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The designation of an ICD-10-PCS code designated as an O.R. or Non-O.R. procedure affects the MS-DRG assignment. Codes designated as an O.R. procedure will group the inpatient stay to a surgical MS-DRG. Codes designated as Non-O.R. procedures would not impact the MS-DRG assignment so the inpatient stay would be grouped to a Medical MS-DRG. In general, surgical MS-DRGs are a higher relative weight meaning higher payment for the inpatient stay.

The transition of procedure code re-designation began with CMS including proposals in the FY 2017 IPPS Proposed Rule.  In the FY 2017 IPPS Final Rule, CMS indicated they had received requests and recommendations for over 800 procedure codes and were unable to fully evaluate and finalize comments received for FY 2017. A year later, allowing for time to evaluate requests and recommendations, CMS did in fact propose to re-designate over 800 current ICD-10-PCS codes as Non-O.R. Procedures in the Proposed Rule and finalized 770+ code re-designations.

CMS noted “the proposed changes for FY 2018 go beyond the FY 2017 proposed (and finalized) MS-DRG updates to change the designation of procedure codes from O.R. to non-O.R. that were done for purposes of replicating the logic of the ICD-9 MS-DRGs….for FY 2018 and future fiscal years, we are no longer replicating the ICD-9 MS-DRGs…we are using ICD-10 coded claims data for the first time to propose changes to the ICD-10 MS-DRG classifications and to compute the relative weights. Therefore, our proposals and final policies for FY 2018 are based solely on the ICD-10 claims data from the FY 2016 MedPAR file.”

FY 2019 IPPS Final Rule

CMS continued reviewing ICD-10 claims data for FY 2019 and finalized the re-designation of nine (9) ICD-10-PCS codes from O.R. Procedures to Non-O.R. Procedures and seventy (70) ICD-10-PCS codes from Non-O.R. to O.R. The following two tables detail the volume of codes changed by Code Group. 

 Potential Financial Impact of Changes

In the absence of a valid O.R. Procedure code, hospitals will still receive reimbursement for the Medical Principal Diagnosis. The challenge is to identify the potential financial impact of the MS-DRG shift from a Surgical MS-DRG to a Medical MS-DRG. To do this I turned to our sister company, RealTime Medicare Data (RTMD) to provide the CY 2017 paid claims data for Alabama for all ICD-10-PCS codes with an O.R. Procedure re-designation where it was the Principal Procedure on the paid claim. This following table highlight the O.R. to Non-O.R. Re-designation findings.

 

MMP conducted a similar review of the changes made in FY 2018. Through claims analysis we were able to identify the Medical MS-DRG that would have been billed in the absence of the O.R. procedure. In general, we found that hospitals could expect anywhere from a 35% to 45% decrease in payment. Applying the same findings to FY 2019, that would equate to the state of Alabama realizing a potential $1.6 million to $2.1 million decrease in paid claims revenue.

This last table highlights the Non-O.R. to O.R. re-designation findings.

 If you reverse the expected decrease in payment to an expected increase of 35% to 45%, this would equate to the state of Alabama realizing a potential $271,000 to $348,000 increase in paid claims revenue.

For those interested, detailed discussion about the ICD-10-PCS code re-designations can be found on pages 41249 through 41257 of the Final Rule.  

Q:

We have a new physician that wants to use isoproterenol injections for ablation procedures.  Is there a HCPCS code for this drug as an injectable?  If there is not a specific code for it, would this drug qualify for the C9399 code? Is there any reimbursement for this drug? It is high cost and we want to evaluate the financial impact of using it.

A:

Isoproterenol has been around for years, so C9399 would not be applicable unless there is a formulation one of the drug newly released from the FDA.

There are HCPCS codes available for the inhalation form of isoproterenol, but I am not aware of a HCPCS code for the injectable form.  Without a HCPCS code, you will have to report the drug without a HCPCS code and revenue code 250, thus, no separate reimbursement for that line item drug.

This week, during a school fall break, I went to the zoo with my grandchildren. This presented the perfect opportunity to teach my young granddaughter the famous phrase from the movie The Wizard of Oz, “Lions, and tigers, and bears. Oh my!” For those of us that deal with Medicare reviews, there are no literal lions, and tigers and bears, but we do sometimes have a reason to fear. Our refrain could be “MACs, and RACs, and CERT. Oh my!” Below is a discussion of the latest review issues and concerns from some of these types of reviewers.

There was not a lot of new medical review activity by Medicare Administrative Contractors (MACs) this month in the Targeted Probe and Educate (TPE) program. Some MACs remain silent on their review topics. Whether this means they are not conducting any reviews or are not sharing that information on their websites is unknown. Novitas, the MAC for Jurisdictions H and L, added new topics for reviews focused on DRG validation and partial hospitalization programs (PHP) for outpatient psychiatric services. DRG validation reviews generally focus on coding accuracy and the codes being supported by documentation in the medical record. WPS J5 reported on their TPE review of DRG validation with excellent results – no providers moved on to Round 2 so this review appears to be concluded for J5.

For the partial hospitalization program review, the PHP Checklist on the Novitas website indicates they expect to see:

• An initial psychiatric evaluation, including history and mental status examination,
• Physician certification/recertification and documentation of physician supervision,
• Description of illness requiring services, and psychiatric diagnosis to support medical necessity,
• Documentation that the services are designed to reduce or control psychiatric symptoms so as to prevent inpatient hospitalization and to improve or maintain the patient’s level of functioning,
• Progress notes for each service rendered, and
• Documentation to support a minimum of 20 hours per week of therapeutic services.

Novitas also released results of their Round 1 review of Hyperbaric Oxygen Therapy (HBO). Denials rate for HBO ranged from approximately 2% to 35% in JH and from approximately 20% to 56% in JL. Insufficient documentation is the reason for all denials. Records lacked documentation of medical necessity, treatments, physicians’ orders, tests/notes to support the diagnosis being treated, response to treatment or measurable signs of healing, and failed standard treatment of diabetic wounds.

Over the past few months, Recovery Auditors, still commonly referred to as RACs, have added new issues.

• In July, APC Validation was added to all RAC regions. This is a coding review to verify procedures are assigned CPT/HCPCS codes accurately and that “match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.”
• HMS, the RAC for Region 4, posted a review of facet injections at the end of August. HMS quotes information from several Local Coverage Determinations (LCDs) – L34993, L34974, and L34892 – that describe the requirements for injections and blocks. For example, pain must have been present for 3 months or greater and a detailed pain history is essential and must provide information about prior treatment and responses, such as analgesics and physical therapy, for paravertebral facet joint injections.
• A new issue for Cotiviti RAC Regions 2 and 3 from September is the review of the medical necessity of transthoracic echocardiography (TTE) for hospital inpatients and outpatients, and patients in a skilled nursing facility (SNF). The medical necessity of this procedure will be based in large part on the requirements as described in several LCDs. Please refer to the LCD for your MAC region to determine the specific indications and requirement for TTE. For example, the Palmetto LCD includes such statements as:
• When there are no signs or symptoms of heart disease, the use of TTE is not covered for hypertension.
• The role of TTE in the emergency room assessment of individuals presenting with chest pain is not defined at this time. This use is not accepted as a standard-of-care. For TTE to be allowed, clinical findings supporting myocardial dysfunction must be present. When these findings are not present, this use is not covered.
• TTE is used annually in follow-up of chronic valvular disease to document the course over time. Generally, it is not medically necessary to repeat these examinations more frequently than annually. When the patient’s plan of care includes imminent valvular surgery, more frequent exams may be necessary.

Other RAC issues affecting outpatient hospitals are discussed in the Medicare Quarterly Provider Compliance Newsletters. The July newsletter explains that Vagus Nerve Stimulation is only considered reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. It is not covered for other types of seizure disorders or for resistant depression. The article goes on to list the specific ICD-10-CM diagnosis codes that are covered for vagus nerve stimulation. The October newsletter has an article on outpatient services overlapping or during an inpatient stay. Please refer to a June Wednesday@One article for information on how to avoid overlapping claims.

As you can see, there is a smorgasbord of issues for review as usual. Hospital providers have to constantly be on the lookout for lions, and tigers, and bears. Oh my!!

MMP initially ran this article September 12, 2018, click here to read the original article. Since then CMS posted a correction to the 2019 IPPS Final Rule on October 3rd. This correction included the following important update to inpatient cases involving the drug VABOMERE™ which is available for a new technology add-on payment.

Notice in 2019 IPPS Final Rule Correction published in the Federal Register October 3, 2018:

“On page 41311, we made a typographical error in describing which National Drug Code (NDC) will be used to identify cases involving VABOMERE™ that are eligible for new technology add-on payments in FY 2019. Specifically, we are correcting the NDC code of 65293–0009–01, which erroneously was missing an extra digit. In addition, we were made aware after the final rule that NDC 70842–0120–01 can also be used to identify cases of VABOMERETM. Therefore, cases involving the use of VABOMERE™ that are eligible for new technology add-on payments in FY 2019 will be identified with either of the following NDCs: 65293–0009–01 and 70842–0120–01.”

New Technology

Melinta Therapeutics, Inc.’s application for new technology add-on payments for VABOMERE™ for FY 2019 was approved by CMS. The maximum new technology add-on payment for cases involving the use of VABOMERE™ for FY 2019 is $5,544.

What is VABOMERE™ (Meropenem-vaborbactam)?

VABOMERE™ is a combination product containing meropenem and vaborbactam. This drug is indicated for treating adult patients diagnosed with complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganisms: Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae species complex.

Issue

There is no unique ICD-10-PCS procedure code for VABOMERE™ for FY 2019 leaving hospitals with no way to uniquely identify the use of VABOMERE™ on an inpatient claim.

How to identify the use of VABOMERE™ on an Inpatient Claim

CMS revised their policy to allow the use of an alternative code set to identify an oral medication when there is no inpatient procedure code for purposes of new technology add-on payments in the FY 2013 IPPS Final Rule. Specifically, they adopted the National Drug Code (NDC) as an alternative code set to identify the use of DIFICID™ effective for discharges on or after October 1, 2012.

While VABOMERE™ is administered by IV infusion and not orally, CMS acknowledges that “it is the first approved new technology aside from an oral drug with no uniquely assigned inpatient procedure code” and believes for purposes of identifying the use of VABOMERE™ this is a similar circumstance to the use of DIFICID™.

For FY 2019, cases eligible for the FY 2019 new technology add-on payments will be identified by the NDC code 65293-0009-01 (VABOMERE™ Meropenem-Vaborbactam Vial) or NDC code 70842-0120-01. Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE™.”

Who Needs to Know this Information?

Your hospital Pharmacy should be made aware of this information so they can collaborate with your Billing Office to ensure you receive the add-on payment for eligible claims.

Resources

Billing guidance can be found on page 49837 of the October 3, 2018 Final Rule Correction Notice published in the Federal Register which can be accessed from the CMS FY 2019 IPPS Final Rule Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

Additional information about VABOMERE™ can be found on the Melinta Therapeutics, Inc. website at http://www.vabomere.com/.

Q:

We are doing hydration infusions pre- and post-IV contrast studies (e.g., CT, IVP, etc.) for patients with elevated creatinine levels.  The question was asked whether we should be charging for it.  Can we report hydration infusions in this scenario (CPT codes 96360, 96361)?

A:

The definitive documentation you need is in Coding Clinic for HCPCS, 3Q 2007, pages 6-9.

In that discussion, they say hydration ‘cannot’ be reported in that scenario, with the specific example of a patient with an elevated creatinine receiving IV hydration to prevent damage to the kidneys.

Hydration is incidental to the CT scan, and not separately reportable.

There is a similar Coding Clinic article (4Q 2007, page 6) asking about patients with mitral valve prolapse coming in for an endoscopy, who are given a prophylactic antibiotic. Again, administration of the antibiotic is part of the pre-procedure preparation and should not be reported separately.

One frustration of healthcare workers is that they spend almost as much time on documentation and complying with burdensome regulations as they do taking care of patients. The current government Administration has promised to provide some relief by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities. To this end, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule on September 17, 2018 reforming some Medicare regulations to reduce the amount of time and resources that healthcare facilities have to spend on CMS-mandated compliance activities that do not improve the quality of care. According to the CMS Administrator, this will allow hospitals and healthcare professionals to focus on their primary mission of treating patients.

Here are some of the proposals to change the Medicare Conditions of Participation (CoP) that affect hospitals either directly or indirectly:

• Hospital systems could elect to have one unified and integrated Quality Assessment and Performance Improvement (QAPI) program for all of its member hospitals instead of individual programs for each hospital. Such a program must be in compliance with State and local laws, consider the unique circumstances and differences of the member hospitals, and be able to address needs and issues specific to each hospital.
• Hospitals could establish a medical staff policy that would allow a pre-surgery/pre-procedure assessment for an outpatient in certain circumstances, instead of a comprehensive medical history and physical examination (H&P). The assessment would have to be documented in the patient’s medical record. The hospital’s policy would have to consider medical factors (such as the patient’s diagnosis and other conditions, type of surgery, etc.), nationally recognized guidelines and standards of practice, and applicable state and local health and safety laws.
• Like the above described unified quality program, the rule also proposes allowing a unified and integrated infection control program for multi-hospital systems. The same considerations of the differences and unique needs of each hospital apply for a unified infection control program as they do for the unified quality program.
• Hospitals and other facilities are required by law to have processes for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This requirement is not changed but the requirement to document participation in collaborative and cooperative planning efforts, including documentation of contact efforts, is proposed to be eliminated. There are also proposals to provide flexibility in the time frame of review of Emergency Preparedness plans, decrease the required frequency of training to every two years instead of annually, and allow flexibility in the types of testing exercises for both inpatient and outpatient exercises.
• Remove the requirement for hospitals to perform autopsies in all cases of unusual deaths and of medical-legal and educational interest. Hospitals would follow State laws regarding such medical-legal requirements.

There are also proposals that address changes to critical access hospitals (CAHs) annual review of policies and procedures, hospital and CAH swing-bed requirements, requirements for transplant centers, and clarification of who is allowed to document progress notes in a psychiatric hospital. Other proposals address different types of providers.

One proposal for ambulatory surgery centers (ASCs) may be of interest to hospitals. CMS is proposing to remove the requirement that ASCs have a transfer agreement with a hospital and that the ASC surgeons have admitting privileges at a hospital. CMS sites hospitals’ refusals to sign such agreements and the EMTALA requirements that hospitals must treat emergencies as reasons why the current requirements do not affect patient safety and therefore are no longer needed.

If you would like more information, please refer to the proposed rule, the press release, and/or the CMS Fact Sheet.  

Q:

We have documentation that a PICC line nurse inserted a “PIV” in the patient’s right lower arm with a 20-gauge needle / angiocath. If the nurse had also documented the vein as the cephalic, basilic, or dorsalic, could we report this as a PICC line insertion, CPT code 36569?

A:

This sounds like a regular IV start that happened to be done by the PICC nurse.

Usually, if the PICC nurse puts in a true PICC line, they will specifically call it a PICC line. In your question, the PICC nurse calls it a PIV = peripheral IV, and they used a 20-gauge needle.

In order to report a PICC line, you would also need documentation of the final position of the catheter tip in a central vessel or right atrium – per CPT guidelines.

We usually see this documented by a chest x-ray or with a tip confirmation system like Sherlock.

Based on the details stated in the question, and assuming the PIV will be used for medications and/or IV fluids, there is not a CPT code to report.

It’s just an IV start - - even if it was difficult and required the skills of a PICC nurse.

Q:

Should decompression/release of a spinal nerve root be assigned along with the spinal fusion code(s) if the decompression is performed at the site of the fusion?

A:

Yes, if there is a distinct intent, then both release and the fusion can be coded at the same level.  This issue will be addressed in an upcoming Coding Clinic.

Resource: Maria Ward, MEd, RHIT, CCS, CCS-P, Director, HIM Practice Excellence, Coding Services at AHIMA

If you are a fan of old TV Westerns like I am, the phrase “just passing through” may conjure up the image of the Old West lawman confronting the new, potentially trouble-making, cowboy in town. The Sheriff or Marshall or Ranger often suggests the cowboy pass on through the town quickly without disturbing the peace of the local community. Medicare has items and products that “pass-through” payment wise for a limited amount of time such as pass-through drugs and biologicals.

“For CY 2019, we are proposing to continue to pay for pass-through drugs and biologicals at ASP+6 percent…” 2019 Outpatient Prospective Payment System (OPPS) Proposed Rule

Those of us that deal with Medicare hospital regulations and payments hear a statement similar to the one above every year. Most of us also know that pass-through drugs and biologicals are identified in the OPPS addenda with a payment status indicator of “G.” And somewhere, back in the beginning of OPPS, the requirements and rules of drug pass-through payments were created. But even for those of us that see this annually, do we really know what “pass-through” means, what the rules are, and if those rules are working as intended?

The regulations for pass-through drugs/biologicals can be found in Section 419.64 of the Code of Federal Regulations (CFR) and are summarized in the annual OPPS rule. Basically, Section 1833(t)(6) of the (Social Security) Act provides for temporary additional payments or “transitional pass-through payments” to hospitals for certain drugs and biologicals.

• These payments are for orphan drugs; drugs, biologicals and brachytherapy sources used in cancer therapy; and radiopharmaceuticals – all for which payment has been made since the implementation of OPPS.
• Transitional pass-through payments are also provided for certain “new” drugs and biologicals that were not being paid for as a hospital outpatient service as of December 31, 1996 and whose cost is “not insignificant” in relation to the OPPS payments for the procedures or services associated with the new drug or biological.
• For pass-through payment purposes, radiopharmaceuticals are included as “drugs.”
• Transitional pass-through payments for a drug or biological can be made for a period of at least 2 years, but not more than 3 years, after the payment was first made for the product as a hospital outpatient service under Medicare Part B.
• The pass-through payment equals the amount determined under section 1842(o) of the Act minus the portion of the APC payment that CMS determines is associated with the drug or biological.
• Prior to CY 2017, CMS expired pass-through status for drugs and biologicals on an annual basis through notice-and-comment rulemaking.
• Beginning CY 2017, CMS accepts applications and begins pass-through payments for newly approved pass-through drugs and biologicals on a quarterly basis. This allows the maximum pass-through payment period for each pass-through drug without exceeding the statutory limit of 3 years.
• When pass-through status expires, drugs and biologicals of certain groups that are “always packaged” become packaged. This includes anesthesia drugs; drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including diagnostic radiopharmaceuticals, contrast agents, and stress agents); and drugs and biologicals that function as supplies when used in a surgical procedure.
• When pass-through status expires for “not always packaged” drugs and biologicals, the standard methodology for providing payment for drugs and biologicals is used. This means drugs/biologicals whose estimated per day cost exceeds the OPPS drug packaging threshold for that calendar year are separately paid at the applicable relative ASP-based payment amount which is currently ASP+6% for drugs not purchased through the 340B program.
• The decreased payment rate for drugs purchased through the 340B program does not apply to pass-through drugs and biologicals. Providers are to report pass-through drugs purchased through the 340B program with the informational only modifier “TB.”

For some reason, in Section 1301(a)(1) of the Consolidated Appropriations Act of 2018 (Public Law 115-141), Congress extended the pass-through status of drugs or biologicals whose period of pass-through payment status ended on December 31, 2017, and for which payment was packaged into a covered hospital outpatient service furnished beginning January 1, 2018. For drugs and biologicals meeting the criteria, the pass-through status is extended for a 2-year period beginning on October 1, 2018, through September 30, 2020. The four products that meet these criteria and with reinstated pass-through status are noted in the table at the end of this article. The law also defines the calculation of the pass-through payment amount for a portion of the extension. It further requires adjustment of the APC payment amount to remove the packaged costs of such drug or biological from the covered outpatient service with which it was packaged. This resulted in new payment rates for 10 APCs from October 1, 2018 through December 31, 2018. The affected APCs and more discussion on Public Law 115-141 can be found in the October 2018 OPPS Update MLN Matters Article.

Section 1301 of the Law also included a requirement for a study and report by the Government Accounting Office (GAO) which may reflect the reasoning for this extension. Congress requests an analysis of the impact of the drug packaging policy on utilization of affected drugs/biologicals, the availability of treatment options, the health outcomes of Medicare beneficiaries, and also the impact on price competition and cost-sharing as a result of these changes to the Law. You can read the complete Section 1301 of the Law at this link - https://www.congress.gov/bill/115th-congress/house-bill/1625/text/enr (Tip: Search for the term “pass-through” in the document to locate the applicable section quickly.)

Since Congress is not known for swift action, it may be years before revisions, if any, are made to the pass-through policy for drugs and biologicals. Until then, these products will only be passing through for a limited period of time.

The table below contains the products with reinstated pass-through status and other code/status changes from the October 2018 OPPS Update.

MEDICARE TRANSMITTALS – RECURRING UPDATES

Healthcare Provider Taxonomy Codes (HPTCs) October 2018 Code Set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10857.pdf

October 2018 Integrated Outpatient Code Editor (I/OCE) Specifications Version 19.3

October updates to the I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10900.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10925.pdf

October 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Changes, new codes, and billing instructions for various OPPS payment policies.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10923.pdf

Influenza Vaccine Payment Allowances - Annual Update for 2018-2019 Season

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10914.pdf

Annual Clotting Factor Furnishing Fee Update 2019

Announces the clotting factor furnishing fee for 2019 is $0.220 per unit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10918.pdf

International Classification of Diseases, Tenth Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)

A maintenance update of ICD-10 conversions and other coding updates specific to NCDs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10859.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2018 Update - REVISED

Informs MACs of the October 2018 addition of new HCPCS codes, Q5108 (Injection, fulphila) and Q5110 (Nivestym). The codes are payable by Medicare effective with dates of service on or after July 12, 2018, for Q5108 and effective with dates of service on or after October 1, 2018, for Q5110.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10834.pdf

 

OTHER MEDICARE TRANSMITTALS

Update to Chapter 15, Pub. 100-08, Certification Statement Policies

Modifications to certain provider enrollment certification statement policies, specifically, allowing upload provider enrollment certification statements using PECOS functionality.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10845.pdf

Revisions to the Telehealth Billing Requirements for Distant Site Services – REVISED

Revised to correct the effective date of the GT modifier.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10583.pdf

New Waived Tests

New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10958.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing

When IMRT is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). You should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18013.pdf

 

MEDICARE RULES

Medicare and Medicaid Programs; Proposed Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction

A proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities.

Provisions in the proposed rule would, for example:

• Eliminate a duplicative requirement on transplant programs to submit data and other information more than once for “re-approval” by Medicare.
• Streamline hospital outpatient and ambulatory surgical center requirements for conducting comprehensive medical histories and physical assessments.
• Allow multi-hospital systems to have unified and integrated Quality Assessment and Performance Improvement programs for all of their member hospitals.
• Simplify the ordering process for portable x-rays and modernize the personnel requirements for portable x-ray technologists.
• Remove duplicative ownership disclosure requirements for Critical Access Hospitals.

https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-proposed-regulatory-provisions-promote-program-efficiency-0

 

OTHER MEDICARE UPDATES

 Federal Register: Changes to the Low-Volume Hospital Payment Adjustment Under the IPPS

Announces changes to the payment adjustment for low-volume hospitals under the hospital IPPS for acute care hospitals for FY 2011-2017.

https://www.gpo.gov/fdsys/pkg/FR-2018-08-23/pdf/2018-18271.pdf

Updated Guidance to Hospitals and CAHs Concerning Swing Beds

CMS is providing updated guidance to surveyors for the special requirements for Hospital and CAH providers of long-term care services (LTC), also known as “swing beds”.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-26-Hospital-CAH.pdf

 

MEDICARE EDUCATIONAL RESOURCES

 Diabetes Self-Management Training Accrediting Organizations Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DSMT-Fact-Sheet-909381.pdf

CMS Provider Minute Video: The Importance of Proper Documentation — Reminder

Explain importance of proper documentation and how it affects items/services, claim payment, and medical review.

https://www.youtube.com/watch?v=10pmw4czf08&feature=youtu.be

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Video: The Importance of Proper Documentation
• Bill Correctly for Device Replacement Procedures

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Medicare Preventive Services On-Line Educational Tool

Information on Medicare preventive services that includes:

• A link to the National Coverage Determination (NCD) webpage for the service, if it applies
• HCPCS/Current Procedural Terminology (CPT) codes
• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes
• Coverage requirements
• Frequency requirements
• Medicare beneficiary liability

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html