to Symbiotica, Inc., for the COVID-19 Self-Collected Antibody Test System. This test requires a prescription from a health care provider, is intended as an aid in identifying individuals who have had an “adaptive immune response to SARS-CoV-2, indicating the person may have had a recent or previous COVID-19 infection. Samples collected at home are sent to a Symbiotica, Inc. laboratory for analysis.”

April 8, 2021: Revised MLN Booklet: Hospital Value Based Purchasing

In the Thursday April 8, 2021 MLN Connects newsletter, CMS noted that they have updated the MLN Booklet titled Hospital Value Based Purchasing. CMS made the following content updates to this booklet:

  • Added information on relief for clinicians, providers, hospitals, and facilities participating in quality reporting and value-based purchasing programs due to the COVID-19 public health emergency,
  • Added Hospital VBP domains and relative weights for FYS 2018-2023,
  • Revised Hospital VPB measures for FYS 2021-2023, and
  • Revised baseline and performance periods for FYs 2021-2023.
April 8, 2021: CMS Memorandum: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers Issued in Response to COVID-19

CMS released this memorandum to State Survey Agency Directors. In the memorandum summary, CMS indicated they are ending the following waivers for nursing homes:

  • The emergency blanket waivers related to notification of Resident Room or Roommate changes, and Transfer and Discharge notification requirements:
    • The emergency blanket waiver for certain care planning requirements for residents transferred or discharged for cohorting purposes, and
    • The emergency blanket waiver of the timeframe requirements for completing and transmitting resident assessment information (Minimum Data Set (MDS).
April 9, 2021: CDC’s Understanding Viral Vector COVID-19 Vaccines Webpage Updated

There has been confusion and distrust reported in the news and anecdotally on social media regarding the COVID-19 vaccines. Specifically, there has been concerns about the COVID-19 virus being in the vaccine. The CDC’s Understanding Viral Vector COVID-19 Vaccines webpage currently starts with providing the following “What You Need to Know” information:

  • “Viral vector vaccines use a modified version of a different virus (the vector) to deliver important instructions to our cells.
  • The benefit of viral vector vaccines, like all vaccines, is those vaccinated gain protection without ever having to risk the serious consequences of getting sick with COVID-19.”

Also available on this webpage is a printable infographic titled “How Viral Vector COVID-19 Vaccines Work.”

Beth Cobb

Hospital Compare Update & Hospital Quality Program Updates
Published on Feb 05, 2020
20200205
 | Coding 
 | Quality 

In a January 23, 2020 CMS Blog, CMS Administrator Seema Verma shared CMS’ plans to improve tools found at Medicare.gov (Hospital, Nursing Home, Home Health, Dialysis Facility, Long-term Care Hospital, Inpatient Rehabilitation Facility, Physician and Hospice Compare Tools). Administrator Verma notes while the Compare tools are among the most popular, “each one functions independently with varying user interfaces that make them difficult to understand and challenging to navigate.”

CMS plans to improve the customer experience by combining and standardizing the eight existing Compare tools. “The new “Medicare Care Compare” on Medicare.gov will offer Medicare beneficiaries and their caregivers and other users a consistent look and feel, providing a streamlined experience to meet their individual needs in accessing information about health care providers and care settings. In the new, unified experience, patients will be able to easily find the information that is most important to help make health care decisions, like getting quality data by the type of health care provider.”

CMS plans to launch “Medicare Care Compare” this spring, kicking off with a transition period allowing the public to use the new combined Compare alongside the existing tools before they are retired. It just so happens CMS has promised a spring 2020 release of sub-regulatory guidance to the new Discharge Planning Conditions of Participation (CoP) Final Rule that went into effect in November 2019. Updates to both can’t come soon enough as hospitals work to comply with the new CoPs requirement of sharing data from the Compare websites to beneficiaries seeking post-acute care services at the time of discharge.

In the meantime, CMS made data updates to Hospital Compare in January. Among the changes were data updates for the Hospital Readmission Reduction Program (HRRP) and Hospital-Acquired Condition (HAC) Reduction Program.

Hospital Readmissions

CMS began reducing Medicare payments for Inpatient Prospective Payment System Hospitals (IPPS) hospitals with excess readmissions in October 2012. CMS calculates readmission rates for specific conditions through the Hospital Readmission Reduction Program (HRRP). Current specific conditions include:

  • Heart Attack (AMI),
  • Heart Failure (HF),
  • Pneumonia (PNA),
  • Chronic Obstructive Pulmonary Disease (COPD),
  • Hip/Knee Replacement (THA/TKA), and
  • Coronary Artery Bypass Graft Surgery (CABG).

For FY 2020, Medicare estimates hospitals will lose $563 million. A hospitals specific penalty amount will be deducted from each inpatient claim billed during the FY. You can read more about the penalties in an October 1, 2019 Kaiser Health News (KHN) article by Jordan Rau.

Hospital-Acquired Condition (HAC) Reduction Program

The HAC Reduction Program began in FY 2015 and is a Medicare pay-for-performance program supporting the CMS effort to link Medicare payments to quality in the inpatient hospital setting. Hospitals ranking in the worst-performing quartile with respect to risk-adjusted HAC quality measures are subject to a 1 percent payment reduction.

Per a January 31, 2020 Kaiser Health News (KHN) article by Jordan Rau, 786 hospitals will receive lower payments during FY 2020.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Beth Cobb

FY 2020 IPPS Final Rule: Part 1
Published on Aug 20, 2019
20190820

CMS proposed significant changes to the current severity designation of diagnosis codes in the FY 2020 Inpatient Prospective Payment System (IPPS) Proposed Rule. Most significant were the proposed changes to current Major Comorbidities and Complications (MCCs) diagnosis codes.  

RealTime Medicare Data (RTMD) paid claims data helped to quantify the potential impact of the proposed MCC changes. Specifically, analysis of FY 2018 Medicare fee-for- service paid claims data for the state of Alabama provided answers to the following questions: 

  • What are the Top 10 diagnosis codes proposed for a new severity designation from MCC to CC or Non-CC?
  • What is the volume of claims and actual payment for claims that had been paid where the MS-DRG required an MCC and there was only one MCC coded, and
  • What is the volume of claims and actual payment further drilled down by MCCs with a proposed change to CC and MCCs with a proposed change to Non-CC?

This first table highlights the top 10 MCCs proposed for a severity designation change to CC or Non-CC.

Top 10 MCC Codes by Volume for Alabama
ICD-10-CM Diagnosis CodeCode DescriptionVolume of ClaimsCurrent Severity DesignationProposed Severity Designation
N18.6End stage renal disease9,191MCCCC
E43Unspecified severe protein-calorie malnutrition3,661MCCCC
L89*All Stage 3 & 4 Pressure Ulcer Codes Combined (Note: This volume is for all 50 proposed codes)955MCCCC
I46.9Cardiac arrest, cause unspecified408MCCNon-CC
D61.810Antineoplastic chemotherapy induced pancytopenia338MCCCC
G93.5Compression of brain306MCCCC
J95.821Acute postprocedural respiratory failure207MCCCC
 All Fracture Codes Combined (Note: This volume is for 38 proposed codes)137MCCCC
K63.1Perforation of intestine (nontraumatic)130MCCCC
K57.31Dvrtclos of lg int w/o perforation or abscess w bleeding108MCCCC
I49.01Ventricular fibrillation106MCCCC
Data Source: RTMD data representing Alabama paid claims in FY 2018.

This next table compares all Alabama paid claims for FY 2018 to claims with MCCs proposed for severity designation change.

FY 2018 Compare
 Claims VolumeActual Payment
All Alabama Paid Claims200,727$1,939,529,965
All Claims Impacted by Proposed MCC Severity Designation Change16,455$220,445,086
Claims with MCC proposed change to CC15,796$211,561,447
Claims with MCC proposed change to Non-CC659$8,883,639
Note: MCC Severity Rate Change Claims represent MS-DRGs impacted by presence of MCC and the claim only had one MCC coded.

Finalized Severity Changes for FY 2020

In the Final Rule many “commenters expressed concern that the extensive changes proposed to the severity level designations…would no longer appropriately reflect resource use for patient care and could have a significant unintended or improper adverse financial impact.”

CMS listened and in general did not finalize the proposed changes. Changes that were made include the following:

  • Table 6I.1 – Additions to MCC List: Five diagnosis codes were added to this list,
  • Table 6I.2 – Deletions to the MCC List: No diagnosis codes were deleted for FY 2020,
  • Table 6J.1 – Additions to the CC List: Seventy-five diagnosis codes were added to this list; and
  • Table 6J.2 – Deletions to the CC List: Five diagnosis codes were removed from the CC List.

In addition to the above tables, the Complete MCC List (Table 6I) and the Complete CC List (Table 6J can be found on the CMS FY 2020 IPPS Final Rule Home Page. Also, click here for download from this article is a document highlighting the FY 2020 additions and deletions to the MCC and CC lists for FY 2020.

Beth Cobb

A Day for Making Decisions and Planning
Published on Apr 16, 2019
20190416

“I’m late, I’m late! For a very important date! Not time to say ‘hello, goodbye,’ I’m late, I’m late, I’m late!”

  • The White Rabbit in Lewis Carroll’s classic story, Alice in Wonderland

Yesterday, April 16th was National Healthcare Decisions Day and the first National Care Transitions Awareness Day. Although this article is a day later, it is never too late to put the patient first.

April 16th: National Healthcare Decisions Day (NHDD)

NHDD is an initiative of The Conversion Project which is dedicated to helping people talk about their wishes for end-of-life care. According to the NHDD website, this day “exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.”

Effective January 1, 2016, the CMS began paying for Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). ACP is a face-to-face service between a physician (or other qualified health professional) and the patient discussing advance directives with or without completing relevant legal forms.

The Annual Wellness Visit, Health Risk Assessment and Advance Care Planning

My husband recently had an office visit with his Primary Care Physician and for the first time his Physician discussed advance directives and even sent him home with a blank copy of an advance directive that he could complete. My husband also said that between him and his Physician they filled out what seemed “like a million” forms answering questions about his health history.

While writing this article, I realized this office visit was probably my husband’s Annual Wellness Visit (AWV). Section 4103 of the Affordable Care Act (ACA) established a Medicare Annual Wellness Visit beginning in 2011. An AWV is covered by Medicare once every 12 months and entails the Physician developing or updating a personalized prevention plan, and performing a Health Risk Assessment.

The Health Risk Assessment involves collecting and analyzing health-related data used by health providers to evaluate the health status or health risk of an individual. According to the Centers for Disease Control (CDC)’s A Framework for Patient-Centered Health Risk Assessments, “chronic illnesses account for an estimated 83% of total U.S. health spending and virtually all (99%) of Medicare’s expenditures are for beneficiaries with at least one chronic condition.

One component of the Health Risk Assessment (HRA) is voluntary Advanced Care Planning.  Minimum elements for voluntary ACP services include a discussion about the following:

  • Future care decisions that may need to be made,
  • How the beneficiary can let others know about care preferences,
  • Caregiver identification, and
  • Explanation of advanced directives, which may involve the completion of standard forms.

You can learn more about the Annual Wellness Visit in an MLN Booklet (ICN905706) and more about Advanced Care Planning in an MLN Advance Care Planning Fact Sheet.

April 16, 2019: First National Care Transitions Awareness (NCTA) Day

Even with Annual Wellness Visits and Health Risk Assessments, Medicare patients get admitted to the hospital. Unfortunately, of the approximately 2.6 million Medicare beneficiaries who are discharged from a hospital, one in five are readmitted within 30 days, at a cost of over $26 million every year.¹ 

According to the CMS Effective Care Transitions, Improve Cost Savings Graphic and Fact Sheet:

  • Nationally, inadequate care coordination and care transitions are responsible for $30-54 billion in wasteful spending,
  • 57% of Providers report things fall through the cracks when patients transfer from one facility to another,
  • 50% of Hospital-Related medical errors are attributed to poor communication during transitions of care, and
  • Chronically ill patients will see an average of 16 physicians per year.

Yesterday, April 16, 2019 marked the first National Care Transitions Awareness (NCTA) Day. This day is meant to raise awareness about the importance and value of care transitions and care coordination. In an FAQ Session posted on the CMS Quality Improvement Organization (QIO) website, Jean Moody-Williams and Dr. Adebola Adeleye share the inspiration behind NCTA Day.

“Health care can be very complex, and it requires effective coordination efforts as beneficiaries’ transition from one point of care to another, such as from a hospital to a nursing home. Effective care transitions require a team-based approach that treats people holistically — addressing their socioeconomic circumstances, cultural beliefs and values, as well as their health care needs.

To practice this same holistic approach for the care of our beneficiaries, CMS mobilized a team of individuals across the agency representing the various aspects of our care transitions programs and initiatives to form the CMS CTPAC Affinity Group. This group works to align our care transitions efforts by improving communication and coordination, and eliminating duplication across our programs. 

Early on in our discussions, the CTPAC Affinity Group identified the need to increase awareness and promote action around care transitions and expectations during the process, especially in the beneficiary population. One of our priorities at CMS is to put patients first, and we believe beneficiaries are an essential part of the health care team. If people are well informed about ways to improve their care, they can become more active participants. Ultimately, active patient participation helps us at CMS be more effective in advancing quality care and patient safety as people transition through the health care continuum.”

Staying Connected After NCTA Day

CMS invites you to join their Care Transitions Listserv to receive future communications about upcoming events and opportunities. You can register at https://www.healthcarecommunities.org/NCTA. You can also learn more about Care Transitions from CMS leadership on their YouTube channel.

Source

¹The CMS Community-based Care Transitions Program webpage at: https://innovation.cms.gov/initiatives/CCTP/).

New RAC Activity
Published on Feb 18, 2019
20190218

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

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

Hyperbaric Oxygen Therapy (HBOT) for Diabetic Wounds

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

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

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

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

Complex Medical Necessity Panniculectomy

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

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

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

Cryosurgery of the Prostate Medical Necessity

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

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

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

Medical Necessity Vertebroplasty and Kyphoplasty

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

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

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

Debbie Rubio

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