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One of the most talked about changes in the 2014 IPPS Final Rule has been the new 2-Midnight Benchmark guidance for Physicians. Physicians are directed to write the order for an inpatient admission when they have the expectation that a Medicare beneficiary will need medically necessary inpatient services beyond a 2-Midnight Benchmark. I can almost hear it now, but what about…

CMS did indicate that there would be exceptions to when a beneficiary would not exceed 2-Midnights but would still be appropriate as an inpatient. Specific examples include:

• Unforeseen circumstances such as death or transfer,
• The patient rapidly improves and the reasonable expectation was clearly documented in the record, or
• A patient leaves against medical advice (AMA).

On November 27, 2013 CMS released an updated Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 download to include the new potential exception to the 2-midnight rule of mechanical ventilation initiated during the present visit.

CMS has identified the following potential exception to the 2-midnight rule:

1. Mechanical Ventilation Initiated During Present Visit: CMS stated in its discussion of rare and unusual circumstance that treatment in an Intensive Care Unit, by itself, does not support an inpatient admission absent an expectation of medically necessary hospital care spanning 2 or more midnights. Stakeholders have notified CMS that they believe beneficiaries with newly initiated mechanical ventilation support an inpatient admission and Part A payment. CMS believes newly initiated mechanical ventilation to be rarely provided in hospital stays less than 2 midnights, and to embody the same characteristics as those procedures included in Medicare’s inpatient –only list. While CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, if the physician expects that the beneficiary will only require one midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate.

It is important to pay attention to the NOTE included in this update that indicates that “this exception is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment.” So, those outpatient patient procedures that require mechanical intubation during the procedure where the patient is weaned from ventilator support during recovery may not be an appropriate exception to the 2-Midnight Rule.

CMS continues to seek suggested exceptions from the hospital industry. If you have suggestions you can send them by email to IPPSAdmissions@cms.hhs.gov and enter “Suggested Exceptions to the 2 Midnight Benchmark” in the subject line.

We would like to share with our readers that CMS will be hosting another Special Open Door Forum: Final Rule CMS-1599-F: Discussion of the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on Thursday December 19th from 1:00pm-2:00pm Eastern Time. You can go to the Special Open Door Forum CMS webpage at http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html for more details on how to participate.

MMP also encourages you to continue to watch for 2-Midnight Benchmark and Physician Certification Guidance updates on the CMS Inpatient Hospital Review page at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

In the last I-10 Corner article we covered Part One of Musculoskeletal System in ICD-10-CM. For this week, Part Two will address the procedures for the Musculoskeletal System. For the PCS portion, we will cover some key points and guidelines that are necessary for you to assign the correct ICD-10-PCS codes.

For those of you who attended AHIMA’s ICD-10-CM/PCS training classes you already know the underlying meaning of the title. In ICD-10-PCS, this sentence helps us to identify the names of the seven characters and what they represent for a code in PCS. Notice below the sharp contrast between ICD-9 and ICD-10-PCS for a left total knee replacement:

ICD-9-CM: Total Knee Replacement, 81.54

ICD-10-PCS: Left Total Knee Replacement, with insertion of total knee prosthesis 0SRD0JZ

‍ICD-10-PCS for the Musculoskeletal System – Part 2

11 of the 31 Body Systems pertain to the MS System                  

• Muscles
• Tendons
• Bursae and Ligaments
• Head and facial bones
• Upper bones
• Lower bones
• Upper joints
• Lower joints
• Anatomical regions general
• Anatomical regions upper extremities
• Anatomical regions lower extremities Example of Root Operation Groups typically seen with Chapter 13
• Excision – Biopsy of muscle
• Detachment – Below knee amputation
• Division - Osteotomy
• Release – Carpal tunnel release
• Reattachment – Reattachment of hand
• Reposition – Fracture reduction
• Transfer – Tendon transfer
• Replacement – Total hip replacement
• Supplement – Placing a new acetabular liner in a previous hip replacement
• Revision – Re-cementing hip prosthesis
• Fusion – Spinal fusion
• Inspection – Diagnostic Arthroscopy
• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

Arthroplasty of Hip and Knee

Often, the hip bearing surface was not known and was not reported. In ICD-10-PCS, you must know the type of surface for arthroplasty of the hips and knees in order to assign the correct procedure code.

You need to know:

• laterality
• type and material the device is made of, i.e., synthetic substitute or autologous tissue substitute
• specific surface replaced in partial hip and knee replacements
• cemented vs. un-cemented

ICD-10-PCS Coding Guideline

Conventions

A11

Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

B3. Root Operation

Overlapping Body Layers

B3.5

If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.

Example: Excisional debridement that includes skin and subcutaneous tissue and       muscle is coded to the muscle body part.

Fusion Procedures of the Spine

B3.10a

The body part coded for a spinal vertebral joint(s) rendered immobile by a spinal fusion procedure is classified by the level of the spine (e.g. thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.

Example: Body part values specify Lumbar Vertebral Joint, Lumbar Vertebral Joints, 2 or More and Lumbosacral Vertebral Joint.

B3.10b

If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

Example: Fusion of lumbar vertebral joint, posterior approach, anterior column and fusion of lumbar vertebral joint, posterior approach, posterior column are coded separately.

B3.10c

Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:

• If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device
• If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
• If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute

Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device.

Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute.

Release procedures

B3.13

In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.

Example:         Lysis of intestinal adhesions is coded to the specific intestine body part value.

Release vs. Division

B3.14

If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.

Examples: Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division.

B4. Body Part

Branches of body parts

B4.2

Where a specific branch of a body part does not have its own body part value in PCS, the body part is coded to the closest proximal branch that has a specific body part value.

Example: A procedure performed on the popliteus tendon is coded to the lower leg tendon body part.

Tendons, ligaments, bursae and fascia near a joint

B4.5

Procedures performed on tendons, ligaments, bursae and fascia supporting a joint are coded to the body part in the respective body system that is the focus of the procedure. Procedures performed on joint structures themselves are coded to the body part in the joint body systems.

Example: Repair of the anterior cruciate ligament of the knee is coded to the knee bursae and ligament body part in the bursae and ligaments body system.

Knee arthroscopy with shaving of articular cartilage is coded to the knee joint body part in the Lower Joints body system.

Skin, subcutaneous tissue and fascia overlying a joint

B4.6

If a procedure is performed on the skin, subcutaneous tissue or fascia overlying a joint, the procedure is coded to the following body part:

• Shoulder is coded to Upper Arm
• Elbow is coded to Lower Arm
• Wrist is coded to Lower Arm
• Hip is coded to Upper Leg
• Knee is coded to Lower Leg
• Ankle is coded to Foot

Fingers and toes

B4.7

If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedures performed on the toes are coded to the body part value for the foot.

Example: Excision of finger muscle is coded to one of the hand muscle body part values in the Muscles body system.

Do you know the difference between a National Coverage Determination (NCD) and a Coverage Decision Memorandum? And most importantly, which is binding on Medicare contractors and therefore on providers?

This is addressed in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

National Coverage Determinations (NCDs) are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an item or service is considered to be covered (or not covered). Once published in a CMS program instruction, an NCD is binding on all Medicare Administrative Contractors (MACs), Quality Improvement Organizations (QIOs), Program Safeguard Contractors (PSCs) (now known as ZPICs) and beginning 10/1/01 are binding for Medicare+Choice organizations.

“CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. … The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

This month, I would like to point out a revision to the Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, NCD 100.1. Effective for dates of service on and after September 24, 2013, facility certification will no longer be required for coverage of covered bariatric surgery procedures. A complete discussion of the policy revisions can be found at MLN Matters Article MM8484.

There is also an interesting Decision Memorandum that was published August 13, 2013 concerning coverage of Cardiac Pacemakers. The memo combines the covered indications (documented non-reversible symptomatic bradycardia) for both single and dual chamber pacemakers. Remember however, that as stated above this decision is not binding until it is published as a CMS program instruction updating the NCD manual. We will provide additional information when this occurs.

Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.

The Office of Inspector General (OIG) began reporting Hospital Medicare Compliance Reviews in March of 2011. Almost three years into these reviews the OIG has posted results from seventy-nine (79) hospitals. To date, hospitals in thirty states have been subject to a Compliance Review, three hospitals have had the amount to be returned to the Contractor extrapolated and only one hospital “generally complied with Medicare requirements for billing.”

In keeping with the holiday spirit instead of “remembering our favorite things,” here are the Twelve (12) top Inpatient (IP) and Outpatient (OP) “at risk issues for noncompliance” that the OIG has been looking at during their reviews:

• IP Short Stays,
• OP & IP claims paid in excess of charges,
• OP & IP manufacturer credits for replaced medical devices,
• IP claims billed with high severity level DRG codes,
• OP claims billed with Modifier 59,
• IP same-day discharges and readmissions,
• IP transfers,
• IP claims with payments greater than $150,000,
• OP claims paid in excess of $25,000,
• OP claims billed with E&M services,
• IP hospital-acquired conditions and POA reporting, and
• IP Psychiatric Facility (IPF) ED adjustments.

In the past several weeks we have written several articles about the 2014 IPPS Final Rule, including the Probe and Educate Program that is effective from October 1, 2013 through March 30, 2014. During this time Medicare Administrative Contractors (MACs) will be conducting pre-payment probes for medical necessity of IP stays with a 0 – 1 midnight length of stay. During this time the Recovery Auditors (RA) are not allowed to review claims within this time period. A word of caution, this has been the top issue for OIG Medicare Compliance Reviews and the OIG can and probably will continue to review this risk area as they are not impacted by the Probe and Educate Program.

On the afternoon before Thanksgiving at 4:26 pm, my email inbox dinged with the arrival of the much anticipated 2014 OPPS Final Rule announcement. The Proposed Rule released earlier this year contained the most significant proposed changes to the Outpatient Prospective Payment System since its inception in 2000, including major changes to visit levels, the new concept of “comprehensive APCs”, and dramatic increases in packaging. So would CMS carry through on all these proposals? I anxiously began to read…

So let’s start with some good news:

• They are not consolidating the five ED levels into one visit level. For 2014, hospitals will continue to use their existing self-defined five “E&M” levels to report ED visits. And there are still five incremental payment levels for these ED services.
• They did finalize the establishment of comprehensive APCs but are delaying the implementation of this until 2015 and making some favorable modifications. Comprehensive APCs bundle the payment of all adjunctive services into the payment of the procedure code for 29 device-dependent APCs.
• They eliminated two categories of proposed packaging – ancillary services with a status indicator of “X” and diagnostic tests on the bypass list. This means that routine x-rays, pathology services, a number of diagnostic respiratory services, plus many other services will not be packaged in 2014, but will continue to be paid separately.
• They modified the packaging of add-on codes to exclude drug administration services and add-on codes associated with the future comprehensive APCs. For 2014 these types of add-on codes will continue to be paid separately.
• They are creating new HCPCS codes to allow two levels of payment for skin substitute applications – a lower level of payment for low-cost skin substitutes and a higher level of payment for high-cost skin substitutes since the actual skin substitutes will be packaged.

But of course, CMS did not forsake or modify all of their proposals for 2014.

• The five levels of new and established clinic visits (10 codes in total) are being deleted and replaced with one clinic visit code – G0463 with an unadjusted payment rate of $92.53.
• The two levels of Observation composites (Extended Assessment and Management composites) are being consolidated into one composite level. This composite will be paid when at least eight observation hours are billed on the same day or the day after a clinic visit (G0463), a high level ED visit (99284, 99285, G0384, or 99291) or a direct referral to observation (G0379) if there is not a procedure code with an SI of “T”. The Observation composite unadjusted payment rate is $1,198.91.
• Packaging has been extended to include:
• All drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure including stress agents and Cysview
• Drugs and biologicals that function as supplies when used in a surgical procedure including skin substitutes with the modification of two payment levels noted above
• Clinical Diagnostic Laboratory Tests with the exceptions of laboratory tests unrelated to a primary service (billed on a 14x type of bill) and molecular pathology tests
• Procedures described by add-on codes with the exceptions of drug administration codes and add-on codes associated with the proposed comprehensive APCs
• Stress test (CPT code 93017) when performed with myocardial perfusion imaging
• Device removal procedure when performed with a separately coded device repair or replacement procedure
• Providers will no longer report device credits using modifiers FB and FC, but will now use value code FD and report the amount of the actual credit.
• The nuclear medicine-to-radiopharmaceutical edits are being removed for 2014 although providers are still expected to report these services correctly. CMS is considering whether to continue claim processing procedure-to-device edits when comprehensive APCs are implemented in 2015. It was not clearly stated in the final rule whether these types of edits will remain for 2014.
• The remaining stereotactic radiosurgery (SRS) HCPCS codes are being replaced with the SRS CPT codes, specifically HCPCS code G0173 is replaced with CPT code 77372 and HCPCS codes G0251, G0339 and G0340 are replaced with CPT code 77373. The final rule also provides guidance on the correct usage of the SRS CPT codes.

Obviously there is a lot more information and details in the over 1200 pages of the display copy of the Final Rule, but hopefully this addresses the major changes in which most providers are interested. We encourage everyone to listen and read carefully over the next month to gather all the information you will need for the new year concerning OPPS. In this week’s newsletter, please notice the 2014 Winter Outpatient Webinar that MMP will be presenting on December 12, 2013 at 1:00 pm CDT. In this webinar we will address the CPT and HCPCS code changes for 2014 and the OPPS final rule.

Happy Thanksgiving, Merry Christmas, and Happy New Year!!

ICD-10-CM Chapter 13 Musculoskeletal System – Part 1
In the last I-10 Corner article we covered Infectious and Parasitic Diseases. Our next chapter to review is the Musculoskeletal System which we will cover in two parts. Part one will cover ICD-10-CM and Part two will address ICD-10-PCS. In ICD-10-CM, we will highlight some changes we thought were important for you to be aware of. For instance, The Musculoskeletal System chapter received numerous code expansions partly due to ‘laterality’ being required for code assignment.

Example: Right Medial Epicondylitis

First, take a look below and see how the subchapters or blocks have expanded.

This chapter contains the following blocks:

M00-M02        Infectious Arthropathies

M05-M14        Inflammatory Polyarthropathies

M15-M19        Osteoarthritis

M20-M25        Other Joint Disorders

M26-M27        Dentofacial Anomalies [including malocclusion] and Other Disorders of Jaw

M30-M36        Systemic Connective Tissue Disorders

M40-M43        Deforming Dorsopathies

M45-M49        Spondylopathies

M50-M54        Other Dorsopathies

M60-M63        Disorders of Muscles

M65-M67        Disorders of Synovium and Tendon

M70-M79        Other Soft Tissue Disorders   

M80-M85        Disorders of Bone Density and Structure

M86-M90        Other Osteopathies

M91-M94        Chondropathies

New in Chapter 13

• Big code expansion in this chapter to identify type, site and laterality
• Clarifications for coding joint vs. specific affected bone (see coding guideline)
• Acute traumatic vs. chronic/recurrent conditions are defined with coding instructions
• Osteoporosis and Pathological Fracture information now included in ICD-10-CM Coding Guidelines
• Many codes relocated from other chapters in ICD-9-CM, i.e., Gout, Osteomalacia and Malocclusion
• Lots of other instructions such as:
• Use an external cause code
• Code first underlying disease
• Code also any associated underlying condition
• Use additional code to identify
• Code first poisoning due to drug or toxin
• Code first underlying neoplasm
• Use additional code to identify infectious agent
• Instructions for coding pathological fractures, needs 7th digit extension to identify episode of care (see below)
  Example:
  A Initial encounter for fracture
  D Subsequent encounter for fracture with routine healing
  G Subsequent encounter for fracture with delayed healing
  K Subsequent encounter for fracture with nonunion
  P Subsequent encounter for fracture with Malunion
  S Sequela
• Intraoperative and Postprocedural Complications of the Musculoskeletal System located within this chapter
• Acute traumatic fractures reassigned to Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes

ICD-10-CM Coding Guidelines

1. Site and laterality
   Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.
2. Bone versus joint
   For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
3. Acute traumatic versus chronic or recurrent musculoskeletal conditions
   Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13. Recurrent bone, joint or muscle conditions are also usually found in chapter 13. Any current, acute injury should be coded to the appropriate injury code from chapter 19. Chronic or recurrent conditions should generally be coded with a code from chapter 13. If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.
4. Coding of Pathologic Fractures
   Seventh (7th) character A is for use as long as the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, evaluation and treatment by a new physician. Seventh (7th) character D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae.
   Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
   See Section I.C.19. Coding of traumatic fractures.
5. Osteoporosis
   Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis.
6. Osteoporosis without current pathological fracture
   Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.
7. Osteoporosis with current pathological fracture
   Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

Musculoskeletal System examples of why you need to brush up on your Anatomy and Physiology

Infectious Arthropathy - may also be referred to as Pyogenic or Septic Arthritis. Organisms invade the joint by:

• direct infection of joint; example: infected surgical hip wound
• indirect contamination; infection in bloodstream

Enteropathic Arthropathy - diseases of joints linked to gastrointestinal tract inflammation such as Inflammatory Bowel Disease or Crohn’s Disease.

Palindromic Rheumatism - is a sudden onset of inflammation in one or several joints. Lasts a few hours to a few days and is suddenly gone.

Dorsopathies - is a general term referring to conditions affecting the back or spine. Conditions such as Scoliosis, Spondylosis and Intervertebral disc disorders are included here.

Fragility Fracture -sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone.

Skeletal Fluorosis - this is excessive intake of fluoride causing the bones to become hardened and vulnerable to fractures.

In closing, the more you study this chapter the less you will feel overwhelmed. Once you do this, you will become familiar with the clinical information so that you can educate your physicians of what is required for more specific documentation.

Don’t forget to consult Coding Clinic for ICD-10-CM/PCS information!

In recent years, sleep studies have become big business in healthcare. But is your facility performing these services for the appropriate reasons and meeting the Medicare requirements? Don’t snooze – the OIG is watching!

In October the OIG published a report of their findings on Questionable Billing for Polysomnography Services. The OIG conducted this review because of increasing numbers of services and concerns about potential false claims. Claims for polysomnography services increased 39% from 2005 to 2011, resulting in an increase in Medicare spending of almost $160 million. Also, there was a recent settlement of over $15 million related to fraudulent billing of these types of services. According to the report, in 2011 Medicare paid nearly $17 million for polysomnography services that did not meet one or more of three Medicare requirements.

The most significant finding was for claims submitted with an inappropriate diagnosis code based on Local Coverage Determinations (LCDs). This accounted for over $16M of the improper payments. Also surprising is the fact that 85% of the claims that did not have an appropriate diagnosis code were from hospital outpatient departments. Of the fifteen Medicare Administrative Contractor (MAC) jurisdictions in the audit, eight had LCDs for hospital outpatient sleep study services. Interestingly, Cahaba GBA does not have a local coverage policy and Palmetto GBA only has a Part B policy. However, both Novitas JH and JL have Sleep Study LCDs as well as First Coast, Noridian, CGS, and WPS.

According to Novitas’ policies, the covered indications for sleep studies include narcolepsy, sleep apnea, and parasomnia (excludes typical, uncomplicated and non-injurious parasomnias when the diagnosis is clearly delineated). The policies also include a number of conditions for which sleep studies are not covered, for example chronic insomnia.

Other conditions of coverage include:

• The center is under the direction and control of a Physician/Medical Director. Diagnostic testing does not require direct supervision if the data is interpreted by a physician.
• Patients are referred to the sleep disorder center by the beneficiary's treating physician, and the center maintains a record of the physician's orders and referral.
• The need for diagnostic testing is confirmed by medical evidence, e.g., physician histories and examinations (for example including the sleep history; and exams of the respiratory, cardiovascular, and neurological systems) and any applicable laboratory/diagnostic tests, all documented in the patient’s clinical records.

Concerns from the OIG report beside inappropriate diagnoses include:

• Statutory prohibitions on self-referral specify that Medicare patients receiving polysomnography services at hospital outpatient departments must be ordered by a provider who does not have a financial relationship with the hospital.
• Same-day duplicate claims
• Unbundling of a split-night service - For example, if a provider begins a diagnostic service at 9 p.m. and can make a diagnosis of sleep apnea early on, the provider may then begin the titration at midnight or later and complete a split-night service. In this scenario, a provider should submit a single split-night claim.
• Although occasionally appropriate, frequently performing separate diagnostic and titration services on consecutive nights is unusual.
• Lack of evidence of a visit with the ordering provider during the preceding year. An in-person evaluation is required to determine if polysomnography services are needed and the study should be performed at least within a year of the evaluation.

Although your specific area may not have a local coverage policy, it is wise to be aware of the acceptable requirements for sleep study testing. And watch carefully for new policies for your area – MACs tend to imitate each other.

On November 12th CMS hosted a third, follow-up Special Open Door Forum (ODF) to allow hospitals and practitioners to ask questions regarding the Hospital Inpatient Admission Order and Certification and the 2 Midnight Benchmark for Inpatient Hospital Admissions. While you wait for CMS to post the transcript here is a run down from the Question and Answer (Q&A) portion of the call:

Question(s): More than one caller sought clarification on when care started in the Emergency Department for the 2 Midnight Benchmark. Specific “scenarios” provided by callers:

• What if a triage nurse does more than simply take vital signs and begins to initiate orders and/or treatment protocols that were designed by Physicians. Is this when care starts?
• What if a patient begins receiving treatment in an Ambulance prior to reaching the hospital at the direction of an Emergency Department Physician? Is this when care starts?

Answer: Pre-hospital care time does not count towards the 2 Midnight Benchmark. To meet the spirit of the regulation a Provider (MD, NP or PA) would need to initiate the care to start the time. Of note, CMS is currently considering when a triage nurse initiates a treatment protocol designed by a Physician.

Question: Will claims submitted with date of service from October 1, 2013 through March 31, 2014 later be audited by Recovery Auditors?

Answer: These claims are “off the table” for Recovery Auditors to perform “patient status reviews.” CMS went on to remind callers that they can request claims from this time for Coding Validation and Medical Necessity of Surgical Procedure reviews. This caller asked when this would be put in writing. CMS indicated that this was answered in the first question of the most recently released Questions and Answers on the CMS website.

Question: Regarding the Probe and Educate Program, a caller asked what would happen if the records were not reviewed timely and based on those findings the MAC requests additional records for review.

Answer: CMS indicated that the initial sample will be complete in entirety from October 1 – December 31 dates of service claims. After a review is complete the MACs will identify the denial rate and provide education. The Goal with the program is that a follow up sample would be from claims with dates of services after education had been provided to a hospital.

Question: A caller recognized that in recent information made available on the CMS website it was unclear whether or not Critical Access Hospitals would be part of the Probe and Educate Program and asked for clarification.

Answer: CAHs are not included in the Probe and Educate Program but are still subject to the rules.

Question: A caller provided an example of a patient presenting to the Emergency Department at 10:00 pm who was subsequently admitted as outpatient with observation services. The following morning the patient was no better, no sicker and not safe for discharge. At this point would it be appropriate to write the Inpatient order?

Answer: Yes, update to an Inpatient status.

Question: In regards to the medical review process, will MACs and RAs consider that a verbal order for inpatient admission written by a Nurse Practitioner or Resident that is co-signed by the Attending meets the Physician Certification Requirement?

Answer: Yes, as long as the Inpatient admission is conducted pursuant to an Inpatient order.

Question: One caller requested additional guidance regarding how to treat patient transfers to their hospital in regards to the 2 Midnight Rule.

Answer: CMS indicated that they are still working on this guidance and did note that they are excluding transfer cases from the Probe and Educate Review until the further guidance has been issued.

CMS has identified “rare and unusual” (exceptions) circumstances when a patient would not remain in the hospital greater than 2 Midnights but still be appropriate as an Inpatient. Current exceptions include patient death, patient transfer, patient left AMA or a patient who rapidly improves and is stable for discharge. The last call to be accepted during the ODF was an additional suggestion for an exception. When a patient is admitted and is receiving medically necessary inpatient services but the family requests Hospice care prior to the 2nd Midnight and the patient is discharged home with Hospice. CMS requested that this suggestion be sent to them to take a closer look at this.

CMS indicated during the ODF that they will soon be adding additional guidance regarding the patient order and certification to the website. MMP strongly recommends that you read these two downloads and continue to check the Inpatient Hospital Review page on the CMS website frequently for updates.

Link to Inpatient Hospital Review page:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

Methicillin-resistent Staphylococcus Aureus (MRSA) Infection

MRSA is a very tough to treat infection caused by a strain of staph bacteria that has become resistant to commonly used antibiotics generally used to treat ordinary staph infections.

• Can be life threatening.
• MRSA infection can be contagious by:
• Person-to-person / skin-to-skin contact.
• Coming in contact with materials or surfaces touched by a MRSA infected person or carrier

• A “carrier” is a person that that harbors the organism (MRSA) without manifesting symptoms of the infection.
• A carrier (Z22.322) can transmit the MRSA infection.
• Requires “isolation” while being treated.
• Typically causes skin sores and infections such as:
• Abscess
• Boils
• Stys
• Ulcers
• Cellulitis
• Impetigo
• Carbuncles
• MRSA can quickly spread once the germ has entered into the body.
• Bones
• Joints
• Bloodstream (Sepsis - )
• Muscle, Fascia (Necrotizing Fasciitis)
• Organs
• Brain (Meningitis)
• Heart (Endocarditis)
• Lungs (Pneumonia)
• Kidneys (UTI associated with Foley Catheter)

Health Care-Associated MRSA (HA-MRSA)

• Affects people who have been treated in a health-care facility such as:
• Hospitals
• Nursing Homes
• Rehab facilities
• Dialysis center
• Physician’s office
• Commonly seen in patients with:
• Weakened immune system from:
• Illness
• Long term medication therapy
• Cancer treatment
• Surgical history within a year
• Lengthy admissions to hospitals and/or long-term care facilities
• Chronic Kidney Disease on hemodialysis
• History of IV drug use

Community-Associated MRSA (CA_MRSA)

• MRSA showing up in healthy people outside of a health care setting
• Healthy people who may also be at risk:
• Military
• Children at day-care
• Athletes
• Prison inmates
• People who share items such as towels and razors
• People who have gotten tattoos and/or piercings

Signs and Symptoms

• Non-healing wound
• Headache
• Fatigue
• Rash
• Fever and chills
• Low blood pressure
• Shortness of breath
• Chest pain
• Weakness

Treatment

MRSA is resistant to some antibiotics but is still a treatable condition. There are some kinds of antibiotics that still work.

• Treatment often starts with Bactrim and Vancomycin.
• Other antibiotics used are:
• Clindamycin
• Minocycline
• Tygacil
• Cubicin
• Zyvox
• Synercid
• Unfortunately, even with these medications, there is emerging antibiotic resistance developing.
• Antibiotics are not always necessary.
• With early detection, in cases of a skin abscess or boil caused by MRSA, an incision and drainage may be all that is necessary.

Selection and Sequencing of MRSA Codes

Coding Guidelines:

• Section I.C.1.e.1.a. – Combination Codes for MRSA Infection:   When a patient is diagnosed with an infection that is due to Methicillin Resistant Staphylococcus Aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., Sepsis, Pneumonia) assign the appropriate combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin Resistant Staphylococcus Aureus or code J15.212, Pneumonia due to Methicillin Resistant Staphylococcus Aureus). Do not assign code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere, as an additional code because the combination code includes the type of infection and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to Penicillins, as an additional diagnosis.
• Section I.C.1.e.1.b. – Other Codes for MRSA Infection:   When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere for the MRSA infection. Do not assign a code from subcategory Z16.11, Resistance to Penicillins.
• Section I.C.e.1.c. – Methicillin Susceptible Staphylococcus Aureus (MSSA) and MRSA Colonization:   The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MRSA is present on or in the body without necessarily causing illness. A positive “MRSA screen positive” or “MRSA nasal swab positive”.
• Assign code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, for patients documented as having MRSA colonization. Assign code Z22.321, Carrier or suspected carrier of Methicillin Susceptible Staphylococcus Aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider.

• Section I.C.1.e.1.d. – MRSA Colonization and Infection:   If a patient is documented as having both MRSA colonization and infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus, and a code for the MRSA infection may both be assigned.

Methicillin-susceptible Staphylococcus Aureus (MSSA) Infection

Another commonly known infection caused by the staph bacteria is Methicillin-susceptible Staphylococcus Aureus (MSSA). MSSA is able to be treated with most penicillin based antibiotics and has yet become resistant to the more common antibiotics enabling the treatment to be cleared up easier than it would be if it was resistant in the case of MRSA.

MSSA can be as serious as MRSA. Signs and symptoms are the same.

The implementation date of ICD-10-CM/PCS is fast approaching. ICD-10-CM/PCS will require coders to possess an in-depth knowledge and understanding of anatomy & physiology and pathophysiology.   Coders’, who are well-versed on how a body in both the healthy state as well as during the disease process should function, will be better prepared to query providers for clarification when additional documentation is required.  In turn, a coder will be able to make appropriate correlations when reviewing documentation and be able to avoid needless queries.

If your hospital performs a procedure involving services approved for a new technology add-on payment, are you getting the money you deserve? The 2014 IPPS Final Rule included add-on payments for several new technology drugs and procedures when performed on hospital inpatients. Providers should include the appropriate procedure, diagnosis, and/or drug codes for these services in order to receive the additional payments.

1). Glucarpidase (Voraxaze®)—treats patients who have been diagnosed with toxic methotrexate (MTX) concentrations as a result of renal impairment. It causes a rapid, continuous reduction of MTX concentrations. The procedure code necessary to report this drug is (00.95). The maximum add-on payment is $45,000 per case.

2). DIFICID™ (Fidaxomicin)—an oral antibiotic tablet that works against Clostridium-Difficile associated diarrhea (CDAD). DIFICID cases are reported with diagnosis code (008.45) to capture the Clostridium-Difficile infection in combination with the National Drug Code (52015-0080-01). Both the diagnosis and NDC codes must be reported on the 837i Health Care Claim Form. The maximum add-on payment is $868.

3). Zenith Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft®—treats patients who have an AAA but are anatomically unsuitable for treatment with current endovascular grafts due to their infra-renal aortic neck being too short. The procedure code necessary to report the graft is (39.78). The maximum add-on payment is $8,171.50.

4). Argus® II Retinal Prosthesis System—treatment for patients with Retinitis Pigmentosa that have little or no light perception in either eye. The system consists of an implant (epiretinal prosthesis), an external component, and a fitting system. The procedure code necessary to report the prosthesis is (14.81). The maximum payment is $72,028.75.

5). Zilver® PTX® Drug-Eluting Peripheral Stent—treatment of peripheral arterial disease of the superficial femoral arteries. The stent is coated with Paclitaxel, a drug that treats patients with advanced forms of cancer. The procedure code necessary to report the stent is (00.60). The maximum add-on payment is $1,705.25.

6). Kcentra™--a replacement therapy for fresh frozen plasma (FFP) for patients with an acquired coagulation factor deficiency due to Warfarin and who are experiencing a severe bleed. The procedure code necessary to report this drug is (00.96) (Infusion of 4-Factor Prothrombin Complex Concentrate). The maximum add-on payment is $1,587.50.