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8/30/2024
Medicare Transmittals & MLN Articles
August 5, 2024: MLN MM13706: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2025 Update
Make sure key stakeholders are aware of new codes and recent coding changes that will be effective January 1, 2025. Change Request (CR) 13706 includes the following NCDs and NCD specific updates:
- 20.33 TMVR/TEER: Effective January 1, 2025, any existing edits that require ICD-10 I34.0 and I34.1 be listed as primary will be deleted, along with clinical trial ICD-10 Z00.6 as secondary. These codes can appear in any position, and
- 210.10 STIs: June 30, 2024 is the end date for CPT 0353U. Effective July 1, 2024 add CPT 0455U (used for combined chlamydia and gonorrhea testing).
Also, CR 13706 removed the delayed termination of the Appropriate Use Criteria (AUC) Program modifiers with an effective date for the AUC modifier removal noted as being January 1, 2025. https://www.cms.gov/files/document/mm13706-icd-10-other-coding-revisions-national-coverage-determinations-january-2025-update.pdf
August 6, 2024: MLN MM13707: Hospice Payments: FY 2025 Update
This article provides information about payment rates, inpatient and aggregate caps, and wage index updates effective October 1, 2024. https://www.cms.gov/files/document/mm13707-hospice-payments-fy-2025-update.pdf
August 6, 2024: MLN MM13632: Hospital Outpatient Prospective Payment System: July 2024 Update - Revised
In this second iteration of this MLN article, CMS updated the number of certain drugs, biologicals, and radiopharmaceuticals and added new subsections g and j in Section 7. Substantive content changes are in dark red. https://www.cms.gov/files/document/mm13632-hospital-outpatient-prospective-payment-system-july-2024-update.pdf
August 19, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment - Revised
This article was initially released May 3, 2024. In this update CMS has clarified that MACs will process G0136 using the Physician fee Schedule. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf
August 21, 2024: MLN MM13750: Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations Policy
Make sure your billing staff knows about updated Medicare coverage requirements for pneumococcal vaccinations and changes to align with the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccination coverage. https://www.cms.gov/files/document/mm13750-revisions-medicare-part-b-coverage-pneumococcal-vaccinations-policy.pdf
August 22, 2024: MLN MM13766: Inpatient Psychiatric Facilities Prospective Payment System: FY 2025 Updates
This article highlights key information for your billing staff for FY 2025, for example the refinements to adjustment factors and electroconvulsive therapy (ECT) payment per treatment. https://www.cms.gov/files/document/mm13766-inpatient-psychiatric-facilities-prospective-payment-system-fy-2025-updates.pdf
August 26, 2024: MLN MM13757: New Waived Tests
Make sure your billing staff knows about Clinical Laboratory Improvement Amendments (CLIA) requirements, the one new CLIA-waived test approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13757-new-waived-tests.pdf
August 29, 2024: MLN MM13734: Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2025 Changes
This thirteen-page article provides updates that will be effective October 1, 2024. For example, regarding the Hospital-Acquired Condition (HAC) Reduction Program, CMS expects to issue the final list of hospitals that are subject to the HAC Reduction Program for FY 2025 to MACs in mid-September 2024. https://www.cms.gov/files/document/mm13734-inpatient-long-term-care-hospital-prospective-payment-system-fy-2025-changes.pdf
Coverage Updates
August 5, 2024: CMS Prior Authorization and Pre-Claim Review Initiatives Update
CMS is removing CPTs 64492 and 64494 from the list of codes that require prior authorization as a condition of payment. According to the revised Local Coverage Determinations for Facet Joint Interventions, three or four-level procedures are not medically necessary and non-covered. Therefore, the decision on the prior authorization request will always be non-affirmative, so submitting the request would be unnecessary. The full list of HCPCS codes has been updated to reflect this change. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
August 7, 2024: Final Notice – Transitional Coverage for Emerging Technologies (TCET) (CMS-3421-FN)
CMS announced in the August 8, 2024, edition of MLN connects that CMS has issued a final procedural notice outlining a Medicare coverage pathway to achieve more timely and predictable access to certain new medical technologies for people with Medicare. The new TCET pathway for certain FDA-designated Breakthrough Devices increases the number of National Coverage Determinations (NCDs) that CMS will conduct per year and supports both improved patient care and innovation by providing a clear, transparent, and consistent coverage process while maintaining robust safeguards for the Medicare population.
Link to August 8, 2024, MLN Connects: https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-08-08-mlnc
August 21, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation – Revised
This MLN article was revised to add two procedure codes to the coding instructions (XW133C8 and XW143C8). https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf
Compliance Education Updates
August 12, 2024: OIG Report: Medicare Improperly Paid Hospitals an Estimated $79M for Enrollees Who Had Received Mechanical Ventilation
OIG performed this audit due to prior OIG audits finding hospitals did not fully comply with Medicare requirements for MS-DRGs that require enrollees to have received 96 or more consecutive hours (i.e., 4 days or more) of mechanical ventilation. This audit specifically evaluated if claims reporting a mechanical ventilation start date that was 5 to 10 days before the enrollee discharge date were at risk for billing errors. The audit included inpatient claims with dates of service from October 2015 through September 2021 that were grouped to MS-DRGs 207 and 870. They found that for 17 of 250 sampled claims hospitals did not comply with requirements. Based on this finding, the OIG estimated that Medicare improperly paid hospitals $79.4M for the audit period. CMS concurred with OIG recommendations to recover the identified overpayments and continue to educate providers to reinforce requirements for billing mechanical ventilation. https://oig.hhs.gov/documents/audit/9957/A-09-22-03002.pdf
August 2024: MLN Fact Sheet MLN2886155: A Prescriber’s Guide to Medicare Prescription Drugs (Part D) Opioid Policies – Revised
This MLN Fact Sheet was revised in August to add information on the expansion of the exempted patient definition. Effective January 1, 2025, CMS is expanding the definition of an exempted patient being treated for cancer-related pain to include:
- Patients undergoing active cancer treatment,
- Cancer survivors:
- With chronic pain who’ve completed cancer treatment,
- In clinical remission, and
- Under surveillance only.
MLN Booklet MLN909188: Chronic Care Management Services – Revised
Earlier in May 2024, this MLN Booklet was revised to add new codes describing chronic pain management and treatment and added information about other care management services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
Other Updates
August 1, 2024: FY 2025 Hospital IPPS and LTCH PPS Final Rule (CMS-1808-F)
For FY 2025, the increase in operating payment rates for 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) users is 2.9%.
Link to Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0
August 13, 2024: CMS Memorandum: Updated Model Signage for the Emergency Medical Treatment and Labor Act (EMTALA)
In the memorandum summary, CMS notes that they are “dedicated to safeguarding the health and safety of millions of individuals, a commitment that includes enforcing federal laws including EMTALA.” Further, CMS regulations require Medicare-participating hospitals to post signage outlining patients’ rights under EMTALA in the emergency department and areas where patients will be examined or treated, or wait to be examined or treated, for emergency medical conditions (EMCs). CMS is releasing updated model signage that hospitals may use to meet this obligation.” https://www.cms.gov/files/document/qso-24-17-emtala.docx
August 13, 2024: CMS Posts Content for Health Care Providers in Preparation of Coverage Transition from Part D to Part B of Antiretroviral Drugs to Prevent HIV
CMS is encouraging pharmacies and other affected parties to prepare now for this expected transition. They expect to release the final National Coverage Determination (NCD) in late September 2024. Coverage under Part B will begin once the final NCD is released. https://www.cms.gov/medicare/coverage/prep
August 15, 2024: HHS Press Release: Negotiating for Lower Drug Prices Works, Saves Billions
HHS announced agreements for new lower prices for 10 drugs that are “some of the most expensive and most frequently dispensed drugs in the Medicare program and are used to treat conditions such as heart disease, diabetes, and cancers.” New prices go into effect January 1, 2026 for people with Medicare Part D prescription drug coverage. CMS will continue to select up to 15 more drugs for 2027 and 2028, and up to 20 more drugs each year after that, as required by the Inflation Reduction Act (IRA).
Additional resources were included in the Thursday, August 15, 2024 edition of MLN Connects at https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-08-15-mlnc
August 2024: CMS FAQs about Add-on HCPCS Code G2211
CMS has published an FAQ document about office/outpatient (O/O) evaluation and management (E/M) visit complexity add-on HCPCS code G2211 (visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)). https://www.cms.gov/files/document/hcpcs-g2211-faq.pdfBeth Cobb
8/30/2024
CMS published details about this five-year mandatory model as part of the FY 2025 IPPS and LTCH PPS Final Rule. CMS indicates that it will incentivize coordination between care providers during a surgery as well as the services provided during the 30 days after surgery with the aim of:
- Improving the quality of care of people with Medicare undergoing certain surgical procedures;
- reducing hospitalization and recovery time;
- lowering Medicare spending; and
- driving equitable outcomes.
The model is set to start in January 2026 and end in December 2030.
TEAM Participation
All acute care hospitals, with limited exceptions, located within the mandatory Core-Based Statistical Areas (CBSAs) that CMS selected will be required to participate in TEAM.
CMS will allow a one-time opportunity for hospitals that participate until the last performance period in the BPCI Advanced model or CJR model, that are not located in a mandatory CBSA to voluntarily opt into TEAM.
A final list of the selected mandatory CBSAs is available in the FY 2025 IPPS Final Rule Table X.Z.-05: Final List of CBSAs for Selection into TEAM
TEAM Episode
An Episode will include non-excluded Medicare Parts A and B items and services and would begin with an anchor hospitalization or anchor procedure and will end 30 days after hospital discharge.
The following table is available in the final rule and provides the specific TEAM episode categories and related billing codes.
|
Episode Category |
Billing Codes (MS-DRG/HCPCS) |
|
Lower Extremity Joint Replacement (LEJR) |
MS-DRG: 469, 470, 521, 522 HCPCS: 27447, 27130, 27702 |
|
Surgical Hip and Femur Fracture Treatment (SHFFT) |
MS-DRG: 480, 481, 482 |
|
Coronary Artery Bypass Graft Surgery (CABG) |
MS-DRG: 231, 232, 233, 234, 235, 236 |
|
Spinal Fusion |
MS-DRG: 402, 426, 427, 428, 429, 430, 447, 448, 450, 451, 471, 472, 473 HCPCS: 22551, 22554, 22612, 22630, 22633 |
|
Major Bowel Procedure |
MS-DRG: 329, 330, 331 |
|
Source: Table X.A.-08: Final Team Episode and Billing Categories in FY 2025 IPPS Final Rule |
|
Billing Medicare
TEAM participants will continue to bill Medicare FFS for services furnished to Medicare FFS beneficiaries. However, the TEAM participant may also receive a reconciliation payment amount from CMS depending on their Composite Quality Score (CQS) and if their performance year spending is less than their reconciliation target price.
Participants may also owe CMS a repayment amount, subject to their quality performance adjustment, if their spending is above the reconciliation target price.
Target Prices will be based on 3 years of baseline data, prospectively trended forward to the relevant performance year, and calculated at the level of MS-DRG/HCPCS episode type and region.
The Target Prices will include a discount factor, a normalization factor, a retrospective trend adjustment factor, and a beneficiary and provider level risk-adjustment.
Moving Forward
Determine if your hospital is in one of the selected mandatory CBSA. If your hospital will be part of this model, you can find additional information and resources available on the CMS Innovation Center’s TEAM webpage at:https://www.cms.gov/priorities/innovation/innovation-models/team-model
Resource
CMS FY 2025 IPPS Final Rule webpage: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2025-ipps-final-rule-home-page
Beth Cobb
8/12/2024
Medicare Transmittals & MLN Articles
June 24, 2024: Changes to the Laboratory National Coverage Determination Edit Software: October 2024 Update
CMS advises providers to make sure your billing staff know about newly available codes, recent coding changes, and how to find NCD coding information.
June 25, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024
Initially released on June 13, 2024, this article was updated to remove HCPCS codes J3393, J3394, J9172, J9322, and J9324 from table of the change request, which now has 12 codes. https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf
June 25, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule
Initially released May 3, 2024, this article was updated to clarify claims processing requirements for ICD-10-CM diagnosis code Z13.1 and previously processed claims. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf
June 27, 2024: Change Request (CR) 13649: Utilization of KX Modifier Medicare Physician Fee Schedule Payment for Dental Services Inextricably Linked to Covered Medical Services
This CR provides instructions to A/B MACs regarding usage of the KX modifier for dental services inextricably linked to covered medical services under the Medicare Physician Fee Schedule. CMS includes four examples of types of evidence that providers must submit to demonstrate the inextricable link between the dental service and covered medical service. https://www.cms.gov/files/document/r12702otn.pdf
July 18, 2024: MLN MM13717: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: October Update
Make sure your billing staff knows about the next private payor data reporting period of January 1, 2025 – March 31, 2025, and new and deleted HCPCS codes.
July 18, 2024: MLN MM13286: Lymphedema Compression Treatment Items: Implementation
Now in it’s fourth iteration, this MLN article was updated on July 18th to add information on how to prevent claims denial due to duplicate payments for compression bandaging systems. https://www.cms.gov/files/document/mm13286-lymphedema-compression-treatment-items-implementation.pdf
Compliance Education Updates
July: CMS’ Oral Health Cross-Cutting Initiative Fact Sheet
In the July 25, 2024, edition of MLN Connects, CMS released this Fact Sheet noting that overall health and well-being are impacted by oral health, affecting individuals, families, and communities. CMS is committed to eliminating barriers to oral health as part of our broader goal of improving quality, equity, and outcomes in the health care system. The CMS Oral Health Cross-Cutting Initiative aligns our programs and policies to better address oral health needs, and the fact sheet highlights this important work and accomplishments to date.
- Link to MLN Connects: https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983
- Link to Fact Sheet: https://www.cms.gov/files/document/oral-health-cci-fact-sheet.pdf
July: CMS Request for Inpatient for Improving the PEPPER
Also, in the July 25, 2024 edition of MLN Connects, CMS noted they are taking steps to improve the effectiveness, accessibility, and design of the Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) and Comparative Billing Reports (CBRs). They note you can help by responding to their Request for Information (RFI) by August 19, 2024. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983
Other Updates
CMS Publishes CY 2025 Final Rules for Home Health and End-Stage Renal Disease
Links to related Final Rule Fact Sheets:
- June 26, 2024: CY 2025 Home Health Prospective Payment System Proposed Rule Fact Sheet (CMS-1803-P)
- https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1803-p
- June 27, 2024: CY 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule Fact Sheet (CMS-1805-P)
- CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-end-stage-renal-disease-esrd-prospective-payment-system-pps-proposed-rule-cms
June 27, 2024: CDC Recommendations Updated 2024-2025 COVID-19 and Flu Vaccines for Fall/Winter Virus Season
The CDC encourages providers to begin their influenza vaccination planning efforts now and to vaccinate patients as indicated once 2024-2025 influenza vaccines become available.
https://www.cdc.gov/media/releases/2024/s-t0627-vaccine-recommendations.htmlBeth Cobb
8/12/2024
The FY 2025 IPPS Final Rule (CMS-1808-F) was issued by CMS August 1, 2024. This article focuses on finalized changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications.
MDC 05: Diseases and Disorders of the Circulatory System:
Left Atrial Appendage Closure (LAAC) with Concomitant Ablation
Request: Create a new MS-DRG to better accommodate the cost of concomitant left atrial appendage closure and cardiac ablation for atrial fibrillation. “According to the requester, the manufacturer of the WATCHMAN™ Left Atrial Appendage Closure (LAAC) device, patients who are indicated for a LAAC device can also have symptomatic AF. For these patients performing a cardiac ablation and LAAC procedure at the same time is ideal.”
CMS Proposal: After claims analysis CMS indicated that “taking into consideration that it clinically requires greater resources to perform concomitant left atrial appendage closure and cardiac ablation procedures, we are proposing to create a new base MS-DRG for cases reporting a LAAC procedure and a cardiac ablation procedure in MDC 05. The proposed new MS-DRG is MS-DRG 317 (Concomitant Left Atrial Appendage Closure and Cardiac Ablation).”
CMS has proposed to include the nine ICD-10-PCS procedure codes that describe LAAC procedures and 27 ICD-10-PCS procedure codes describing cardiac ablation for the proposed new MS-DRG.
Final Rule: CMS finalized their proposal to create new MS-DRG 317 (Concomitant Left Atrial Appendage Clouse and Cardiac Ablation) in MDC 05, with modification of the list of procedure codes describing cardiac ablation by removing four codes.
|
FY 2025 Shift in R.W. for LAAC with Concomitant Ablation |
||||
|
DRG |
DRG Description |
R.W. |
GMLOS |
ALOS |
|
273 |
Percutaneous & Other Intracardiac Procedures w/MCC |
3.9100 |
3.4 |
5.4 |
|
274 |
Percutaneous & Other Intracardiac Procedures w/o MCC |
3.1208 |
1.2 |
1.4 |
|
317 |
Concomitant Left Atrial Appendage Closure & Cardiac Ablation |
6.1860 |
2.1 |
3.0 |
|
Source: FY 2025 IPPS Final Rule – Table 5 |
||||
Neuromodulation Device Implant for Heart Failure (Barostim™ Baroreflex Activation Therapy)
The BAROSTIM™ system is the first neuromodulation device system designated to trigger the body’s main cardiovascular reflex to target symptoms of heart failure. The system is indicated for the improvement of symptoms of heart failure in a subset of patients with symptomatic New York Heart Association (NYHA) Class III or Class II heart failure, with a low left ventricular ejection fraction, who also do not benefit from guideline directed pharmacologic therapy or qualify for Cardiac Resynchronization Therapy (CRT).
This system was approved for new technology add-on payments for FY 2021 and FY 2022 and was discontinued in FY 2023.
Request: A request was submitted to reassign the ICD-10-PCS procedure codes describing the BAROSTIM™ system from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without MCC respectively) to MS-DRGs 275 (Cardiac Defibrillator Implant with Cardiac Catheterization with MCC), MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC and without MCC respectively); or to other more clinically coherent MS-DRGs for implantable device procedures indicated for Class III heart failure patients. ICD-10-PCS codes uniquely identifying the implantation of the BAROSTIM™ system includes:
- 0JH60MZ (Insertion of stimulator generator into chest subcutaneous tissue and fascia, open approach)
- in combination with
- 03HK3MZ (Insertion of stimulator lead into right internal carotid artery, percutaneous approach) or
- 03HL3MZ (Insertion of stimulator lead into left internal carotid artery, percutaneous approach).
CMS Response: While there is no intravascular component when implanting a BAROSTIM™ system, they did agree that ICD, CRT-D, and CCM devices and the BAROSTIM™ system are clinically coherent in that they share an indication of heart failure, a major cause of morbidity and mortality in the United States, and that these cases demonstrate comparable resource utilization. As such, they are proposing to reassign the cases reporting procedure codes describing implantation of a BAROSTIM™ system to MS-DRG 276, even if there is no MCC reported, to better reflect the clinical severity and resource use involved.
They are also proposing to change the title of MS-DRG 276 from “Cardiac Defibrillator Implant with MCC” to “Cardiac Defibrillator Implant with MCC or Carotid Sinus Neurostimulator.”
Final Rule: CMS finalized their proposal to reassign the implantation of the BAROSTIM™ system to MS-DRG 276, even if there is no MCC reported. Also, the DRG name was changed to the above proposed name.
|
FY 2025 Shift in R.W. for the BAROSTIM™ System |
||||
|
DRG |
DRG Description |
R.W. |
GMLOS |
ALOS |
|
252 |
Other Vascular Procedures w/MCC |
3.4302 |
5.5 |
8.1 |
|
253 |
Other Vascular Procedures w/CC |
2.5529 |
3.8 |
5.1 |
|
254 |
Other Vascular Procedures w/o CC/MCC |
1.7493 |
1.9 |
2.3 |
|
276 |
Cardiac Defibrillator Implant w/MCC or Carotid Sinus Neurostimulator |
6.1940 |
6.2 |
8.3 |
|
Source: FY 2025 IPPS Final Rule – Table 5 |
||||
Beth Cobb
8/12/2024
As part of the Annual Proposed and Final Rule process, CMS evaluates diagnosis codes and their impact on hospital resource utilization. The following timeline of events highlights CMS efforts from FY 2008 to what was finalized in the FY 2025 IPPS Final Rule.
FY 2008 IPPS Final Rule
CMS described their process for establishing three different levels of CC severity into which diagnosis codes would be subdivided. The categorization of diagnoses as a MCC, a CC, or a Non-CC was accomplished by evaluating each diagnosis code to determine the extent to which its presence as a secondary diagnosis would result in increased hospital resource use.
FY 2020 IPPS Proposed Rule
CMS noted with the transition to ICD-10-CM and the significant changes to diagnosis codes since FY 2008, a new comprehensive analysis was warranted. At that time, CMS proposed changes to the severity level designation for 1,492 ICD-10-CM diagnosis codes. After consideration of comments received, the proposal was not finalized.
October 8, 2019
CMS held a listening session that included a review of the methodology CMS utilized to mathematically measure the impact on resource use.
FY 2021 IPPS Final Rule
CMS discussed their plan to continue a comprehensive CC/MCC analysis, using a combination of mathematical analysis of claims data and the application of the following nine guiding principles:
- Represents end of life/near death or has reached an advanced stage associated with systemic physiologic decompensation and disability,
- Denotes organ system instability or failure.
- Involves a chronic illness with susceptibility to exacerbations or abrupt decline.
- Serves as a marker for advanced disease states across multiple different comorbid conditions.
- Reflects systemic impact.
- Post-operative/post-procedure condition/complication impacting recovery.
- Typically requires higher level of care (that is, intensive monitoring, greater number of caregivers, additional testing, intensive care unit care, extended length of stay).
- Impedes patient cooperation or management of care or both.
- Recent (in the last 10 years) changes in best practice, or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use.
FY 2025 IPPS Final Rule
CMS indicates they have continued to solicit feedback since the nine guiding principles were first introduced in the FY 2021 IPPS Final Rule but have received no additional feedback or comments since then.
Effective October 1, 2024, CMS finalized using the nine guiding principles in combination with mathematical analysis of claims to determine the extent to which the presence of a diagnosis code as a secondary diagnosis results in increased hospital resource use.
FY 2025 ICD-10-CM Diagnosis Severity Changes
For FY 2025 there are:
- 4 additions to the MCC list, and
- 104 additions to the CC list.
Social Determinants of Health Z-Codes
For FY 2025, CMS finalized their proposal to change the DRG designation for seven SDOH-Z codes from non-cc to CC and includes:
- Z59.10 (Inadequate housing, unspecified)
- Z59.11 (Inadequate housing environmental temperature)
- Z59.12 (Inadequate housing utilities)
- Z59.19 (Other inadequate housing)
- Z59.811 (Housing instability, housed, with risk of homelessness)
- Z59.812 (Housing instability, housed, homelessness in past 12 months)
- Z59.819 (Housing instability, housed unspecified).
CMS notes in the final rule that “we hope and expect that this finalization will foster the increased documentation and reporting of the diagnosis codes describing social and economic circumstances and continue to serve as an example for providers that when they document and report Z codes, CMS can further examine the claims data and consider future changes to the designation of these codes when reported as a secondary diagnosis.”
Resource
FY 2025 IPPS Final Rule at https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2025-ipps-final-rule-home-pageBeth Cobb
7/10/2024
CMS has released the 2025 ICD-10-CM diagnosis code tables, the ICD-10-CM Coding Guidelines, and updated ICD-10-PCS procedure code tables and index and Addendum.
It is important to annually review the ICD-10-CM Official Guidelines for Coding and Reporting as “these guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”
When reading the guidelines, look for what is new and for when the guidelines indicate that you should query the provider if documentation is unclear. Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1st start of the 2025 CMS Fiscal Year.
Resources
- CMS.gov webpage: 2025 ICD-10-CM: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-cm
- CMS.gov webpage: 2025 ICD-10-PCS: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs
Beth Cobb
6/26/2024
Medicare MLN Articles
May 23, 2024: MLN MM13620: HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: October 2024
This article reviews discontinued HCPCS codes, new HCPCS codes, and HCPCS codes subject to and excluded from CLIA edits as of October 1, 2024. https://www.cms.gov/files/document/mm13620-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-october-2024.pdf
June 3, 2024: MLN MM13632: Hospital Outpatient Prospective Payment System: July 2024 Update
Make sure your billing staff knows about payment system updates for July including new CPT and HCPCS codes, covered devices for OPPS pass-through payments, drugs, biologicals and radiopharmaceutical, and skin substitutes.
June 13, 2024: MLN MM13658: DMEPOS Fee Schedule: July 2024 Quarterly Update
In this article you will find updates to CY 2024 fee schedule amounts for certain DMEPOS codes and information in changes in payment policy and new fee schedule information for HCPCS codes K1007 and E2298.
https://www.cms.gov/files/document/mm13658-dmepos-fee-schedule-july-2024-quarterly-update.pdf
June 13, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024
This article includes July updates for new CPT and HCPCS codes, coverage of Elios System for patients with primary open-angle glaucoma, and information about skin substitutes.
https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf
June 13, 2024: MLN MM13651: Medicare Benefit Policy Manual Update: DMEPOS Benefit Category Determinations
This article highlights updates to Section 110.8, Medicare Benefit Policy Manual, Chapter 15, and information about added DMEPOS items and their national benefit category determination (BCDs).
Coverage Updates
May 24, 2024: MLN MM13598: National Coverage Determination 200.3: Monoclonal Antibodies for the Treatment of Alzheimer's Disease
Make sure your billing staff knows about FDA-approved monoclonal antibodies, criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf
June 20, 2024: National Coverage Analysis (NCA): Transcatheter Tricuspid Valve Replacement (TTVR)
CMS notes that TTVR is a new technology for use in treating tricuspid regurgitation (TR) and they have received a formal request to provide coverage for the EVOQUE tricuspid valve replacement system (EVOQUE system). This NCA will focus on clinical indications for use of TTVR among Medicare beneficiaries. The public comment period for this NCA is from June 20, 2024, to July 20, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=314
June 25, 2024: NCA: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection
CMS updated this NCA noting that they released a Technical Frequently Asked Questions for Pharmacies. In response feedback, this document provides technical detail following the previous posting of the fact sheet on April 15, 2024. CMS also noted the final NCD is expected to be similar to the proposed published July 12, 2023, and pharmacies should prepare not to ready for this transition. They are sharing as much information as possible before issuing the final NCD to avoid disruptions for beneficiaries. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=310&ncacaldoctype=all&status=all&sortBy=status&bc=17
Compliance Education Updates
May 2024: MLN006559: Medicare Preventive Services
This MLN educational tool was revised in May to update the applicable codes for Hepatitis C screening. This tool includes helpful information related to HCPCS & CPT codes, ICD-10 codes, what Medicare covers, the frequency of screening, what the patient pays and additional miscellaneous notes. You will also find applicable coverage requirements when one has been published for the preventive service (i.e., for bone mass measurement you will find a link to national coverage determination 150.3: Bone (Mineral) Density Studies. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#BONE_MASS
Beth Cobb
6/26/2024
May 28, 2024: CMS Updates to Include Marriage and Family Therapists and Mental Health Counselors for Hospice, Rural Health Clinics, and Federally Qualified Health Centers
In the memorandum summary sent to State Survey Agency Directors, CMS notes the CY 2024 PFS final rule updated the Hospice Conditions of Participation, the Rural Health Clinic (RHC) Conditions for Certification, and the Federally Qualified Health Center (FQHC) Conditions for Coverage to implement provisions of the Consolidated Appropriations Act, 2023.
For Hospices: The interdisciplinary team must now include at least one social worker, marriage and family therapist or mental health counselor as part of the team. The hospice personnel requirements were updated to add these disciplines.
For RHCs and FQHCs: Staffing and personnel requirements were updated to include marriage and family therapists and mental health counselors as part of the collaborative team approach to providing services. Also, definitions of several health care professionals who are already eligible to provide services at RHCs and FQHCs were updated, including the definition of “nurse practitioner,” to align with current standards of professional practice. https://www.cms.gov/files/document/qso-24-12-hospice-fqhc/rhc.pdf
Comprehensive Error Rate Testing Program: Reduced Sample Size Starting Reporting Year (RY) 2025
The CERT selects a stratified random sample of Part A/B claims submitted to the Medicare Administrative Contractors (MACs). The sample size allows CMS to calculate a national improper payment rate and contractor-and-service-specific improper payment rates. The sample size is considered to reflect all claims processed by the Medicare FFS program in the report period. CMS recently announced that beginning with the RY 2025, the sample size will be permanently reduced from 50,000 to 37,500 claims annually. CMS notes on their CERT webpage that “it is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements.”
June 7, 2024: FDA Approves Expanded Age Indication for GSK’s Arexvy
GSK noted in their announcement that “over 13 million US adults aged 50-59 have a medical condition that increased their risk of RSV outcomes.” Further, the US FDA has approved Arexvy (Respiratory Syncytial Virus (RSV) Vaccine, Adjuvanted) for the prevention of RSV lower respiratory tract disease (LRTD) in adults 50 through 59 years who are at increased risk for example, adults with COPD, asthma, heart failure and/or diabetes.
- June 7, 2024 FDA Letter to GlaxoSmithKline (GSK) Biologicals: https://www.fda.gov/media/179248/download?attachment=&utm_medium=email&utm_source=govdelivery
June 10, 2024: OIG Semiannual Report to Congress
OIG released their semiannual report for the 6-month period ending March 31, 2024. Inspector General Christi A. Grim notes that OIG used experts and authorities, highly developed data analysis techniques, and strong partnerships with other law enforcement and oversight entities, OIG identified $2.76 billion in expected recoveries and issued 195 recommendations and completed 60 audits and 18 evaluations in this reporting period. Inspector General Grim went on to indicate that OIG’s health care work consistently yields a positive return on investment of around $10 returned to every $1 invested. https://oig.hhs.gov/documents/sar/9905/Spring_2024_SAR.pdf
June 11, 2024: Long COVID Defined
The National Academies of Sciences, Engineering, and Medicine (NASEM) released a new definition for “Long COVID” – “that it is an infection-associated chronic condition that occurs after COVID-19 infection and is present for at least three months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems.” https://www.nationalacademies.org/news/2024/06/federal-government-clinicians-employers-and-others-should-adopt-new-definition-for-long-covid-to-aid-in-consistent-diagnosis-documentation-and-treatment
June 20, 2024 MLN Connects: Watch out for Medicare Record Request Phishing Scam
CMS notes they have identified phishing scams for medical records. In the June 20th edition of MLN Connects they provide an example, signs of a scam to look for in a request. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-06-20-mlncBeth Cobb
6/19/2024
On June 13, the OIG published the report CMS Could Strengthen Program Safeguards To Prevent and Detect Improper Medicare Payments for Short Inpatient Stays. This audit was initiated to assess program safeguards for ensuring that Medicare claims for short inpatient stays complied with Medicare Requirements.
Two-Midnight Rule
It is hard to believe that so much time has passed since the Two-Midnight Rule went into effect on October 1, 2013. In general, when a hospital stay does not span two midnights, inpatient status is not appropriate. There are caveats, for example, procedures designated as “inpatient only” are appropriate for inpatient billing regardless of the length of stay.
Post two-midnight rule implementation, the OIG concluded in a report that “hospitals were still billing for many short inpatient stays that were potentially inappropriate under the two-midnight rule, and Medicare paid almost $2.9 billion for these stays.” At that time, CMS agreed with the OIG recommendation that they improve oversight of hospital billing under the two-midnight rule.
About the June 13, 2024 13 OIG Report
The OIG focused on program safeguards for short inpatient stays for calendar years 2016 through 2020. Program safeguards used by CMS and it contractors include measuring improper payment rates through the Comprehensive Error Rate Testing (CERT) Program, implementing claims processing edits, and conducting post payment review claims. The audit covered:
- $19.7 billion in Medicare Part A claims, and
- 2.5 million short inpatient stays at 3,340 acute-care hospitals.
After the two-midnight rule went into effect, the CERT added a table to their supplemental improper payment data highlighting projected improper payments by length of stay. The first year this was reported the 0- or 1-day stays projected improper payment rate was 27.8% with a projected improper payment of $2.1B. In the December 2023 data, the 0- or 1-day stays improper payment rate remained high at 21.7% with a projected improper payment of $1.7B.
Report Conclusion
Three weaknesses in the established program safeguards for preventing and detecting improper payments for short inpatient stays and recovering payments. Specifically, the OIG concluded that CMS did not have:
- Adequate information to identify short inpatient stays at risk for noncompliance with the two-midnight rule,
- Prepayment edits for claims at risk for noncompliance with the two-midnight rule, and
- Adequate policies and procedures to review claims at risk for noncompliance with the two-midnight rule and to recover payments.
Weaknesses occurred from CMS mostly relying on post payment reviews by BFCC-QIOs to ensure compliance with the two-midnight rule. Although thousands of claims were reviewed and denied $49.2 million in improper payments during the audit period, this represents only 0.6 percent of the $7.8 billion in improper payments estimated by CMS CERT reviews.
Recommendations to CMS
The OIG made the following four recommendations to CMS:
- Add information to inpatient claims indicating any stay that did not span two or more midnights because of an unforeseen circumstance,
- Develop a list of inpatient-only procedure codes associated with the outpatient procedure codes on the inpatient-only procedure list,
- Implement prepayment edits for claims for short inpatient stays at risk for noncompliance with the two-midnight rule, and
- Update policies and procedures for post payment reviews to focus on claims for short inpatient stays identified as at risk for noncompliance with the two-midnight rule and to focus on overpayment recoveries.
CMS Response to Recommendations
CMS neither agreed nor disagreed with the OIG recommendations, merely stating that they will take them into consideration as it determines appropriate next steps.
I would not get too excited about the recommendation to develop a list of inpatient-only procedure codes associated with outpatient procedure codes on the inpatient-only procedure list. MMP clients have often asked if there was such a list available as hospitals work to identify inpatient-only procedures. Currently, there is no such list. Also, I agree with CMS in that this task would be a challenge as “the ICD-10 and HCPCS code sets are intended to reflect and represent services in different healthcare settings that there would limitations in developing a one-to-one mapping.”
In the meantime, I encourage you to take the time to read this report in its entirety for additional information regarding the OIGs findings, the BFCC QIO 2 Midnight Claim Review Guideline that Livanta, the National Medicare Claim Review Contractor, utilizes in performing short stay audits nationwide, and CMS comments in response to the OIG’s recommendations.
Beth Cobb
6/19/2024
The OIG’s updates its Work Plan on their website monthly and they have indicated that their “work planning process is dynamic, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.”
For June 2024, the OIG has added eleven items to their Work Plan. One of the items of interest for hospitals is titled Medicare Enrollees Leaving Hospitals Against Medical Advice. The OIG notes that “according to some academic researchers, the AMA designation indicates a higher risk that a patient experienced poor quality health care. The researchers also note that hospital stays coded with the AMA designation may be associated with increased patient morbidity and mortality percentage rates. In addition, the researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation. The percentage rates that hospitals have been designating that Medicare enrollees left AMA have increased over the past three decades. This data brief will analyze the percentage rates and outcomes for enrollees that hospitals designate as left AMA as well as provide CMS and other stakeholders with information that can be used to address health disparities and improve enrollee outcomes.”
The OIG is expected to issue a report in FY 2025. In the meantime, I turned to our sister company, RealTime Medicare Data (RTMD) to learn about this group of Medicare beneficiaries in CY 2023. The RTMD database includes paid claims data for all fifty states and Washington D.C.
The following insights were pulled from all Medicare Fee-For-Service paid claims in calendar year 2023 with a discharge disposition code of “07” which stands for “left against medical advice or discontinued care.”
All Claims with Discharge Disposition “07”
Volume: 72,370
Total Payment: $779,351,684.25
Average Payment: $10,769.14
ALOS: 3.054 Days
Surgical Claims with Discharge Disposition 07
Surgical Volume: 5,021
Total Payment: $134,587,109.49
Average Payment: $26,810.18
ALOS: 6.089
Top 5 MDCs by Surgical Volume
MDC 5: Circulatory System: 1,335 claims
MDC 8: Musculoskeletal System & Connective Tissue: 828 claims
MDC 18: Infectious & Parasitic Disease: 517 claims
MDC 6: Digestive System: 411 claims
MDC 11: Kidney & Urinary Tract: 363 claims
Top Surgical MS-DRG Group: MS-DRGs 853 and 854: Infectious & Parasitic Diseases with O.R. Procedures with and without MCC: 465 claims
Top 5 Provider States by Surgical Volume
California: 734 claims
Florida: 575 claims
Texas: 372 claims
New York: 354 Claims
Pennsylvania: 188 claims
Medical Claims with Discharge Disposition 07
Medical Volume: 67,349
Total Payment: $644,764,574.76
Average Payment: $9,573.48
ALOS: 2.82
Top 5 MDCs by Medical Volume:
MDC 5: Circulatory System: 13,664 claims
MDC 4: Respiratory System: 7,808 claims
MDC 1: Nervous System: 5,976 claims
MDC 6: Digestive System: 5,860 claims
MDC 18: Infectious & Parasitic Diseases: 5,692 claims
Top MS-DRG Pair: MS-DRGs 871 and 872: Septicemia or Severe Sepsis without MV >96 hours with and without MCC respectively: 5,320 claims
Top 5 Provider States by Medical Volume
California: 9,962 claims
Florida: 8,334 claims
New York: 5,595 claims
Texas: 5,330 claims
Pennsylvania: 2,334 claims
Social Determinants of Health and Discharge Disposition 07
As mentioned previously, “researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation.”
Social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. ¹ For this reason, I also looked for claims with a Social Determinant of Health (SDOH) Z code listed as a secondary diagnosis.
Out of this group of claims where the beneficiary left AMA, 3,519 Z-Codes were listed as a secondary diagnosis. Note, there were claims where more than one Z code had been coded so this number does not represent 3,519 individual Medicare beneficiaries. That said, there were 2,354 unique claims where one of the homelessness Z-codes was on the claim and 24 unique claims where one of the inadequate housing Z-codes were on the claim.
Resource
U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion: Health People 2030: Social Determinants of Health webpage: https://health.gov/healthypeople/priority-areas/social-determinants-health
Beth Cobb
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