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I love making lists – all sorts of lists: daily to-do’s, grocery lists, my favorite songs/books, long-term goals, etc. There is something satisfying about organizing things into a list format. For those fellow list-lovers out there, the long-awaited instructions on billing of pacemakers to Medicare should be right up your alley. There are lists of covered conditions, non-covered conditions, HCPCS codes, CPT codes, ICD-9 procedure codes, covered diagnosis codes, and sometimes allowed diagnosis codes.

Medicare has finally issued the manual guidance concerning the new guidelines for coverage of single chamber and dual chamber permanent cardiac pacemakers. Under the new guidelines, effective for dates of service on and after August 13, 2013, Medicare covers implanted permanent single chamber or dual chamber cardiac pacemakers for:

1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction.
2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example, syncope, seizures, congestive heart failure, dizziness, or confusion).

The list of conditions for which implanted cardiac pacemakers are not covered is much longer than the list of covered indications. Diagnosis codes for a few of the non-covered indications (exceptions) may be accepted on claims that also contain a covered diagnosis for the bradycardia. The non-covered conditions include:

1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia.
2. Asymptomatic first degree atrioventricular block. *(exception)
3. Asymptomatic sinus bradycardia.
4. Asymptomatic sino-atrial block or asymptomatic sinus arrest. *(exception)
5. Ineffective atrial contractions (for example, chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia. *(exception)
6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart).
7. Syncope of undetermined cause. *(exception)
8. Bradycardia during sleep.
9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block. *(exception)
10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy.
11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia. *(exception)
12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

Hospital Claim Requirements

For outpatient claims, implantable cardiac pacemakers are reported with the following -

Pacemaker device HCPCS Codes

• C1785 – Pacemaker, dual chamber, rate-responsive (implantable);
• C1786 – Pacemaker, single chamber, rate-responsive (implantable);
• C2619 – Pacemaker, dual chamber, nonrate-responsive (implantable);
• C2620 – Pacemaker, single chamber, nonrate-responsive (implantable);

CPT Procedure Codes

• 33206 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial
• 33207 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) –ventricular
• 33208 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial and ventricular

A –KX modifier must be appended to the procedure claim line(s) to attest that documentation is on file verifying the patient has non-reversible symptomatic bradycardia, with symptoms such as syncope, seizures, congestive heart failure, dizziness, or confusion. Claims with one of the above listed pacemaker insertion CPT codes without the KX modifier will be returned to the provider.

Report pacemaker insertion procedures on a hospital inpatient claim with one of the following procedure codes:

• 37.81 Initial insertion of single chamber device, not specified as rate responsive
• 37.82 Initial insertion of single chamber device, rate responsive
• 37.83 Initial insertion of single chamber device

Both inpatient and outpatient claims require one of the following diagnosis codes for the services to be covered by Medicare:

• 426.0 Atrioventricular block, complete (I44.2)
• 426.12 Mobitz (type) II atrioventricular block (I44.1)
• 426.13 Other second degree atrioventricular block (I44.1)
• 427.81 Sinoatrial node dysfunction (I49.5)
• 746.86 Congenital heart block (Q24.6)

 

 

There are diagnoses from the “non-covered” indications (exceptions) that the Medicare Administrative Contractors may decide to accept on claims, but only when reported with one of the above “covered” diagnosis codes. The claim must contain one of the covered diagnosis codes in addition to one of the following diagnosis codes. Also note, this coverage is at the discretion of the MAC. One more note - after ICD-10 implementation, the presence of code R55 (syncope and collapse) will result in denial. These codes are:

• 426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block;
• 426.11 First degree atrioventricular block/ I44.0 Atrioventricular block first degree;
• 426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block/ I45.19 Other right bundle-branch block;
• 427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia;
• 427.31 Atrial fibrillation/ I48.1 Persistent atrial fibrillation/ I48.91, Unspecified atrial fibrillation;
• 427.32 Atrial flutter/ I48.3 Typical atrial flutter/ I48.4 Atypical atrial flutter or I48.91 Unspecified atrial fibrillation; or
• 780.2 Syncope and collapse/R55 Syncope and collapse (R55 is the ICD-10 dx code but is not payable upon implementation of ICD-10 and is only included here for information purposes). 

 

For additional information, please refer to the MLN Matters Article MM9078, Transmittal R3204CP, and Transmittal R179NCD. This includes instructions on professional billing, listing of I-10 procedure codes, and coverage not addressed by the NCD that is left to the discretion of the Medicare Administrative Contractors.

Now you have Medicare’s lists… When hospitals implement these instructions, they will want to have a checklist of their own to make sure they have addressed all the requirements for coverage.

Other recent coverage updates include:

Can you sometimes tell by the tone of someone’s voice or the way they drag out the words, that there is a condition to their answer? “Well, nooo…” You just know the conjunction “but” is coming. Medicare generally communicates with providers in writing, but experience tells us there is often a condition to Medicare’s answers.

A few years ago there was a lot of discussion in Medicare billing circles about whether a physician’s signature is required on a laboratory requisition. And in typical Medicare fashion, the answer was a clear, “No…, but…” The “but” being that although the signature of the ordering physician is not required on the requisition, there has to be an order or documentation of intent to order the lab tests that is signed by the physician. This documentation can be located in the physician’s office chart, but needs to be submitted to the Medicare contractor in the case of a medical review of the claim. And the provider being reviewed (i.e. the testing lab), whose payment is at risk, is the one ultimately responsible for submitting the supporting documentation.

With all the reminders of these requirements that circulated back then, surely most hospital-based and independent laboratories understood what was expected. Therefore, I was a bit surprised to see an announcement back in December concerning a significant increase in pathology and laboratory service errors identified by data analysis of the Comprehensive Error Rate Testing (CERT) program findings. In response to the increase in errors, CERT published a document addressing the lab and pathology errors.

CERT identifies insufficient documentation and incorrect coding as the reasons for the significant errors, but the main issue addressed in the publication is missing or incomplete documentation.

“If a physician’s order for a diagnostic test is not included in the medical record, the physician must document the intent to order the laboratory service.” This documentation must state the specific tests the physician is ordering. Simply stating “ordering lab” is not sufficient. Also the documentation of intent must be signed by the physician or there must be a signed physician’s order for the lab tests. A signed order or signed documentation of intent to order must be sent to the Medicare contractor reviewing the record to support the services billed. Without this documentation, the claim will be denied.

“Documentation must support the medical necessity for the services performed.” Per the Medicare Claims Processing Manual, Chapter 16 , section 120.1 – “Diagnoses are required on all claims” and such diagnostic information must be supplied to the performing laboratory by the ordering physician. There are twenty-three National Coverage Determinations (NCDs) for lab services and individual Medicare Administrative Contractors (MACs) often have Local Coverage Determinations (LCDs) for other lab services. Both the NCDs and LCDs require certain diagnoses to support the medical necessity of the lab tests; additional indications and documentation may also be required by the coverage policies. Two examples of required lab documentation from the CERT document include:

• Blood Glucose - The ordering physician must include evidence in the patient’s clinical record that an evaluation of history and physical preceded the ordering of glucose testing and that manifestations of abnormal glucose levels were present to warrant the testing.
• Thyroid Function tests - When thyroid function tests are billed at a greater frequency than the norm (two per year), the ordering physician’s documentation must support the medical necessity of this frequency.

One more requirement – signatures must meet the Medicare signature guidelines as described in the Medicare Program Integrity Manual, Chapter 3, section 3.3.2.4.

In summary, if the CERT contractor reviews your laboratory claims, be sure to:

1. Respond timely to the CERT medical record request
2. Providers have 75 days to submit requested records
3. CERT will accept late documentation
4. Include all necessary documentation
5. A signed order or documentation of intent to order labs signed by the ordering physician
6. Signatures must meet Medicare signature requirements
7. Documentation to support the medical necessity of the services
8. Lab results/reports
9. Appeal unfavorable decisions to your local MAC
10. Include additional supporting documentation

That “no signature” thing comes with a huge conditional “but”!

 

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

 

Recently a hospital reported to MMP that they were cited for an underpayment by the Recovery Auditor because they had billed for a portion of a drug that is only available in a single-dose vial. The hospital, following the appropriate United States Pharmacopeia (USP) standards for compounding, had split the single-dose vial into incremental portions in syringes. They billed Medicare for the dose administered to a patient and the wastage amount of one of the prepared syringes. The RAC denied this as an underpayment – what should the hospital do?

My research revealed that the splitting of single-dose vials is a huge controversy. The Centers for Disease Control and Prevention (CDC) has released a statement opposing the splitting of single-use vials due to safety concerns, except in times of severe shortages of medicines.   CMS has even weighed in on the issue with a memo to the State Survey Agency Directors requiring adherence to strict standards for repackaging of single use vials.

But often single-use vials contain more medication than the routine dose. Drug wastage raises concerns about the high costs of drugs and the ever increasing number of drug shortages. For these reasons, hospital pharmacies may aliquot a single-dose vial into smaller doses. A patient will then be administered the ordered dose from the prepared syringe and any remaining amount within the syringe will be wasted. The hospital should bill for the amount of the drug given and wasted from the single syringe used. This will result in the billing of an amount less than the amount in the single-use vial. Like the situation above, this may cause a Medicare contractor to question your billed units.

The hospital will have to appeal the denial and provide documentation to the contractor that supports:

• Their process for splitting the single-use vial, including adherence to the required criteria
• The dosage within the syringe that was used
• The amount administered to the patient and the amount wasted

If the denial comes from a Recovery Auditor and your hospital has time, you may be able to resolve the issue during the discussion period.

And you probably never thought you would object to an underpayment finding!!

Wives, do you ever tell your husband how much money you saved him because you bought something on sale? In the medical realm, hospitals sometimes get medical devices “on sale” – well, actually at reduced or no cost for various reasons, such as premature replacements, product recalls, or as part of a clinical trial. Since the device is free or at a reduced cost, Medicare doesn’t want to reimburse the hospital for a full cost device. Therefore, hospitals must communicate the “special price” to Medicare on the claim with specific codes in order not to receive an overpayment.

Last year CMS changed the way hospitals report devices on outpatient claims when the device is provided at no cost, with full credit, or with partial credit that is 50% or greater than the cost of the device. Prior to this change, hospitals used modifiers –FB and –FC to communicate this information on the claim. Effective January 1, 2014, the use of modifiers FB and FC were discontinued, and hospitals were instructed to use Value Code FD and condition codes 49 or 50 to report device credits. However, condition codes 49 and 50 only describe devices that are replaced –

• Condition Code 49 – Product Replacement within Product Lifecycle
• Condition Code 50 – Product Replacement for Known Recall of a Product

Sometimes the original device for initial implantation is provided to the hospital at no cost, such as a free sample or due to a medical device clinical trial. Therefore for claims received on and after July 1, 2015, CMS is adding a new condition code for hospital reporting to identify medical devices for initial device placement provided at no or reduced cost due to a clinical trial or free sample (MLN Matters MM8961). The new condition code is:

• Condition Code 53 – Initial Placement of a Medical Device Provided as Part of a Clinical Trial or Free Sample

To report medical devices for initial device placement provided at no or reduced cost, hospitals will report the:

• Value Code “FD” (Credit Received from the Manufacturer for a Medical Device)
• The amount of the device credit in the amount portion for value code “FD”
• Condition Code 53
• A charge of $0.00 for the device (or a token charge of $1.00 if required by the billing system)

The OPPS payment deduction for device credits for device-dependent APCs is limited to the lesser of the device credit amount reported in the FD value field or the device offset amount for that APC.

If the device is furnished as part of a clinical trial, the claims requirements for institutional billing of clinical trials must also be followed.

Hospital Compliance Audits performed by the Office of Inspector General (OIG) have consistently identified errors with the lack of reporting device credits. From my years working in a hospital, I realize tracking and reporting such credits would be a very detailed process, involving numerous departments. But to prevent overpayments, hospitals must come up with appropriate processes to know when a credit is received or should be received, the credit amount, the reason for the credit, and get the correct data on the claim to report that credit to Medicare. So as with the wife’s “on sale” purchase, “on sale” devices still come with a price!

I try to write an article for the second Wednesday of the month newsletter about Medicare coverage policies and an article about Medicare contractors’ medical reviews for the third Wednesday. You may have noticed however, that these two topics are often intermingled. It brings to mind the age-old riddle – which came first, the chicken or the egg? Is a particular medical review based on the guidelines of a coverage policy or did the results of a review identify the need to develop a coverage policy? Actually, both scenarios occur, so sometimes it’s the chicken and sometimes the egg!

The December 2014 OIG Compliance Review of Ochsner Medical Center included the findings of a new issue not addressed in previous OIG compliance reviews. The issue is certain cochlear implant services did not meet the medical necessity requirements of the National Coverage Determination (NCD 50.3). As often is the case, the NCD requirements are extremely detailed. Cochlear implants are covered if the following conditions are met:

• Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment
• Limited benefit from amplification (test scores of less than or equal to 40%)
• Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
• Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
• No contraindications to surgery; and
• The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
• Clinical trial services are covered for individuals meeting the selection guidelines above and with hearing test scores of greater than 40% and less than or equal to 60%.

The key to coverage criteria is not only must it be met, but it must be documented in the medical record in order to support that the service met Medicare’s coverage requirements. The OIG review found one patient whose hearing test score was 42% and one patient without a documented hearing test. These two errors resulted in an overpayment of over $56,000.

Another recent coverage decision with numerous detailed requirements is the Final Decision Memo for Lung Cancer Screening with Low Dose CT. This decision memo was released last Thursday (February 5, 2015). The eligibility criteria for screening include:

• Current smoker or one who has quit within the past 15 years
• Asymptomatic (no signs or symptoms of lung cancer)
• Age 55-77
• A 30-pack years smoking history (one pack-year = smoking one pack per day for one year)

In addition to the eligibility criteria, the decision memo lists detailed requirements for the order for low dose CT, including what it must contain, when it can be written, and the requirements for what a lung cancer counseling visit must include. There are also required criteria for the reading radiologist and the imaging facility. The details of the policy are quite extensive. Remember - although the effective date of the policy is February 5, 2015, it may be a while before CMS issues the official NCD and provides billing instructions. Medicare Administrative Contractors may not be ready to process these claims until the effective date of the forthcoming manualization of this decision.

One last update concerning NCDs - MLN Matters Article MM8954 provides guidance on the use of new HCPCS code G0276 for (Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)). Per this update, G0276 is to be used on and after January 1, 2015 only if the clinical trial is blinded, randomized, and controlled, and contains a placebo procedure control arm. Use procedure code 0275T for clinical trials for all PILD for LSS services for dates of service prior to January 1, 2015 and after January 1, 2015 for services not meeting the criteria for G0276.

So remember – after the chicken comes the egg – or is it, after the egg, comes the chicken?!? Whichever, but if there is a coverage policy, there may be a medical review in your future – so make sure you follow the criteria for cochlear implants, low dose CT lung cancer screening, and PILD for LSS and of course – document, document, document!

Updates of Local Coverage Determinations for last month include:

Q:

What should we do when Acute Respiratory Failure is documented but the clinical signs and symptoms describing the patient do not reflect the severity of the diagnosis?

 

A:

Coders in this day and time have to know and be aware of more clinical factors than ever before. Look at the patient’s clinical presentation and what tests are performed. Below is a listing of just a few basic things MMP suggests looking for:

1.Documented signs / symptoms

• SOB (shortness of breath) / Respiratory distress
• Delirium and/or anxiety
• Pursed lips
• Syncope
• Use of accessory muscles
• Tachycardia
• Tachypnea
• Confusion
• Sleepiness
• Depressed consciousness
• Cyanosis (bluish color to skin, lips and/or fingernails)

2.Per Coding Clinic, Acute Respiratory Failure is supported as a diagnosis when at least 2 of the following critical values (ABG’s) are met.

• pH < 7.35
• PO2 < 60
• PCO2 > 50

Note: The above ABG levels may not apply to the patient with chronic lung disease (e.g., COPD). If a baseline PO2 is known, a decrease by 10mmHg or more indicates acute Hypoxic Respiratory Failure.

3.Type of oxygen treatment, i.e., oxygen via mask, Bipap, nasal cannula or vent?

4.Generally, patients are placed in ICU for close monitoring.

MMP recommends coding Acute Respiratory Failure if there are sufficient clinical indications and the physician has documented the diagnosis. Most importantly, if you don’t see sufficient clinical signs/symptoms/indicators documented, the physician should be queried for clarification. It is recommended that all clinical indications in the record and the type of treatment the patient received, be documented in the physician query.

On January 26th, Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” According to the CMS Press Release, “this is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.”

This call to action by Secretary Burwell brings to mind the Institute for Health Improvement’s (IHI) Plan-Do-Study-Act (PDSA) cycle that involves planning a test or observation, trying out the test on a small scale, analyzing data and studying the results and finally, refining the change based on what was learned.

Plan-Do-Study

Long before the Affordable Care Act, it was obvious that the current state of healthcare in the United States was more reactive than proactive and that the current Prospective Payment System was not financially sustainable.

In a related Fact Sheet to the January 26th announcement, CMS indicated that “the Affordable Care Act offers many tools to improve the way providers are paid to reward for quality and value instead of quantity, to strengthen care delivery by better integrating and coordinating care for patients, and to make information more readily available to consumer and providers. Doing so will improve coordination and integration of health care, engage patients more deeply in decision-making and improve the health of patients – with a priority on prevention and wellness.”

While not an all-inclusive list, specific examples of progress attributed to the Affordable Care Act by CMS include:

• Years 2011, 2012 and 2013 saw the slowest growth in real per capita national healthcare expenditures on record in part due to slow growth in per-beneficiary spending across Medicare, Medicaid, and the private insurance beneficiary population.
• “Looking forward, due primarily to the persistent slowdown in health care costs, the Congressional Budget Office now estimated that Federal spending on Medicare and Medicaid in 2020 will be $188 billion below what it projected as recently as August 2010.”
• The Partnership for Patients has been instrumental in “patient harm falling by 17%, saving 50,000 lives and billions of dollars.”
• The Affordable Care Act tied Medicare payment for hospitals to readmission rates. Since 2012 the efforts made by hospitals “translates into an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.”
• Providers are engaged as evidenced by the fact that currently “there are 424 organizations currently participating in Medicare ACOs, serving over 7.8 million Medicare beneficiaries” and the “ACOs participating in the Shared Savings Program and the Pioneer ACO Model combined generated over $417 million in savings for Medicare.”
• The three mandated quality programs for hospitals (Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program and Hospital-Acquired Condition Reduction Program) reward hospitals for the quality of care they provide to patients.
• Improvement in the availability of information to guide the beneficiary in their decision-making has been made available through Physician Compare, updates to Hospital Compare, and the May 2013 release of Charge Data for Hospital and Physician Services by CMS.

Act

Again, Secretary Burwell made the HHS call to action by setting explicit alternative payment model goals and value based payment goals to “help drive the health care system towards greater value-based purchasing – rather than continuing to reward volume regardless of quality of care delivered.”

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

The Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organizations (ACOs), the Bundled Payment for Care Initiative, and the Comprehensive Primary Care Initiative are examples of current Alternative Payment Models. “HHS is working with private payers, including health plans in the Health Insurance Marketplace and Medicare Advantage plans, as well as state Medicaid programs to move in the same direction toward alternative payment models and value-based payment to providers and to meet or exceed the goals outlined above wherever possible.”

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

The Hospital Value Based Purchasing Program, Hospital Readmission Reduction Program and the Hospital-Acquired Condition Program are the three Affordable Care Act Mandated Quality Programs that have begun to tie a hospitals payment to quality of value.

How to Reach the Goals

Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network. This Network “will accelerate the transition to more advanced payment models by fostering collaboration between HHS, private payers, large employers, providers, consumers, and state and federal partners. Working together, Learning and Action Network partners will:

• Serve as a convening body to facilitate joint implementation and expansion of new models of payment and care delivery
• Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models
• Collaborate to generate evidence, share approaches, and remove barriers
• Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, and risk adjustment
• Create implementation guides for payers and purchasers

Alignment between HHS, private sector payers, employers, providers, and consumers will help health care payments transition more quickly from pure fee-for-service to alternative payment models – a critical step toward better care, smarter spending, and healthier people.” The first Network meeting is set for March 2015.

As health care in this country is propelled towards new payment models and payment for quality instead of quantity, there are a couple of valuable resources that hospitals should be familiar with.

First is the CMS Innovation Center. Per the Affordable Care Act, “the purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.” I encourage you to visit their website to find out where and what Innovation is Happening in your state and while there check out the November 10, 2014 CMS Innovation Center Update Webinar that featured Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer.

A second resource is the Health Care Transformation Task Force. On January 28, 2015, just two days after the CMS announcement, this group “whose members include six of the nation’s top 15 health systems and four of the top 25 health insurers, challenged other providers and payers to join its commitment to put 75 percent of their business into value-based arrangements that focus on the Triple Aim of better health, better care and lower costs by 2020.”

Resources:

Fact Sheet: Better Care, Smarter Spending, Healthier People: Why It Matters: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Paying Providers for Value, Not Volume: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Improving Out Health Care Delivery System: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html 

American Hospital Association Response to January 26th Announcement:

http://www.aha.org/presscenter/pressrel/2015/150126-pr-medicare.shtml

American Medical Association Response to January 26th Announcement: http://www.ama-assn.org/ama/pub/news/news/2015/2015-01-26-hhs-shifting-medicare-reimbursements-volume-value.page

 

I love reading, writing and the English language – I am such a grammar geek that I actually belong to a “grammar” blog. In writing, you want to make sure you are choosing your words wisely and appropriately – in other words, definitions matter. As we see in this quarter’s Medicare Compliance Newsletter, definitions also matter when billing for your services to Medicare, especially the definitions related to procedure and diagnosis codes.

Last week we addressed a couple of CERT issues from the January Medicare Quarterly Provider Compliance Newsletter that affected hospital inpatient claims. This week we will look at some deficiencies with outpatient records identified by the Recovery Auditors.

Extracorporeal Photopheresis – CPT 36522

Medicare covers extracorporeal photopheresis (drug and UVA light treatment of white blood cells) only for certain conditions per National Coverage Determination 110.4. This procedure is covered by Medicare for:

• Palliative treatment of skin manifestations of cutaneous T-cell lymphoma that has not responded to other therapy
• Patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment
• Patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment

Medicare claims for CPT 36522 must contain one of the following ICD-9 diagnosis codes for the above covered conditions to support medical necessity and be eligible for Medicare payment: 202.10-202.18 and 202.20-202.28, 996.83, or 996.85. A RAC automated review identified overpayments for claims with this service that did not contain an appropriate diagnosis code.

Facet Joint Injections

According to the newsletter, “Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint.” Due to findings from RAC reviews, Medicare reminds providers about the following facts of facet joint injections:

• It is expected that facet injections reported with CPT codes 64490-64495 will be performed under fluoroscopic guidance.
• Multiple nerves innervate each facet joint, but injections are to be reported per facet joint level, not per nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them. For example, CPT codes 64490 and 64493 are used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve; CPT codes 64491, 64492, and 64494, 64495 report all nerves at the second and third additional levels and not each additional nerve.
• Codes 64490-64495 are unilateral procedures.
• Use modifier 50 to report bilateral injections (facet joint injections on both the right and left sides of one level of the spine). If multiple bilateral injections are performed, modifier 50 should accompany each facet CPT joint injection code that was performed on both sides of one level.
• Only one facet injection code should be reported at a specific level and side injected (e.g., right L4-5 facet joint), regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level.

IV Infusion Units

Providers are to report only one “initial” intravenous infusion code for chemotherapy and therapeutic infusions (CPT codes 96413, 96365, and 96369) per day unless the patient has two different infusion sites or more than one visit on the same day. In the case of two infusion sites or multiple encounters, it is appropriate to append a -59 modifier to the second “initial” service. An initial infusion code is defined in MLN Matters Article MM3818 as the code that “best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur." Also be sure to follow the CPT reporting hierarchy for drug administration codes in selecting the initial service.

Hospitals need to bear in mind that for drug administrations, observation services spanning more than one day are considered one encounter as explained in the Medicare Claims Processing Manual, Chapter 4, section 230:

“Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.”

As always, it benefits providers to pay attention to the details when billing Medicare – such as the definitions of “initial” infusion and facet joint “level” versus nerve. In coding and billing, definitions matter!

 

Yes, it is true that in this age of electronic health records (EHRs) that most Physician notes are no longer written with a pen. However, in the January 2015 release of the Medicare Quarterly Compliance Newsletter, there are two Comprehensive Error Rate Testing (CERT) review findings that share the denial commonality of “the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.” So hand written or electronic, it is a fact that the denials were due to the Physician’s pen.

First, for those that may still be unfamiliar with this newsletter, it is a resource provided by the CMS to serve as an “educational product, to help providers understand the major findings identified by MACs, Recovery Auditors, Program Safety Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General.” If you are interested in viewing past issues, the CMS maintains a Newsletter Archive of all of the newsletters to date.

The January edition of the newsletter includes findings from the Office of Inspector General (OIG), Recovery Auditor and CERT. This article focuses on two of the CERT findings.

Surgical Procedures Related to Hemodialysis being billed as an Inpatient
Provider Types Affected: Physicians and Hospitals

 

Background

Placement of an arteriovenous fistula (AVF) is the best option for beneficiaries requiring hemodialysis for end-stage renal disease (ESRD). The procedure is typically an outpatient procedure. “Inpatient hospital admission is appropriate when the beneficiary has some other acute problem requiring inpatient care or when a serious post-operative complication arises.”

Medicare payment to a hospital for surgical procedures includes the procedure itself and all normal post-op recovery and monitoring even if the monitoring extends overnight. Also, hemodialysis and a beneficiary’s need for chronic hemodialysis “does not justify an inpatient hospital admission for a vascular access-related procedure.”

Review Finding

Most improper payments identified by the CERT were due to the hospital inappropriately billing Medicare for the surgery and post-op care as an inpatient hospital admission.

Denial due to the Physician’s Pen

The CERT asserted that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

What You Should Know

“Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

The 2 Midnight Rule and Elective Procedures
Provider Types Affected: Physicians Facilities and Hospitals

Background

The 2014 IPPS Final Rule (CMS-1599-F) 2-Midnight Rule provision maintains that an inpatient admission and payment under Medicare Part A is generally appropriate when the physician:

1. “Expects the beneficiary to require a stay that crossed at least two midnights; and
2. Admits the beneficiary to the hospital based upon that expectation.”

Medicare Administrative Contractors (MACs) have been performing reviews under the Probe and Educate Program that began with admissions on or after October 1, 2013 and is currently set to end on March 31, 2015.

This review focuses on the review findings “as they pertain to admissions for elective procedures.”

Exception to the 2 Midnight Rule and Unforeseen Circumstances

When the Expected Length of Stay was Less Than 2 Midnights

It would not be appropriate to admit a beneficiary as an inpatient when they present for an elective surgical procedure that is not designated as Inpatient Only by Medicare and the physician does not expect to keep the patient in the hospital beyond 2 midnights.

Contractors will deny this type of claim unless there is documentation in the record of an approved exception. Currently the only approved exception is “newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment).”

When the Expected Length of Stay was 2 or More Midnights

There are times when a physician expects a beneficiary to require a 2 midnight or longer hospitalization but due to unforeseen circumstance the stay is less than 2 midnights. CMS approved examples of unforeseen circumstances includes “unexpected death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital.”

Denial due to the Physician’s Pen

The CERT again asserted in this review that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

Two examples of Medicare Part A Inpatient Denied Claims provided in this review include a vascular procedure where the documentation did not support the inpatient admission and a urologic procedure where there was no inpatient order and the documentation did not support a 2 midnight expectation.

What You Should Know

Just as in the first CERT review findings, this article asserts that what you should know is that “Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

I encourage you to take the time to read this entire newsletter as it provides the issues, what you should know as well as valuable links to resources to find more information about each review type.

 

Q:

Have the Medicare coverage requirements for pneumococcal vaccinations changed?

 

A:

Yes, the Advisory Committee on Immunization Practices (ACIP) has issued new recommendations for pneumococcal vaccinations and Medicare has modified their coverage requirements in response to the new recommendations.

As announced in MLN Matters Article MM9051, effective for dates of service on and after September 19, 2014, Medicare will cover the administration of two different pneumococcal vaccinations.

• An initial pneumococcal vaccine to all Medicare beneficiaries who have not previously received a vaccine (based on ACIP recommendations a 13-valent pneumococcal conjugate vaccine – PCV13 should be administered first)
• Followed by a second, different vaccine a year later (23-valent pneumococcal polysaccharide vaccine – PPSV23)

Patients, age 65 and older, who have already received the PPSV23 vaccine, should receive the PCV13 vaccine a year or more after the date of their last PPSV23 vaccine.

These new guidelines differ from the previous coverage of pneumococcal vaccine which was only for individuals at high risk of serious pneumococcal disease (age 65 and older, risk from chronic disease, or immune-compromised patients) with a repeat vaccine after five years for only patients at highest risk (May 1, 1981- September 18, 2014).

Note that a physician’s order is not required for patients to obtain a pneumococcal vaccine.