2-Midnight Benchmark and Medicare Inpatient-Only Procedures

Question:

In light of the new 2-Midnight Benchmark for Physicians, does this mean that inpatient-only procedures that require a 1-day length of stay would now need to be billed as an outpatient?

Answer:

No, per the excerpt from the 2014 IPPS Final Rule below, admissions for a procedure on the Medicare inpatient-only list regardless of the length of stay should be an inpatient and billed as an inpatient stay.

“Comment: Commenters indicated that inpatient-only procedures that require a 1-day length of stay would be affected by this proposed policy and may not be adequately reimbursed under Medicare Part B. The commenters requested that CMS specify that all services on the inpatient-only list should automatically be deemed to meet inpatient service criteria, even if the beneficiary is in the hospital for less than 2 midnights. Conversely, another commenter suggested that excluding inpatient-only procedures, which may or may not require 2-midnight stays, contradicts a time-based policy.

Response: In the proposed rule, we stated that procedures on the OPPS inpatient-only list are always appropriately inpatient, regardless of the actual time expected at the hospital, so long as the procedure is medically necessary and performed pursuant to a physician order and formal admission. Procedures designated as inpatient-only are deemed statutorily appropriate for inpatient payment at § 419.22(n). As such, we believe that inpatient-only procedures are appropriate for exclusion from the 2-midnight benchmark. Under this final rule, inpatient-only procedures currently performed as inpatient 1-day procedures will continue to be provided as inpatient 1-day procedures, and therefore this rule will not result in any change in status or reimbursement.”

Source: Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations 50947

2-Midnight Benchmark and Psychiatric Services

Question:

Does the new 2-Midnight Benchmark apply to Inpatient Psychiatric Services?

Answer:

Yes, per the excerpt from the 2014 IPPS Final Rule below, the 2-Mignight Benchmark does apply to Inpatient Psychiatric Services.

“Comment: Commenters questioned the applicability of the proposed rule to differing types of hospital facilities. Commenters specifically requested clarity regarding application of the rule to IRFs and IPFs. Commenters further asserted that this distinction may conflict with State laws requiring inpatient admissions post 24 hours, and such States should be granted exception.

Response: In the proposed rule, our reference to section 1861(e) of the Act was intended to specify that CAHs were included in the proposed policies, not that we were proposing that IPFs or other non-IPPS hospitals should be excluded. Having considered the public comments to the proposed rule, we believe that all hospitals, LTCHs, and CAHs, with the exception of IRFs, would appropriately be included in our final policies regarding the 2-midnight admission guidance and medical review criteria for determining the general appropriateness of inpatient admission and Part A payment. Due to the inherent differences in the operation of and beneficiary admissions to IRFs, such providers must be excluded from the aforementioned admission guidelines and medical review instruction. We disagree with the commenters’ assertion that the 2-midnight admission and medical review policies conflict with existing state laws regarding observation. The 2-midnight benchmark does not prohibit physicians from ordering inpatient admission in accordance with state law; rather, this policy indicates when Medicare payment will be deemed appropriate. To the extent that State law requires admission in situations where Medicare payment would not be appropriate, providers should work with their States to resolve those discrepancies.”

Source: Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations 50949

A Medicare patient presents to your hospital to have her pacemaker replaced. Is your hospital due a manufacturer’s credit because the pacemaker is still under warranty, is being recalled, or has malfunctioned? How do you know? If a credit is due, did you receive it? And if you received the credit, did you pass the appropriate information on to Medicare by including the correct modifiers and/or codes on the claim? Understanding and implementing the rules on credits for replaced devices is important in order to receive correct payment and to prevent non-compliance.

The Office of Inspector General (OIG) continues with their compliance reviews of hospitals which look at a number of high-risk issues that the OIG has previously identified. One issue that affects both inpatient and outpatient billing and appears on almost every OIG compliance audit is “manufacturer credits for replaced medical devices not reported.” For example, in four compliance audits published in September, overpayments for manufacturer credits not reported totaled almost $350,000.

Federal regulations require reductions in the inpatient (IPPS) or outpatient (OPPS) payment for the replacement of an implanted device if

1. the device is replaced without cost to the provider or the beneficiary,
2. the provider receives full credit for the device cost, or
3. the provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device.

The biggest challenge for hospitals is not the billing instructions (explained below), but internal policies and processes to identify, obtain, and properly report credits from medical device manufacturers. Within the hospital, this will require coordination and communication between the hospital purchasing department, the product manufacturer, the department performing the procedure (usually cardiology or surgery), patient accounts, and possibly the physician performing the procedure.

Making this even more difficult is the government’s expectation that not only will hospitals correctly report credits they have received, but also that they be aware of when they are due a credit. The Medicare Provider Reimbursement Manual states that Medicare providers are expected to pursue free replacements or reduced charges under warranties for medical devices. The OIG discusses this in their reports as the “prudent buyer principle.”

A recent FDA rule may make the process easier for hospitals to track devices. On September 25, 2013, the FDA finalized a rule that requires most medical devices to have a “unique device identifier” (UDI). This will allow devices to be tracked from the manufacturer to the seller to the buyer to the patient. This new identifier may assist hospitals in tracking credits received and credits due them.

The instructions for reporting device credits on the Medicare claim are found in the Medicare Claims Processing manual: Chapter 3, section 100.8 for inpatient claims and Chapter 4, section 61.3 for outpatient claims.

Inpatient Claims

The important things to remember for inpatient billing regarding device credits include:

• Report condition code 49 or 50 -
• 49 Product Replacement within Product Lifecycle—Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.
• 50 Product Replacement for Known Recall of a Product—Manufacturer or FDA has identified the product for recall and therefore replacement.

• Report value code FD with the amount of the credit, or cost reduction, received by the hospital for the replaced device. Medicare deducts this amount from the final IPPS payment.
• Inpatient device credits only apply to specific MS-DRGs defined by Medicare. A list of the applicable DRGs can be found in MLN Matters Article MM7457.

Outpatient Claims

Outpatient claims must include:

• Modifier FB when the hospital receives a device at no cost or with full credit -
• If the replacement device costs the same or less than the device being replaced, the hospital would report a charge of less $1.01 for the replacement device.
• If the replacement device costs more than the credit for the device being replaced, the hospital would report a device charge of the difference between its usual charges for the replacement device and the device being replaced.
• Modifier FC when the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device due to warranty, recall, or field action.
• Modifiers FB and FC are applied to the procedure code (not the device code)
• Medicare payment is reduced by the full offset payment amount for modifier FB and partial offset amount for modifier FC.
• Outpatient device credits only apply to specific APCs defined by Medicare. The list of applicable APCs can be found at the Hospital OPPS webpage.

MMP encourages hospitals to make sure they have sufficient systems in place to identify manufacture credits for replaced devices they are due or have received, and to perform correct billing to report these credits. Remember, the OIG is watching!

Sepsis, Severe Sepsis and Septic Shock

In ICD-10-CM, there are some terminology changes and revisions. An example in Chapter 1 is that the term Sepsis has replaced Septicemia.

Sepsis is a potential life threatening disease in which the body has a reaction to the presence of pathogenic organisms or toxins that have been released in the bloodstream and tissues.

• Also call “blood poisoning”.
• Patients with Sepsis will appear very sick.
• Diagnosis based on clinical signs and symptoms of infection or systemic inflammation and not on location of infection.
• Sepsis can be diagnosed without positive blood cultures especially when the patient has recently been treated with antibiotics.
• Signs and symptoms can be different from person to person.
• Elderly 80 year old female with UTI may have fever, tachycardia with an increase in white blood count
• A 3 year old child with appendicitis may have low body temp and low white count.
• The same signs and symptoms for Sepsis can also be caused by other disorders.

Coders should never code Sepsis based solely on clinical signs and symptoms alone. Provider clarification and documentation is imperative for the correct code assignment.

Note: When coding Sepsis, it is very important to read the Coding Guidelines and to stay abreast with the ever-changing quarterly updates.

Sepsis has 3 stages. Each stage is indicative of a higher level of severity.

1. Sepsis:     Coding Guideline – Section I.C.1.d.1.a.
2. Assign the appropriate code for the underlying systemic infection showing the type of causal organism. Example:   E coli Sepsis - A41.51.
3. Assign code A41.9 for Sepsis without a specified organism documented.
4. Signs and Symptoms – Patient must exhibit at least 2 of the following:
5. Fever above 100.4 or below 95.
6. Heart rate (tachycardia) higher than 90 beats per minute.
7. Respiratory rate higher than 20 breaths per minute or PaCO2<32 mmHg (4.3 kPa)
8. Confirmed or probable infection.
9. Shaking chills.
10. Leukocytosis
11. Greater than 10% immature bands
12. Hemorrhagic skin rash
13. Hypotension
14. The term “Urosepsis” is not to be considered synonymous with “Sepsis”.
15. There will no longer be a default code for Urosepsis.
16. Provider must be queried for clarification on whether the patient has Sepsis and/or UTI.
17. Severe Sepsis:     Coding Guideline – Section I.C.1.d.1.b.
18. Sepsis with an associated acute organ dysfunction/failure.
19. Coding Guideline – Section I.C.1.d.1.a.iv
20. Documentation must indicate that the acute organ dysfunction is associated with the Sepsis.
21. Query provider if documentation does not clearly show whether the acute organ dysfunction is associated to Sepsis or another condition.
22. Requires a minimum of two codes:
23. Code for underlying systemic infection.
24. Following code from subcategory R65.2.
25. Additional code should also be assigned to identify specific acute organ dysfunction/failure.
26. Patient’s usually treated in ICU.
27. Signs and Symptoms – Patient must exhibit at least 2 of the signs/symptoms listed above and at least one of the following:
28. Significant decrease in urine output.
29. Altered mental status (AMS).
30. Decrease in platelet count.
31. Difficulty breathing.
32. Abdominal pain.
33. Acidosis
34. Nausea and vomiting
35. Diarrhea
36. Cold, clammy and pale skin
37. Septic Shock:     Coding Guideline – Section I.C.1.d.2.
38. Severe Sepsis with extreme hypotension lasting for more than one hour without the return to normal pressure following adequate IV fluid infusion or the need for vasopressors/inotropes to maintain blood pressure.
39. Code for the underlying systemic infection should be sequenced first.
40. Assign following code R65.21 – Severe Sepsis with Septic Shock.
41. Severe Sepsis with Septic Shock must be assigned if Septic Shock is documented in the medical record, even if the term Severe Sepsis is not documented.

Sepsis due to a Post-procedural Infection:     Coding Guideline – Section I.C.1.d.5.

• Code assignment is based on provider documentation clarifying a relationship between the infection and the procedure.
• A code for the post-procedure infection should be assigned first – Example:
• T83.51 - Infection and Inflammatory Reaction due to Indwelling Urinary Catheter
• T80.21 – Infection due to Central Venous Catheter
• Appropriate code from subcategory R65.2 should be assigned if patient is diagnosed with Severe Sepsis along with a code to identify the associated acute organ dysfunction.

Patients at Risk

• Elderly
• Very young babies
• Diabetics
• Recently hospitalized and/or recent invasive surgical procedures
• With wounds or injuries, such as burns
• Weakened immune systems secondary to illnesses and/or drug therapy

Common Sources of Infection

• Urinary Catheters
• Surgical incisions
• Open wounds such as pressure ulcers, burns etc.
• Invasive devices such as IV catheters, breathing tubes etc.
• Surgical drains
• Prosthetic devices

Common Body Sites Where Infections May Start – (Examples)

• Bones – (Diabetics with Osteomyelitis)
• Bloodstream
• Intestines – (Diverticulitis, Peritonitis)
• Kidneys – (Urinary Tract Infection, Pyelonephritis)
• Lungs – (Pneumonia)
• Pancreas – (Pancreatitis)
• Skin – (Cellulitis, Pressure Ulcers)

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.

National Correct Coding Initiative (NCCI) edits have been around since 1996 and Medically Unlikely Edits (MUEs) since 2007, but do you know what they are, why they were developed, how to read the tables, and when and how to appropriately by-pass these Medicare edits? And more importantly, do you realize these edits impact your reimbursement and compliance risk?

Both sets of edits were developed by CMS to reduce inappropriate payments for Part B claims. NCCI edits are based on coding guidelines, conventions and practices and are designed to prevent improper coding and payment. CCI edits originally applied only to physician billing, but there are now tables for physicians and a subset of edits for hospital providers. There are separate MUE tables for practitioner services, facility outpatient services, and DME supplier services.

The MUE table is straightforward with a column for the CPT/HCPCS code and a column for the MUE limit. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors' use only.  

The NCCI table includes code pairs that generally should not be reported together for a number of reasons as explained in the Coding Policy Manual. If both codes of a code-pair edit are reported together for the same date of service by the same provider without an NCCI-modifier, the column 1 code will be paid and the column 2 code will be denied. In addition to the code pair, effective date, and deletion date if applicable, the table includes a modifier indicator that indicates if a modifier is allowed to by-pass the CCI edit when appropriate. An indicator of “1” means a modifier is allowed, “0” means a modifier is not allowed to by-pass the edit and “9” is not applicable (canceled edits).

NCCI edits and MUEs are updated quarterly. The latest versions of the edits are available on Medicare’s NCCI webpage. Also, Medicare publishes the revisions for the quarter for both CCI edits and MUEs.   The MUE updates include additions, deletions, and revisions to the MUE quantity. The CCI edits include additions, deletions and revisions to the modifier indicator.

Tips on Dealing with the Edits

• First and foremost, modifiers should only be used to by-pass the edits when it is appropriate to do so.
• Modifiers are allowed for CCI edits when separate procedures are performed, such as a separate encounter, separate anatomic sites, or separate specimens. Modifiers are appended to the column 2 code of a code pair.
• For MUEs a modifier would be appropriate when the quantity performed exceeds the MUE limit. Separate line items must be reported on the claim so that no single line item quantity exceeds the MUE limit. Modifiers are added to the second and additional line items.
• There are “date of service” MUEs that cannot be bypassed with a modifier. All units of a code with a date of service MUE are denied if the quantity for that date exceeds the MUE limit.
• Acceptable modifiers to by-pass edits include anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI; global surgery modifiers: 24, 25, 57, 58, 78, 79; and other modifiers: 27, 59, 91.
• Refer to the NCCI Policy Manual for a better understanding of the edits and their reasoning. There is a general chapter and then chapters for each CPT/HCPCS code group (such as codes 80000-89999). This manual contains valuable information about correct coding and the edit principals.
• Coders generally apply modifiers for surgical codes when appropriate, but ancillary code pairs may not be identified until processing through facility billing systems. Input from the ancillary department is often necessary to know if it is appropriate to append a modifier to by-pass the code-pair edit. Hospital billers should have a system in place and contact people in the ancillary areas to assist with CCI edits.

NCCI edits and MUEs apply to Medicare and Medicaid claims. Some other payers may also expect providers to follow the edits. MMP recommends you check with payers to determine if they follow these edits or perhaps have some “coding” edits of their own.

This month MMP will focus on some of the important changes and guidelines covering Chapter One “Certain Infectious and Parasitic Diseases”.

Chapter 1 is divided into 22 separate blocks covering two alpha characters A00-B99 and includes:

• Diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin.

Type I Excludes:

• Certain localized infections – refer to body system related chapters.
• Influenza and other acute respiratory infections (J00-J22)

Type 2 Excludes:

• Carrier or suspected carrier of infectious disease (Z22.-)

A separate subchapter was created for “Infections with a Predominantly Sexual Mode of Transmission” (A50-A64) to appropriately group these type diseases together:

• Human Immunodeficiency Virus (HIV) is excluded in this range of codes.

For cases with infections shown to have an associated drug resistance, code Z16 should be assigned in addition to the infection code to show the associated drug resistance.                      

• Coding Guideline I.C 1.c. – Infections Resistant to Antibiotics:  Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant.

Streptococcal Sore Throat has been relocated from Chapter 1 to Chapter 10 – Diseases of the Respiratory System.

Tuberculosis (TB):  

• ICD-10-CM will not ask for information denoting how the disease was identified.
• The codes for Tuberculosis have been restructured and consolidated. Assignment is now based on anatomical site or type.

Intestinal Infections:

• Codes will now identify type of infection.
• Viral
• Bacterial
• Fungal or parasitic/amebic
• Options available for “Other “ and “Unspecified”

Categories B95.0-B99.9 are supplementary codes to identify the infectious agent(s) in diseases classified elsewhere in which there is no organism identified as part of the infection code.

• Refer to Coding Guideline I.C.1.b.

Human Immunodeficiency Virus (HIV) Infections

HIV is the virus that can lead to AIDS (Acquired Immunodeficiency Syndrome).   People with this illness are much more vulnerable to infections due to the attack and alteration to their immune system. This is prone to get worse as the disease progresses. The human body is not capable of fighting off this virus. Once a person is infected with HIV, it is an affliction for the rest of their life.

HIV is found in the body fluids of an infected person and can be transmitted:

• From one person to another through blood-to-blood and/or sexual contact.
• Newborn infants can acquire HIV:
• During pregnancy
• Through delivery
• Through breast feeding
• Blood transfusion
• Sharing hypodermic needles

There is a subcategory and four codes to classify the HIV virus in ICD-10-CM.

B20 - Human Immunodeficiency Virus (HIV) disease

Assign code B20 as the principal diagnosis when a patient is admitted with an HIV-related condition. An additional diagnosis code should be used to identify all reported manifestations of HIV infection.

• Refer to Coding Guideline I.C.1.a.2.a.
• Code only confirmed cases of HIV infection.
• Confirmation does not require a positive serology or culture for HIV. The physician’s diagnostic statement is sufficient.
• Refer to Coding Guideline I.C. 1.a.1.
• People with HIV can acquire many infections that are called “Opportunistic Infections” or OIs.

Includes:

• Acquired Immune Deficiency Syndrome (AIDS)
• AIDS-related Complex (ARC)
• HIV Infection, Symptomatic

Excludes Type 1:

• Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status (Z21)
• Exposure to HIV virus (Z20.6)
• Inconclusive Serologic Evidence of HIV (R75)

Z21 - Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status

Code Z21 is used for reporting a patient diagnosed with a positive HIV status but has never been diagnosed with any type of manifestation or OI.

• Includes HIV positive NOS
• Once a patient has developed an HIV-related OI, the patient should always be assigned code B20 for any future admission/encounter.
• Code Z21 should never be assigned again for a patient diagnosed with HIV/AIDS even if there is no infection or HIV related condition during that present admission.
• Codes B20 and Z21 should never be assigned together during the same admission.

R75 - Inconclusive laboratory evidence of Human Immunodeficiency Virus (HIV)

• An inconclusive serology test, but no definitive diagnosis or manifestation of the HIV infection.

Z20.6 - Exposure to HIV Virus

This code is assigned only when a patient has been exposed or may have come in contact with the HIV virus.

Some Common HIV Infections:   (this list is not all or inclusive)

• Pneumocystis pneumonia (PCP) - Serious infection which causes inflammation and fluid buildup in the lungs.
• Cytomegalovirus - An opportunistic infection which takes advantage of a patient’s weakened immune system.
• Tuberculosis (TB) - Leading cause of death for people infected with HIV.
• Mycobacterium Avium Complex (MAC) - Usually happens only after a patient has been diagnosed with AIDS and when their CD4 cell counts drop below 50.
• Dementia - AIDS dementia is caused by the HIV virus itself, not by the opportunistic infections.
• AIDS Wasting Syndrome - Occurs when a patient with AIDS has lost at least 10% of their body weight -- especially muscle. The patient could experience at least 30 days of diarrhea, extreme weakness and fever that's not related to an infection.
• Non-Hodgkin’s Lymphoma - As a result of a weakened immune system, a patient is prone to develop certain cancers.
• Lipodystrophy - Also known as “fat redistribution”.   This is when the body has problems in the way it produces, uses, and stores fat.
• Kaposi’s Sarcoma (KS) - Type of cancer affecting mainly the skin, mouth, and lymph nodes (infection-fighting glands). Other organs such as the lungs and gastrointestinal tract can be affected as well.

A list of Meds currently available in the US

‍Note: When coding the HIV Disease and Sepsis, it is very important to read and familiarize yourself with the Coding Guidelines. 

The Office of Inspector General (OIG) recently released the report Medicare Incorrectly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Hours of Mechanical Ventilation. In fact, the report indicates that in the calendar years 2009 – 2011, Medicare overpaid hospitals $7.7 million.

Background

The OIG has done prior hospital compliance reviews of claims with MS-DRGs requiring 96 or more hours of mechanical ventilation. In past reviews the OIG found erroneous claims and as such this review was performed to determine whether payments made to hospitals for MS-DRGs requiring 96 or more hours of mechanical ventilation were correct. Hospitals use procedure code 96.72 (Continuous invasive mechanical ventilation for 96 consecutive hours or more) to identify these patients. This review focused specifically on two MS-DRGs:

• MS-DRG 207: Respiratory System Diagnosis with Ventilator Support 96+ Hours and
• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours.

Audit by the Numbers

• $12,764,239: The amount of Medicare Part A payments covered in this audit.
• 290: The number of hospitals included in this audit.
• 377: The number of inpatient claims that were selected as at risk for billing errors.
• 4 days or less: This audit reviewed claims where the length of stay was 4 days or less.
• 14: The number of records where the Medicare payment was correct.
• 363: The number of records where the Medicare payment was incorrect due to the beneficiary not receiving 96 or more hours of mechanical ventilation.
• $7,714,825: The overpayments made by Medicare to the hospitals

As part of the audit process the OIG had the hospitals conduct an internal review of the claims to determine if the services had been billed correctly. The OIG also requested that the hospital provide them with the “itemized bills and medical record documentation, including timelog for the mechanical ventilation and summary of the inpatient stay to determine whether the beneficiaries had received 96 or more hours of mechanical ventilation.”

The report indicates that “the hospitals confirmed that these claims were incorrectly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.”

Centers for Medicare and Medicaid Services (CMS) Response and Action Plan

The OIG found that CMS did not have controls in place to identify the incorrectly paid claims. Since this review, CMS “implemented a new length-of-stay edit for continuous invasive mechanical ventilation for 96 consecutive hours or more. With this edit, effective October 1, 2012, claims found to have procedure code 96.72 and a length of stay fewer than 4 days are returned to the provider for validation and resubmission.”

Is Correct Coding of Ventilator Hours still on the Radar?

Since this review focused on 2009 through 2011 calendar year claims and an edit was put in place as a control to identify incorrectly paid claims, you may be thinking that this should no longer be an issue. However, other Contractors continue to review and or monitor correct coding of ventilator hours. Before we walk through a timeline of who is reviewing this issue it is important to note that most reviewers have expanded their efforts beyond MS-DRGs 207 and 870 to also include the following MS-DRGs:

• MS-DRG 003: Ecmo or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.
• MS-DRG 004: Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R.
• MS-DRG 927:Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft
• MS-DRG 933: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft

Timeline of Review Efforts around Correct Coding of Ventilator Hours:

• Medicare Quarterly Compliance Newsletter October 2011: In the Volume 2, Issue 1 - October 2011 newsletter the CMS reported that Recovery Auditors reviewed MS-DRGs 003, 004, 207, 870, 927 and 933 due to Providers not adding the correct number of Ventilator hours during an inpatient admission. This Newsletter provides examples of their findings and education resources for hospitals.

• Cahaba GBA, the Medicare Administrative Contractor (MAC) for Alabama, Georgia and Tennessee completed a widespread probe review of MS-DRG 270 and posted the findings to their website on November 14, 2011. Their focus was on coding accuracy and medical necessity for acute inpatient hospitalization. One issue identified was that “documentation did not confirm 96 consecutive hours on ventilator support.” They took no further action as a result of this review but continue to monitor utilization through data analysis to see if further reviews are needed.

• The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is now into their 12th Edition of the Short-Term Acute Care Hospitalizations Users Guide. Ventilator Support has been an at risk target since their 6th Edition Users Guide. Internally, providers can view their report to see if they are an outlier and follow the audit recommendations in the report.

• In the 2013 OIG Work Plan, the OIG indicated that “We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. CMS requires that claims be completed accurately to be processed correctly and promptly. For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.”

As you can see this is certainly not a new issue and hospitals need to remain vigilant in their efforts to correctly code ventilator hours.

The hardest part of Medicare’s new guidance is understanding all of the details and nuances of the rules. For example, there were some surprising guidelines in the temporary instructions for the implementation of the final rule for Part A to B billing of denied hospital inpatient claims that could have a financial impact on hospitals. Drug administrations and nebulizer treatments are some of the more frequent Part B services provided to inpatients and now Medicare is saying these services are not billable on a Part B inpatient claim. I understand these services are included in the room and board charge for inpatients, but how is a hospital to recoup the cost of these services when billing under Part B if these services are not separately billable and there is no inpatient Part A payment?

The temporary instructions were published September 16th in MLN Matters article (SE1333).   A lot of the guidance in this article simply reaffirms the instructions from the final rule. MMP presented that information several weeks ago in an article titled “If ‘A’ Doesn’t Work, Try ‘B’”. 

As a reminder, the basic rule for admissions on or after October 1, 2013 is:

“When an inpatient admission is found to be not reasonable and necessary, the Centers for Medicare & Medicaid Services (CMS) will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, except for those services that specifically require an outpatient status such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatients and not inpatients.”

So this week, I would like to point out a few items from the temporary instructions that are new or clarified guidance.

• One of the most significant clarifications concerns the billing of infusions and injections and nebulizer treatments on the Part B inpatient claim. The article clarifies that routine services generally captured in the room and board rate are not separately billable Inpatient Part B services. This includes IV infusions and injections, blood administrations, and nebulizer treatments provided by the floor nurse.
• In the case of UR self-audit determination that the stay was not medically necessary, the hospital must submit a no-pay, provider liable Part A claim and receive a denial before submitting the Part B inpatient claim (12x type of bill). Provider liability is indicated by the inclusion of Occurrence Span Code “M1” and the inpatient admission Dates of Service on the no-pay inpatient claim. If a Part A claim for payment has already been submitted, the hospital must cancel that claim, submit the no-pay claim, and receive a denial prior to billing Part B.
• Services provided prior to the admission order are billed on a 13x outpatient claim; services provided after the admission order are billed on the 12x Part B inpatient claim. This means “inpatient-only” services (such as procedures on the inpatient only list) provided prior to the admission may not be reported on the inpatient claim even though they are not payable on the outpatient claim. Also if observation services are continued after the admission order is written, they are not billable on the inpatient claim since they are exclusively “outpatient” services.
• The article includes a listing of revenue codes not covered under inpatient Part B medical necessity denials. However, note that when a revenue code can be sometimes covered and sometimes not covered, providers should use the HCPCS code to determine if the service is covered.
• The article encourages providers to remember the medical necessity requirements for outpatient services, specifically those outlined in local coverage determinations (LCDs), and to include all diagnosis codes to support these medical necessity requirements on both the Part B inpatient and outpatient claims.
• Billing of limited Part B services still applies when there is no Part A payment because the beneficiary is not entitled to Part A benefits or has exhausted Part A benefits.

Please refer to the article for complete information including the specific claim requirements for the Part A provider liable claim and the Part B inpatient claim.

For continuing to provide quality patient care while dealing with Medicare’s ever-increasing requirements, MMP applauds the providers of all types of rehabilitative therapy services, with a special recognition of physical therapy providers during October, Physical Therapy Month. We hope our articles on therapy issues help therapists to understand and better implement Medicare’s rules. With that in mind, I would like to address the requirements for the use of the Advance Beneficiary Notice (ABN) for outpatient therapy services.

Prior to January 2013, therapy services provided to a patient that exceeded the therapy cap and were not medically necessary were denied as a benefit category denial. That meant the patient was liable for payment and although encouraged, a notification of liability did not have be given to the patient. The American Tax Relief Act changed denials above the therapy cap amount to be provider liable unless the patient is issued an ABN. Since therapy services below the cap have always required an ABN for patient liability, this change provides more consistency. Now, all therapy services that are not medically necessary, above or below the therapy cap amount, require that an ABN be issued to the patient so that the patient can choose whether to obtain the services and accept financial responsibility for them.

So practically, when would a therapist provide medically unnecessary services? The scenario that requires an ABN be given that I have seen most often is when patients have been receiving therapy services for a condition for a while. The patient’s progress plateaus or reaches its maximum potential for that patient in the therapist’s opinion. Sometimes such patients do not want to discontinue therapy services but the therapy is no longer “medically necessary” according to Medicare requirements. This is an appropriate time to issue an ABN to the patient. The challenge here is explaining the situation to the patient so that he or she understands the Medicare regulations and their impending liability. Just another one of the challenges therapists face beyond their clinical duties!

See the last two pages of MLN Matters Article MM8404 for more information on outpatient therapy services use of an ABN.

We are now into the second day of the Centers for Medicare and Medicaid Services (CMS) 2014 Fiscal Year. For those that were unable to listen to the CMS Special Open Door Forum (ODF) this past Thursday September 26th, CMS appeared to have heard and has responded to the medical community’s concerns around the education and implementation of the new 2-Midnight Benchmark for inpatient admissions and the Physician Certification of all inpatient admissions.

Clarification of CMS Inpatient Hospital Policy, Why Now?

On the same day as the ODF, CMS also released a letter to the American Hospital Association (AHA). In both this letter and during the ODF, CMS indicated that they have been facing “pressures” that include:

• “An increase in the average length of observation stays;
• An increase in the Comprehensive Error Rate Testing (CERT) error rate for short inpatient stays;
• An increase in the number of inpatient appeals; and
• Requests from the hospital industry requesting clarification on inpatient review policy.”

The two year conversation around these “pressures” between CMS and the hospital industry are what prompted the implementation of the 2-Midnight Benchmark and Physician Certification process. CMS announced that the next three months (October 1, 2013 – December 13, 2013) will be a transition period where they will monitor the impact of the changes to ensure that they result in the best interest for Medicare beneficiaries. Further, they announced a New Probe and Education Program.

New Probe and Education Program

This new program will begin with dates of admission on or after October 1, 2013 through December 31, 2013. Specific instructions for Contractors include the following:

• Medicare Administrative Contractors (MACs)
• MACs will shift their pre-payment focus to admissions on or after October 1st through December 31st with “0” or “1” midnight lengths of stay.
• The focus of these reviews will be to “determine the medical necessity of the patient status in accordance with the two midnight benchmark.”
• The Pre-payment Probe limit has been set at 10-25 claims per hospital.
• If a MAC completes a probe and finds no issues they will “cease further such reviews for that hospital from October – December 2013, unless there are significant changes in billing patterns for admissions.”
• If a MAC does identify issues, education will be provided to the hospital and then the MAC will conduct further follow-up as necessary.
• Since these will be pre-payment reviews, a hospital could re-bill any denied claims in accordance with the Part A to Part B rebilling Final Rule.
• MACs will use their review findings to determine a hospital’s compliance with the new inpatient rules and provide feedback to CMS for development of joint education and guidance.

• Recovery Auditors (RAs)
• During this same 90 days, “CMS will not permit Recovery Auditors to review inpatient admissions of one midnight or less that begin on or after October 1, 2013.”
• The RA Pre-payment Demonstration will be suspended during the 90 day period for the 11 states that are participating in this demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO).
• RAs will continue pre-payment reviews for Therapy Caps.

• Caution:
• CMS reminds providers that “physicians should make inpatient admission decisions in accordance with the 2 midnight provisions in the final rule. If at any time there is evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2-midnight presumption could warrant medical review.”
• During this transition period MACs can continue to perform coding validation reviews.
• The CERT contractor, Zone Program Integrity Contractors (ZPICs), Office of Inspector General (OIG), etc. are not limited by this 90 day time period and can continue to pick any claims for review.
• Contractor reviews specifically supporting the medical necessity of a surgery (i.e. total knee replacement) and correct coding reviews can continue during this time.

Dress Rehearsal

Moving forward, CMS has set up an Inpatient Hospital Reviews webpage on their website under Medical Review and Education and encourages hospitals to check this site frequently for updates.

Hospitals should take this time to use the next three months as a dress rehearsal to continue with staff education, proceed with your plans to be compliant with the 2-Midnight Benchmark and develop processes to ensure completion of the Physician Certifications prior to beneficiaries being discharged.

2014 IPPS Final Rule Resources:

Link to the Final Rule:  http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

Link to September 5, 2013 Guidance - Hospital Inpatient Admission Order and Certification:  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf

Link to MLN Matters: SE1333 – Temporary Instructions for Implementation of Final Rule 1599-F for Part A to Part B Billing of Denied Hospital Inpatient Claims

 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1333.pdf

Link to CMS Open Door Forums webpage:  http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html