Knowledge Base Category -
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.
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.
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.
This next table compares all Alabama paid claims for FY 2018 to claims with MCCs proposed for severity designation change.
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.
“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.
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.
¹The CMS Community-based Care Transitions Program webpage at: https://innovation.cms.gov/initiatives/CCTP/).
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:
- Primary treatment of patients with clinically localized prostate cancer, Stages T1 – T3 (diagnosis code is 185 or C61– malignant neoplasm of prostate).
- Salvage therapy for patients:
- Having recurrent, localized prostate cancer;
- Failing a trial of radiation therapy as their primary treatment; and
- 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.
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