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I did not realize the extent of peripheral nerve stimulation procedures until I started reading all of the related Medicare coverage policies – there was so much information, it almost got on my last nerve. All peripheral nerve stimulation is not the same. This is evidenced by several new coverage, or more accurately, non-coverage articles this month from the Medicare Administrative Contractors (MACs). Below is a listing of the MAC local coverage determinations (LCDs) and coverage articles that address peripheral nerve stimulation. Some of the policies listed may have a future effective date due to recent changes in coverage. You can easily view these policies by going to the Medicare Coverage Database and entering the Policy number in the Quick Search ‘Document ID’ field. 

There are different indications for different types of peripheral nerve stimulation.

Peripheral Nerve Stimulation (PNS) for Chronic Pain

Quoting from the Noridian JE Peripheral Nerve Stimulation article:

“Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interventional treatments….PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the known anatomic location of a peripheral nerve.”

Coverage of PNS requires the patients have all of the following:

• Documented chronic and severe pain for at least 3 months,
• Documented failure of less invasive treatment modalities and medications,
• Lack of surgical contraindications including infections and medical risks,
• Appropriate proper patient education, discussion and disclosure of risks and benefits,
• No active substance abuse issues,
• Formal psychological screening by a mental health professional, and
• Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent implantation.

CPT codes for PNS addressed by the Noridian policy include: 61885, 64550, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, and 64595. Also see National Coverage Determination (NCD) 160.7 for other coverage information on Implanted Peripheral Nerve Stimulators.

Peripheral Nerve Stimulation for Urinary and/or Fecal Incontinence

Sacral nerve stimulation coverage for urinary and fecal incontinence is addressed by several MAC policies. Covered indications include:

• Urinary urge incontinence.
• Urgency-frequency syndrome.
• Urinary retention.
• Fecal incontinence.

There are limitations to coverage such as refractory or documented failure or intolerance to conventional therapy; only after a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms; and the exclusion of certain causes of the incontinence. Limitations vary slightly per policy so providers should read carefully the policy which applies to their MAC jurisdiction. CPT codes 64561, 64581, and sometimes 64585 or 64590 are addressed by the Sacral nerve stimulation policies.

Posterior tibial nerve stimulation (CPT code 64566) is generally covered in a physician office setting for urinary urgency, urinary frequency, and urge incontinence. Patients receive one 30-minute weekly treatment in the office for 12 weeks, but most MACs allow treatments for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms. Most MACs require documentation of failed standard anticholinergic drug therapy or intolerance to the anticholinergic drug therapy. Again, requirements vary from MAC to MAC, so providers need to be aware of their MAC’s requirements.

Non-Covered Peripheral Nerve Stimulation

As stated at the beginning of this article, new coverage articles this month detail the correct coding and non-coverage of certain types of peripheral nerve stimulation. Remember, coverage for services not addressed by a national coverage determination or Medicare manuals is determined by the individual MACs. Not all MACs make the same coverage determinations. If coverage of a particular service is not addressed by an LCD or coverage article for your MAC, you will need to contact your MAC to determine if they cover the service or not.

The WPS article for Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) explains that “PENS and PNT therapies combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS)…. PENS is performed with a few needle electrodes (not implanted) while PNT uses very fine needle-like electrode arrays (not implanted) that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.”

Per the WPS article, therapeutic use of these services is non-covered and should be reported with CPT code 64999 and the respective procedure name. They should not be reported with:

• CPT codes 64553-64566 as these apply to percutaneous implantation of neurostimulator electrodes and not appropriate, as PENS and PNT use percutaneously inserted needles, OR
• CPT code 64590 as this applies to insertion or replacement of neurostimulator pulse generator or receiver and not appropriate, as PENS and PNT stimulation devices are not implanted, OR
• HCPCS code range L8680-L8689.
• It would also not be appropriate for providers to use any neurostimulator pulse generator or receiver implantation CPT codes such as CPT 63663, 63685, 63688, 64585, 64590.

Specifically, Biowave’s Deepwave percutaneous neuromodulation pain therapy system is one PENS system that is non-covered. (See NCD 160.7.1.B for discussion of coverage of PENS for diagnostic purposes.)

The two new Noridian coverage articles clarify that Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) is not covered for any condition. PNFS refers to use of a lead placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This service should also be billed with the unlisted CPT code 64999 for both the trial and permanent insertion of the electrode array.

One last peripheral nerve stimulation service for which Novitas JH and JL has a non-coverage policy is Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device).  As with the other non-covered peripheral nerve stimulation procedures, Novitas reports that auricular peripheral nerve stimulation has been inappropriately billed to Medicare using an incorrect CPT code (CPT 64555).  Per the Novitas policy, “The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system….The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.

The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.

While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.” The WPS policy that addresses PENS and PNT also states that any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

With all the different types of peripheral nerve stimulation and the different coverage requirements, make sure your facility is assigning the correct code and that documentation supports the coverage indications. Denied claims can get on your last nerve.

On July 25, 2018, CMS finally released the 2019 Proposed Rule for Outpatient Prospective Payment System (OPPS) for hospitals and Ambulatory Surgical Centers (ASCs) (link to Proposed Rule). Toward the end of the OPPS portion of the rule, there is a section titled “Proposed Nonrecurring Policy Changes” that could also be appropriately named, “Bad News for Hospital Off-Campus Provider-Based Departments.”

Background

Before discussing the proposed rule changes, let’s define some terms and examine some history concerning provider-based departments (PBDs). Provider based entities are created or acquired by the main hospital to furnish healthcare services and are under the ownership, administrative, and financial control of the main provider, in accordance with Medicare’s provider-based rules (42 CFR 413.65). PBDs may be on-campus, that is immediately adjacent to the hospital’s main buildings or within 250 yards of the main buildings, or off-campus, which are PBDs located beyond 250 yards from the main hospital buildings.

The concern over the past several years with PBDs is that they furnish the same types of services provided in a physician office setting but receive higher Medicare payments due to Medicare’s payment rules for outpatient hospital services versus physician fee schedule payments. The Medicare patient (beneficiary) payment share is also more for hospital-based services. In 2015, Section 603 of the Bipartisan Budget Act of 2015, addressed some of these concerns. The Act required “new” off-campus PBDs to be paid under a payment system other than the OPPS that would provide payments more equitable with physician office payments. “New” off-campus PBDs were those PBDs that did not furnish and bill for services prior to the date of enactment of the Act, November 2, 2015.

CMS created other exceptions to the application of Section 603 so the below entities and services are known as “excepted” provider-based departments. Excepted PBDs and excepted services continue to be paid under OPPS.

• On-campus PBDs
• “Grandfathered” off-campus PBDs – those furnishing and billing for services before November 2, 2015
• Services furnished by a dedicated emergency department

This means “non-excepted” PBDs are those new off-campus PBDs that do not meet one of the above exceptions and that will no longer be paid under OPPS.

To implement the requirements of Section 603, beginning January 1, 2017, services provided by non-excepted off-campus PBDs are paid under the Medicare Physician Fee Schedule (PFS) at special rates established for this provision. Currently, and proposed for 2019, these non-excepted services, that would previously have been paid under OPPS, are paid under the PFS at 40% of the OPPS payment rate. Providers append modifier “PN” to these non-excepted services to trigger the reduced payment rate. In addition to the reduced payment rates, OPPS packaging rules and most adjustments continue to apply to these non-excepted services – a double whammy, so to speak. Excepted off-campus PBD services are reported with modifier “PO” to allow CMS to gather data on the volume of these services, but as stated above, payment for excepted services is currently still made under the OPPS rates.

Continuing Concerns

In the proposed rule, CMS states, “the majority of hospital off-campus departments continue to receive full OPPS payment (including off-campus emergency departments and excepted off-campus departments of a hospital), which is often higher than the payment that would have been made if a similar service had been furnished in the physician office setting.” Also, CMS is extremely concerned about the continuing growth of outpatient hospital services. Despite the implementation of a prospective payment system (OPPS) in 2000 and increased packaging in recent years, “the OPPS has been the fastest growing sector of Medicare payments out of all payment systems under Medicare Parts A and B” which CMS attributes in large part to the payment differential between hospital-based services and physician office services. Here are a few quotes from the proposed rule that highlight CMS’s concerns:

“Total spending has been growing at a rate of roughly 8 percent per year under the OPPS, and total spending under the OPPS is projected to further increase by more than $5 billion from approximately $70 billion in CY 2018 through CY 2019 to nearly $75 billion.”

“We (CMS) are concerned that the rate of growth suggests that payment incentives, rather than patient acuity or medical necessity, may be affecting site-of-service decision-making. This site-of-service selection has an impact on not only the Medicare program, but also on Medicare beneficiary out-of-pocket spending.”

“A large source of growth in spending on services furnished in hospital outpatient departments (HOPDs) appears to be the result of the unnecessary shift of services from (lower cost) physician offices to (higher cost) HOPDs. We would consider these shifts in the sites of service unnecessary if the beneficiary can safely receive the same services in a lower cost setting but instead receives care in a higher cost setting.”

“One-third of the growth in outpatient volume from 2014 to 2015 was due to an increase in the number of evaluation and management (E&M) visits billed as outpatient services. This growth in part reflects hospitals purchasing freestanding physician practices and converting the billing from the Physician Fee Schedule to higher paying hospital outpatient department (HOPD) visits… From 2012 to 2015, hospital-based E&M visits per beneficiary grew by 22 percent, compared with a 1-percent decline in physician office–based visits.”

The Proposed Solutions, i.e. the Bad News

CMS is proposing to take action on several fronts to decrease what they see as unnecessary and excessive spending on services provided in off-campus PBDs.

The most significant of these proposals is capping the OPPS payment for clinic evaluation and management (E&M) visits for excepted off-campus PBDs at the PFS-equivalent rate. This means clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs and currently billed with the PO modifier would be paid at the same reduced OPPS rate as those currently billed with the PN modifier by non-excepted PBDs. This would reduce the payment rate for clinic visits (G0463) in excepted off-campus PBDs from the proposed unadjusted Medicare OPPS payment rate of $116 to the reduced PFS (40% of OPPS) rate of $46. CMS also notes the beneficiary liability would correspondingly decrease from $23 to $9. This proposal is not budget-neutral and CMS estimates total savings of $760 million ($610 M Medicare saving and $150 M beneficiary savings).

A second cost-saving proposal is to expand the reduced payments for drugs purchased through the 340B Program to non-excepted off-campus PBDs. The implementation of reduced 340B drug payments last year did not affect the payments for drugs in non-excepted off-campus PBDs since they are not paid under OPPS. With this proposal, separately payable drugs (those with an OPPS status indicator of “K”) furnished and billed by non-excepted off-campus PBDs and purchased through the 340B program would be paid at ASP-22.5% for 2019 and subsequent years instead of the current payment of ASP+6%. In other words, the payment amount for SI “K” 340B drugs in non-excepted PBDs would decrease by 28.5%. Medicare would continue to pay ASP+6% for SI “K” drugs not purchased through the 340B program billed by non-expected off-campus PBDs.

In the last proposal to control increasing payments under OPPS for off-campus PBDs, CMS is proposing to limit the expansion of services in excepted off-campus PBDs. If an excepted off-campus PBD furnishes services from a clinical family of services that it did not furnish in a baseline period, those new services would be non-excepted and paid at the non-excepted reduced PFS payment rate effective January 1, 2019.

• CMS is proposing a one-year baseline period from November 1, 2014 through November 1, 2015, or one year from the first date the PBD furnished services under OPPS for those that began furnishing services after November 1, 2014.
• There are 19 clinical families of services defined by CMS and mapped to the applicable APCs in Table 32 in the Proposed Rule.

One last proposal related to PBDs that does not affect payment – YET – is the creation of a HCPCS modifier to be reported for outpatient hospital services furnished in an off-campus provider-based emergency department. Critical access hospitals (CAHs) would not be required to report this modifier.

It will be interesting to see which of these proposals for discouraging off-campus PBD services paid under OPPS will make it to the final rule. It is clear from reading the proposed rule that CMS is intent on limiting expansion and making payments more site-neutral. This is bad news for hospitals that have increased their bottom line through the expansion of off-campus services.

Q:

Is the “with” guideline used when there is documentation of Diabetes and Arthritis?

A:

No, the “with” guideline does not apply to “not elsewhere classified” (NEC) conditions. Arthritis, a form of Arthropathy, can be due to many other conditions besides Diabetes. Therefore, coders should not assume a cause and effect relationship between Diabetes and a “NEC” condition. The physician would have to document Arthritis as a diabetic complication in order for E11.618 to be assigned.

Diabetes, diabetic (mellitus) (sugar)

with

arthropathy NEC E11.618

References:

Coding Clinic: Second Quarter 2018, page 6

Fourth Quarter 2017, page 100-101

PATIENTS OVER PAPERWORK INITIATIVE

CMS launched the “Patients over Paperwork” initiative in October 2017. This initiative allowed CMS to establish “an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.” CMS is keeping stakeholders informed through information posted to the Patients Over Paperwork webpage as well as Newsletters highlighting ongoing efforts towards meeting their goal.  

July 2018 Newsletter

CMS posted the July 2018 Newsletter this past week making it the 6th Edition. This newsletter:

• Provides updates on how CMS is addressing Skilled Nursing Facility/Nursing Home burden.
• Describes how CMS is simplifying documentation requirements.
• Provides an update on where CMS is meeting with stakeholders to discuss burden.
• Reminds stakeholders about opportunities to provide feedback through requests for information from CMS.

Today, we delve into the specifics about reducing SNF/Nursing Home Burden and Opportunities for Providing Feedback to CMS

Addressing Skilled Nursing Facility/Nursing Home Burden

After what is described as spending hundreds of hours reviewing information, CMS indicates they listened, learned and acted.

• Listen: In response to Requests for Information (RFI) in 2017, CMS received 154 comments on burden related to the nursing home experience. In addition to soliciting comments and to capture customer perspectives CMS spoke with 93 people during visits to 3 nursing homes and hosted 22 listening sessions around the country.
• Learn: CMS found that Comments received from RFIs grouped into 9 themes. The themes were then grouped together and 15 actions that could be taken to address burden were identified. As a product of the site visits, CMS designed a Nursing Home Journey map depicting residents, families, and staff interaction in a nursing home.
• Action: One example provided in the newsletter are the changes being proposed in the Skilled Nursing Facility Prospective Payment System (SNF PPS) FY 2019 Proposed Rule. CMS highlights a proposed new case-mix model, Patient-Driven Payment Model (PDPM) “which would move Medicare towards a more unified post-acute payment system that better accounts for resident characteristics and unique care needs of the patients while also reducing significantly the administrative burden associated with SNF PPS.” They also highlight the proposal of a new factor to account for costs associated with a measure when evaluating measures for removal from the SNF Quality Reporting Program (QRP) measure set.

 

OPPORTUNITY TO PROVIDE FEEDBACK TO CMS

Medicare Physician Fee Schedule (MPFS) and Quality Payment Program

CMS touts in this newsletter the proposals being made are “historic” and if finalized,
“clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients.” In addition to clinicians there are several proposed revisions that could affect hospitals. A discussion of these proposals can be found in a related FAQ. Public comments must be received no later than 5 p.m. on September 10, 2018.

Stark Law

Through the RFI process CMS identified compliance with the Stark Law and its accompanying regulations as being a top area of burden. CMS is requesting input on several issues with the Law and “is particularly interested in the public’s input on the structure arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law.”

The comment period ends August 24, 2018. The RFI can be downloaded at https://www.federalregister.gov/documents/2018/06/25/2018-13529/medicare-program-request-for-information-regarding-the-physician-self-referral-law.

In addition to the MPFS Proposed Rule and Stark Law RFI, CMS lists several 2019 Proposed Rules aiming to reduce burden and provides links to the individual Proposed Rule and Fact Sheets. MMP strongly encourages you to review relevant proposed rules and provide comments.

Several years ago, our neighbor gave us a “stick” to plant. He said it was a fig tree. My husband and I were both doubtful this stick would ever become anything, let alone a fig tree. That fig tree is now about 12 feet around and 15 feet high, loaded with beautiful, sweet figs. It is so tall in fact that I have to have a ladder to gather the fruit growing up high. I often however, pick the low-hanging fruit as I pass by the tree. As well as the reality of my fig tree, “low-hanging fruit” is a saying for all easily obtained gains.

CMS quarterly publishes the Provider Compliance Newsletter about common billing errors and other erroneous activities related to Medicare Fee-for-Service (FFS) program. The newsletter provides examples of errors and offers tips on ways to avoid them. Articles identify the types of providers affected by the issues, such as physicians, non-physician practitioners, outpatient hospital, etc. as well as whether the errors were identified by the Comprehensive Error Rate Testing (CERT) program or by the Recovery Auditors (RACs). It is also not unusual for other types of Medicare reviewers, especially the Medicare Administrative Contractors (MACs), to select issues identified by the CERT or RACs for their medical review activities. High-risk issues can be easy “low-hanging fruit” for finding overpayments to recoup.

The July 2018 Medicare Quarterly Provider Compliance Newsletter includes an article related to outpatient hospital services concerning Medicare coverage of vagus nerve stimulation (VNS). This was at one time an issue being reviewed by the Recovery Auditors. Vagus Nerve Stimulation is a pulse generator,

surgically implanted under the skin of the left chest and connected to the left vagus nerve. Electrical signals sent from the battery-powered generator to the vagus nerve via the lead are in turn sent to the brain. VNS is used to treat certain types of epilepsy.

In July 1999, Medicare issued a National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. The coverage is specifically limited to “partial onset” seizures and other types of seizures are not covered. In May 2007, CMS issued an additional non-coverage decision for the use of VNS for patients with resistant depression.

This means VNS is only covered for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. If you provide VNS for other types of seizures (not partial onset) or for resistant depression, Medicare will not cover the VNS. Specifically, one of the following diagnosis codes must be reported for Medicare to cover VNS:

• G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epileptic
• G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
• G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
• G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
• G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
• G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

Outpatient hospitals need to have systems in place to verify VNS is being performed for an appropriate, covered indication for their Medicare patients. If VNS is used for non-covered indications, inform the patient with an Advance Beneficiary Notice (ABN) so the patient understands they are financially liable for payment. This will allow your facility to avoid being “low-hanging fruit” for recoupments.

MEDICARE TRANSMITTALS

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

Revised criteria that allows the GT modifier to be present on Method II CAH claim lines.

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

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

The article is revised to show the Type of Service Code for CPT code 90739 remains as V.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10624.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.3, Effective October 1, 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10827.pdf

Medical Review of Evaluation and Management (E/M) Documentation

Provides direction to Medicare’s medical review contractors on how to review claims where a medical student documented the E/M service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10627.pdf

Medicare Special Edition Articles

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED

This article was revised on July 11, 2018, to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/SE18006.pdf

 

MEDICARE RULES

2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule

Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

 

MEDICARE EDUCATIONAL RESOURCES

Medicare Billing for Cardiac Device Credits

Learn about billing Medicare inpatient and outpatient cardiac devices and reducing overpayments.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/cardiacdevicecredits-ICN909368.pdf

Beneficiary Notices Initiative (BNI) webpage – updated

New look for Medicare’s Notices webpage.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html

Medicare Fee for Service Recovery Audit Program webpage – updated

New look for Medicare’s RAC webpage

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html

Transition to New Medicare Numbers and Cards Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Medicare Quarterly Provider Compliance Newsletter – July 2018

Addresses common billing errors and other erroneous activities and provides guidance to help health care professionals address and avoid the top issues of the particular quarter.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909378.pdf

 

MEDICARE FAST FACTS

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
• Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

 

OTHER MEDICARE UPDATES

Contract Award for A/B MAC Jurisdiction F

CMS awarded the Jurisdiction F contract to Noridian, the current incumbent contractor for JF.

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

Q:

Are there any proposed rule changes from the 2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule that may affect hospitals?

A:

Yes, there are several proposed revisions that could affect hospitals, although some of these will not be effective until 2020.  Here is a review of some of the issues:

Non-excepted Off-Campus Provider Based Departments

These are off-campus PBDs that did not begin billing Medicare until after November 2, 2015.  The Bipartisan Budget Act of 2015 required services in these PBDs be paid under a payment system other than the Outpatient Prospective Payment System (OPPS) in order to make payments more equitable with payments for similar services provided in a physician office setting. Medicare pays for these services under the Medicare Physician Fee Schedule at a percentage of the OPPS payment rates. For 2019, Medicare proposes to continue to pay 40% of the OPPS rate for these services. Hospitals will continue to bill these services on an institutional claim form using the PN modifier to identity non-excepted services. Packaging and other OPPS claims processing logic also apply to these services.

Clinical Laboratory Fee Schedule (CLFS)

The Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. Under the CLFS final rule, applicable laboratories must report to CMS for laboratory tests the private payor rates, the volume and the specific

HCPCS code associated with the test. Beginning in 2018, Medicare CLFS rates are based on this information specifically, equal to the weighted median of the private payor rates for each test.

The 2019 MPFS Proposed Rule seeks comments on a couple of suggestions that could affect whether a hospital outreach laboratory would meet the definition of an applicable reporting lab or not. One suggestion is using Form CMS-1450 bill type 14x to determine the majority of Medicare revenues and low expenditure thresholds in deciding if a lab must report data. The other suggestion is to use the CLIA certificate rather than the NPI to identify a laboratory that would be considered an applicable laboratory.

Therapy Services

CMS is proposing to discontinue functional limitation reporting beginning January 1, 2019. If finalized, they will also delete the HCPCS codes that were created for this reporting.

The Bipartisan Budget Act of 2018 (BBA of 2018) requires reduced payment for therapy services provided in whole or in part by a therapy assistant beginning in 2022. This includes payment to providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs) but, not to critical access hospitals (CAHs). CMS will create a new modifier that must be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. These two therapy modifiers would

be added to the existing three therapy modifiers – GP, GO, and GN − that are currently used to identify all therapy services delivered under a PT, OT or SLP plan of care, respectively. Modifiers GP and GO will be redefined to be reported when physical or occupational services are provided by a therapist.

Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Effective January 1, 2020, professionals must consult appropriate use criteria (AUC) before ordering applicable advanced diagnostic imaging services and furnishing professionals must report AUC consultation information on the Medicare claim. The first year (2020) is for education and operations testing and claims will not be denied for failure to include proper AUC consultation information.

Information in the proposed rule clarifies that hospital outpatient departments are required to report AUC information on claims. Specifically, the proposed MPFS rule clarifies that AUC consultation information must be reported on all claims for an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system. Applicable settings include a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and proposed this year, an independent diagnostic testing facility (IDTF). The AUC information to be reported on a claim includes which qualified clinical decision support mechanism (CDSM) was consulted; whether the service met, did not meet, or was not applicable for the AUC and the NPI of ordering physician. CMS also proposed to use established coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims.

Although emergency departments are listed specifically in the applicable settings, the exceptions for AUC consulting and reporting are 1) a service ordered for an individual with an emergency medical condition, 2) a service ordered for an inpatient, and 3) a service ordered by an ordering professional with a significant hardship.

To find out more about the above issues, you can find the 2019 MPFS Proposed Rule here. 

Can I be honest?

I have type 2 diabetes and take a pill for it every day, but I don’t like diabetes coding. Diagnosis code assignment for diabetes and diabetes-related conditions has always been confusing to me. When looking at a chart of a patient with diabetes, I frequently go back to the ICD-10 diagnosis coding guidelines and Coding Clinic articles to validate my understanding.

Based on some of the coding proficiency reviews we’ve done over the past couple of years, I think other coders may share some of my confusion.  One of the most common diagnosis coding discrepancies we come across with diabetes coding is the scenario of a patient with Type 2 diabetes who is also taking an oral antidiabetic drug. We usually see the appropriate diagnosis code for Type 2 diabetes, but ICD-10 diagnosis code Z79.84 is not reported for long-term use of an antidiabetic drug when it’s applicable.

Z79.84 was introduced October 2016, and in addition to all the other diabetes-related coding rules we already had, this new code came with, yet, another rule to remember:  When E11- is reported for type 2 diabetes, use an additional code to identify control using an oral antidiabetic / hypoglycemic drug.

In talking with coders and coding supervisors, one of the problems in picking up Z79.84 is that coders may not know which drugs are classified as an antidiabetic. The good news is – we don’t have to know if the drug is a biguanide versus an alpha-glucosidase inhibitor versus SGLT 2 inhibitor, etc., we just need to know which oral medications are considered antidiabetic or hypoglycemic.

Below is a list of the more common oral antidiabetic drugs we see. Did you realize the different preparations of Metformin had so many other names? Keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.84 should be reported in addition to the E11- diabetes code. Click here to see a more comprehensive list on the Healthline.com website.

Metformin / Kazano

Metformin / Invokamet

Metformin / Xigduo XR

Metformin / Synjardy

Metformin / Glucovance

Metformin / Jentadueto

Metformin / Actoplus

Metformin / PrandiMet

Metformin / Avandamet

Metformin / Kombiglyze XR

Metformin / Janumet

Sitagliptin / Januvia

Sitagliptin-Metformin / Janumet

Canagliflozin / Invokana

Canagliflozin-Metformin / Invokamet

Empagliflozin / Jardiance

Glimepiride / Amaryl

Glipizide / Glucotrol

Chlorpropamide / Diabinese

Tolazamide / Tolinase

Tobbutamide / Orinase

Q:

Services for Medicare patients referred to our hospital for outpatient treatments or testing are being denied by Medicare due to “clinical documentation not provided.”  Examples of the types of services being denied are therapeutic outpatient infusions and diagnostic tests such as CT scans. The only information the hospital has is the physician’s order and the nursing documentation or diagnostic report. How are we supposed to provide the clinical documentation to support the medical necessity of the service to the Medicare auditor?

A:

Information addressing this can be found in the Medicare Program Integrity Manual, Chapter 3. The bottom line is the billing provider is ultimately responsible for submitting all supporting documentation for services for which they billed, even if they have to obtain such information from another provider. 

Medicare auditors include the:

• Medicare Administrative Contractors - MACs,
• Recovery Auditors - RACs,
• Comprehensive Error Rate Testing reviewers - CERT and
• Zone or Unified Program Integrity Contractors - ZPICs/UPICs.

These auditors generally request documentation to support the services billed to Medicare from the billing provider. The CERT, and at their discretion, other Medicare auditors, may also request information from the referring provider when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentation necessary to support the service billed and supported by the Local and National Coverage Determinations.

However, because the provider selected for review or appealing a denial is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the requested documentation.  This means hospitals may have to obtain information supporting the medical necessity of services from the referring provider, such as physician office notes, and forward that documentation to the Medicare auditor. Failure to get this documentation to the Medicare auditor can result in payment denial for the billed service.

MEDICARE TRANSMITTALS

July 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

CMS supplies MACs with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE). Also see related content at PalmettoGBA - “The drug pricing files contain the payment amounts used to reimburse for Part B covered drugs for the applicable quarter of 2018. The payment amounts in the quarterly ASP files are 106 percent of the Average Sales Price (ASP) calculated from data submitted by drug manufactures (ASP X 1.06). The ASP rate must be adjusted before applying the 22.5 percent reduction (for 340B-acquired drugs).”

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10667.pdf

Claim Status Category and Claim Status Codes Update

HIPAA requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10777.pdf

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

Changes and billing instructions for various payment policies implemented in the July 2018 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10781.pdf

July 2018 Integrated Outpatient Code Editor (I/OCE) Specification Version 19.2

The I/OCE is being updated for July 1, 2018. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single I/OCE.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10699.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

 

New Medicare Beneficiary Identifier (MBI) Get It, Use It

Explains ways you can get MBIs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf

 

REVISED MEDICARE TRANSMITTALS

 

Diagnosis Code Update for Add-on Payments for Blood Clotting Factor Administered to Hemophilia Inpatients – REVISED

Revised to correct the code description for ICD-10-CM D68.32.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10474.pdf

 

MEDICARE EDUCATIONAL RESOURCES

 

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Provider Minute Vide: The Importance of Proper Documentation
• Bill Correctly for Device Replacement Procedures
• Billing for Stem Cell Transplants

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

 

FEDERAL REGISTRY CMS RULES

 

Medicare Program; Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR): Extreme and Uncontrollable Circumstances Policy for the CJR Model

Finalizes a policy that provides flexibility in the determination of episode spending for Comprehensive Care for Joint Replacement Payment Model (CJR) participant hospitals located in areas impacted by extreme and uncontrollable circumstances for performance years 3 through 5.

https://www.gpo.gov/fdsys/pkg/FR-2018-06-08/pdf/2018-12379.pdf

 

OTHER MEDICARE UPDATES

 

Hospital Appeals Settlement Process Update

May 8, 2018, CMS executed settlements with an additional 612 hospitals, representing approximately 72,000 claims.   

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/Hospital-Appeals-Settlement-Process-2016.html

FY 2019 ICD-10-PCS Procedure Codes

FY 2019 ICD-10-PCS procedure code updates including a complete list of code titles are posted on the 2019 ICD-10-PCS webpage.

FY 2019 ICD-10-CM Codes

FY 2019 ICD-10-CM code updates have been posted on the CDC website at: https://www.cdc.gov/nchs/icd/icd10cm.htm.