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In the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Program performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims. CMS released Change Request 10778 (CR10778) on June 15, 2018 with an effective date of July 17, 2018. This transmittal updates Chapter 12, The Comprehensive Error Rate Testing (CERT) Program, of the Medicare Program Integrity Manual (PIM). Specifically, CR 10778 updates Chapter 12, section 12.3.8 with details on no response and insufficient documentation errors in the CERT Program. Before we look at the “details” let’s set the stage with a little more about the CERT.

About the CERT

The CERT Program calculates the Medicare Fee-for-Service (FFS) program improper payment rate. Any claim paid when it should have been denied or paid at a different amount is considered to be an improper payment by the CERT. Annually, a stratified sample of approximately 50,000 claims that have been submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs are reviewed to determine if they have been paid properly under Medicare coverage, coding, and billing rules.

Claims are counted as total or partial improper payment and the error is categorized into one of the following five major categories:

1. No Documentation,
2. Insufficient Documentation,
3. Medical Necessity,
4. Incorrect Coding, or
5. Other.

The CMS CERT webpage and the CERT Review Contractor website both emphasize that “it is important to note the improper rate is not a fraud rate, but is a measurement of payments made that did not meet Medicare requirements.”

CR 10778

The CERT Review Contractor issues an Additional Documentation Request (ADR) to obtain medical records from providers. They currently have processes in place to report to the MACs when there is no response from a Provider or they receive insufficient documentation. CR10078 provides information to the MACs on actions they may take for these two types of errors.

Key Changes Effective July 17, 2018

The PIM, Chapter 12, section 12.3.8 is currently titled “Contacting Non-Responders and Documentation Requests” and was last updated January 19, 2017. The remainder of this article focuses on the details of what is changing. Specific changes in CR10778 are bolded and italicized.

Title Change

• Current Title: Contacting Non-Responders and Documentation Requests
• Effective July 17, 2018: “Handling Non-Responders and Insufficient Responses to Additional Documentation Requests (ADR)”

Additional Documentation Requests

• Current Guidance: A MAC may contact providers when an additional documentation request (ADR) is issued. ADR claims can be found on the CERT Claims Status Website (CSW).
• Effective July 17, 2018: The CERT review contractor sends the additional documentation request (ADR) to the billing provider and/or supplier. If the CERT review contractor determines that the documentation is missing or insufficient to make a determination on a claim, a subsequent ADR may be sent to the billing provider and/or supplier, the ordering/referring provider, or a third-party, as appropriate.

Contacting Non-Responders

• Effective July 17, 2018: This section will be re-titled “Handling Non-Responders” and include the following guidance.
  

If no response is received within the allotted time of 75 days, the CERT review contractor shall find the claim in error and assign Error Code 99 to the claim. These claims are posted to the Claims Status website (CSW) on the 76th day from the date the first request letter was sent. In addition, claims with Error Code 99 will appear in the next MAC feedback batch.

For claims with Error Code 99, the MACs may proceed at their discretion by doing one of the following:

1. Contact those providers who have failed to submit medical records and encourage them to submit the requested records to the CERT review contractor for review. The MACs should allow feedback to roll over as long as they are working with the provider to obtain documentation and/or CERT is reviewing the claim;
2. Complete MAC feedback, prior to entering an appeal, in accordance with section 12.3.3.3 of this chapter and collect the overpayment immediately in accordance with section 12.3.4 of this chapter; or
3. Collect the overpayment within 10 business days of the deadline for entering the final MAC feedback.
   

The MAC shall not contact any provider and/or supplier selected for CERT review until 30 days after the CERT first ADR has been reported on the CSW. The MAC may contact the third party and encourage them to send the needed medical record documentation to the CERT review contractor. When contacting the provider and/or supplier, the MAC shall remind them to include the barcoded cover sheet included with the CERT request or the CERT claim identification number at the top of the medical record. The MAC can download a barcoded cover sheet from the CSW if needed.

Handling Insufficient Responses – NEW

If the documentation submitted is inadequate to support payment for the service/item billed, or if the CERT review contractor could not conclude that the billed service/item was actually provided, was provided at the level billed, and/or was medically necessary, then the claim is considered to be an error due to insufficient documentation. Insufficient documentation errors are assigned an Error Code 21.

Claims that receive an Error Code 21 will be posted under the MAC feedback section of the CSW. MACs should reach out to the providers/suppliers to submit the requested documentation to the CERT review contractor.

Documentation Request Letters

When requesting medical records from providers, suppliers, and/or third parties, the CERT review contractor uses the CMS approved request letters, found at https://certprovider.admedcorp.com/. The CERT review contractor also sends the request letters in Spanish to providers in Puerto Rico and upon request to providers in other regions. (Note, this is an updated email address to use to find the CMS approved request letters.)

CERT Program, MACs and Hospitals

In their 2017 Medicare Fee-for-Service Supplemental Improper Payment Data Report, the CERT found a 9.5 percent improper payment rate in claims reviewed that had been submitted for payment from July 1, 2015 through June 30, 2016. “No documentation” errors accounted for 2% of the monetary loss findings and “insufficient documentation” errors accounted for 64% of the monetary loss findings. MACs utilize CERT Program review findings as one data source to identify issues for Provider Education and Pre-Payment Reviews. Hospitals need to be aware of the errors, educate key stakeholders within your facility and respond to ADR requests from the CERT.   

I love reading. And although people’s reading preferences vary, sometimes I read a book that is so well written and has such a great storyline that I have to recommend it to my friends. Unfortunately, a lot of my reading is not just for the fun of reading. I read numerous newsletters and government publications to stay current on the happenings of Medicare rules and regulations. Sometimes even this necessary reading leads to an article that I feel compelled to share with others because it clearly and thoroughly explains a Medicare issue. This week I must recommend the Palmetto GBA article on Resolution Tips for Overlapping Claims.

Overlapping claims can be sneaky. You don’t even know you have one until Medicare rejects your claim. This is because avoiding overlapping claims depends on the information you get from patients and other facilities or agencies and on correct billing by your facility as well as that of other Medicare providers. The basic rules are:

• A patient cannot be an inpatient in two different facilities at the same time,
• Outpatient services are included in inpatient stays with only a few exceptions,
• Some Medicare services (e.g. home health) include certain other outpatient services, and
• Hospice is responsible for all Medicare services related to the hospice condition except the professional services of the patient’s attending physician/practitioner.

The possibilities for overlapping claims is large – per the Palmetto article, “An overlapping situation may occur between hospitals for inpatient stays, which include [Inpatient Psychiatric Hospitals (IPH), Long Term Care Hospitals (LTCH), Inpatient Rehab Facilities (IRF), Critical Access Hospital (CAH)], hospitals for outpatient services, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Hospice agencies, Outpatient Rehab Facilities (ORF), Comprehensive Outpatient Rehab Facilities (CORF), End Stage Renal Disease (ESRD) Facilities, or a combination of one provider type and another.”

Here are some tips I gleaned from this article specifically for hospitals on ways to avoid overlapping claims:

• Verify patient eligibility by questioning the patient/family carefully and by checking Medicare electronic eligibility systems.
• Establish a good relationship with the other providers in your area so that you can work together to resolve overlap situations.
• Ensure your discharge status code is correct. Coders need to accurately understand the discharge status codes and work with Case Managers if the record is unclear. Post-discharge follow-up with the patient may be required – did the patient start home health services as planned, was their nursing home stay approved as skilled, etc. Also understand that you will not always be aware of where the patient goes when they leave your hospital and will only find out when Medicare asks you to adjust your discharge status. It is appropriate to change your discharge status based on Medicare request, although I recommend keeping documentation of this in your medical record or independently verifying the patient’s post-discharge care.
• Know the billing rules when patients go from or to other inpatient facilities – when a patient is discharged and readmitted to an LTCH within 3 days, payment is made to the LTCH; IPFs and IRFs must use condition code 74 when a patient is admitted to a hospital but returns to their facility within 3 days.
• A patient cannot receive home health services or outpatient services during an inpatient stay. Any outpatient services provided to the patient during an inpatient admission must be bundled into the inpatient claim.
• Know and understand the 3-day payment window rule. All services the day of admission are bundled into the inpatient claim; all diagnostic services within 3 days of admission are bundled; and therapeutic services within 3 days of admission that are related to the reason for admission are bundled into the inpatient claim.
• Same-day readmissions to the same hospital are combined to one claim unless the reason for the second admission is unrelated to the reason for the first stay. In that case, you would report condition code B4 on the second inpatient claim.
• Understand consolidated billing rules for SNFs and home health agencies. Certain outpatient services are separately billable to Medicare when provided to a SNF or HH patient. See SNF Consolidated Billing and Home Health PPS for more information.
• Hospice overlaps can be especially challenging for hospitals. If your hospital has an outreach laboratory, testing on hospice patients should generally be billed back to the hospice. The Palmetto article offers the following guidance for all provider types overlapping hospice:

“Providers of all types whose claims are overlapping a hospice election should contact the Hospice agency to determine if the services are related to the terminal illness. If related, payment arrangements should be made with the hospice provider. Services that are not related to the terminal illness should be billed with a 07 Condition Code…. Providers who suspect that the hospice may no longer be in business and are unable to verify if their services are related, or if the hospice has failed to update the revocation indicator should contact their MAC for assistance.” 

Overlapping claims can be sneaky, challenging and frustrating. Again, I recommend this Palmetto article for more complete information. Being more informed and prepared will not remove all the challenges of overlapping claims but knowing what to expect and how best to respond may relieve some frustrations.

Although the official start of summer is not until tomorrow at 5:07 AM Central Time, here in Alabama the oppressive humidity and heat activated thunderstorms have already begun. Additionally, and much to my delight, I am already seeing more lightening bugs in the night sky than in recent years. This brings to mind the oft made statement by Mark Twain, “the difference between the almost right word and the right word is really a large matter. ‘tis the difference between the lightening bug and the lightening.”

The same analogy can be made for documentation in a medical record. CMS posted the FY 2019 ICD-10-CM diagnosis code updates to the CMS website on June 11, 2018. Several of the updates revise or expand a code description. Professional Coders and Clinical Documentation Improvement Specialists should take on the challenge of a little summer reading to find out what is changing. In the meantime, here are a few highlights about what will change come October 1, 2018.

Code Changes by the Numbers:

The FY 2019 ICD-10-CM codes updates includes:

• 279 New Codes
• 143 Revised Titles
• 51 Deleted Codes
• 71,932 Total Codes for FY 2019. (Increase from 71,704 in FY 2018).

The following tables highlights some of the changes come October 1, 2018.

(*)Note, code Z62813 falls within the Z62 category “Problems Related to Upbringing.” This is one of the ICD-10-CM code categories that identifies patients with potential health hazards related to socioeconomic and psychosocial circumstances. Coding Clinic for ICD-10-CM/PCS, First Quarter 2018 advised that it would be acceptable to report these codes based on documentation from non-physician clinicians following the patient. You can read more about the Z55-Z65 code categories in a related MMP article about Social Determinants of Health.

Information about the FY 2019 ICD-10-CM code updates can also be found on the Centered for Disease Control and Prevention (CDC) website at: https://www.cdc.gov/nchs/icd/icd10cm.htm. Reminder, the code updates will be used for discharges occurring from October 1, 2018 through September 30, 2019.

The Office of Inspector General (OIG) has released the Spring 2018 Semiannual Report to Congress. This report summarizes work by the OIG for the reporting period covering October 1, 2017 to March 31, 2018. This Report describes work undertaken “to identify significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”

The Inspector General, Daniel R. Levinson, notes “over the 6-month reporting period OIG worked to enhance the integrity of HHS programs and operations, protect vulnerable populations, and drive value in health and human services…Looking forward, OIG will continue to leverage our staff expertise to inform Department-wide goals, including combating the opioid crises, bringing down the cost of prescription drugs, addressing the cost and availability of health insurance, and transforming our health care system to a value-based system.”

This article highlights OIG overall expected recoveries and statistics found in the report and provides examples of OIG Activities specific to the Centers for Medicare & Medicaid Services (CMS) from the first half of FY 2018.

“Fighting Fraud” by the Numbers

Highlights of Enforcement Accomplishments

• $1.46 billion is the expected investigative recoveries.
• 424 is the number of individuals or entities that engaged in crimes against HHS programs where criminal actions against them have been taken.
• 1,588 is the number of individuals and entities that have been excluded from Federal health care programs.
• 349 is the number of civil actions taken against individuals or entities.

Highlights of Accomplishments in Assessment of Mismanagement and Abuse in HHS Programs

• $187.5 million is the amount the OIG expects to recover.
• $1.5 billion is the amount of potential savings.
• $680 million is the amount of questioned costs during this time period.

Highlights from CMS Medicare Program Reports and Reviews

 

CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor (A-03-14-00010), November 2017

Report Highlights

• 2,145 inpatient claims at 25 providers were reviewed.
• The OIG determined that only 1 claim correctly included the diagnosis code for Kwashiorkor.
• Findings equated to overpayments in excess of $6 million.
• CMS agreed with OIGs recommendations.
• The 25 hospitals reviewed repaid $5.7 million in overpayments.

Note: In January of this year the OIG Announced the Active Work Plan Item: Hospitals Billing for Severe Malnutrition on Medicare Claims. The OIG indicated in the announcement that “this review will assess the accuracy of Medicare payments for the treatment of severe malnutrition. We will determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims.”

Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements (A-01-15-00515), February 2018

 Report Highlights

• Wisconsin Physicians Service (WPS) paid 73 providers for HBO therapy services that did not comply with Medicare requirements.
• OIG estimated WPS overpaid providers in Jurisdiction 5 $42.6 million.
• WPS “generally agreed” to the following OIG recommendations:
• Recover the “appropriate portion of the $300,789 in identified Medicare overpayments,
• Notify providers responsible for the 44,820 non-sampled claims with potential overpayments to investigate and return any identified overpayments, and
• To identify and recovery any improper payments after the audit and strengthen policies & procedures for making payments for HBO therapy.

Note: HBO Therapy Services is a current Targeted Probe & Educate Medical Review target for Palmetto JM. Palmetto’s May 15, 2018 Ask the Contractor Teleconference (ACT) focused on Hyperbaric Oxygen Therapy. You can find Answers to Pre-submitted Questions on Palmetto’s JM website.

While this is not an Active Medical Review for Palmetto JJ (Alabama, Georgia, Tennessee), for those providing HBO therapy services it would be worth your time to read this and ask the question, are we compliant with Medicare requirements?

 

Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Devices (A-05-16-00059), March 2018

 Report Highlights

• All 296 payments reviewed did not comply with Medicare requirements.
• Medicare contractors incorrectly paid hospitals $7.7 million rather than the $3.3 million they should have been paid.
• CMS agreed with the recommendation to “consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits.”

Note: In the Thursday, June 7, 2018 edition of the MLNConnects e-newsletter, CMS included a Provider Compliance Reminder for correct billing for device replacement procedures. The reminder provides links to resources to correctly bill and avoid overpayment recoveries. 

We all know the benefits of a healthy diet and exercise. You can hardly go a day without seeing or hearing information on how eating right and exercising will lead to a longer, healthier, and happier life. Unfortunately, not all of us are proactive when it comes to our health. We wait until an episode or condition has occurred before changing our ways. Better late than never, so it is lucky for many that Medicare covers cardiac and pulmonary rehabilitation. For the providers that furnish these services, it is also wise to be proactive to ensure you meet the Medicare requirements of coverage and billing. Better late than never is not a wise option for providers since your facility could lose valuable reimbursement if you fail to follow the Medicare rules.

In May 2018, the Office of Inspector General added review of outpatient cardiac and pulmonary rehabilitation services to their Work Plan. The OIG notice reminds providers, “For these services to be covered, however, they must be medically necessary and comply with certain documentation requirements. Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements.” In addition to prior OIG reviews, some Medicare Administrative Contractors (MACs) have also reviewed cardiac and pulmonary rehab services. The MAC reviews found significant error rates for these services.

If your facility provides one or both of these services, what should you do to ensure you comply with Federal requirements? The obvious first step is being familiar with Medicare’s requirements. The  Medicare Benefits Policy manual, chapter 15 discusses the coverage of pulmonary rehab in section 231 and cardiac rehab in section 232. Chapter 32 of the Medicare Claims Processing Manual provides instructions on these programs in section 140.

If you do provide these services, it is likely you know the covered conditions and required components of each. So, in this article, let’s focus on the areas that are most prone to be deficient.

Pulmonary rehab is covered for patients with moderate to very severe chronic obstructive pulmonary disease (COPD) (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease. Cardiac rehab is covered for patients with

• Acute myocardial infarction within the preceding 12 months;
• Coronary artery bypass surgery;
• Current stable angina pectoris;
• Heart valve repair or replacement;
• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
• Heart or heart-lung transplant.
• Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

In the case of a medical review, the patient’s diagnosis should be stated as part of the treatment plan but in addition, your record must substantiate the covered diagnosis with documentation from physicians’ office notes, hospital records, findings of diagnostic testing, and/or operative notes. Also verify timeframes (AMI within the last 12 months, optimal heart failure therapy for at least 6 weeks for CHF) and the inclusion of specific measures when required (GOLD class II, III, or IV; VEF of 35% of less; NYHA class II – IV symptoms) are addressed with supporting documentation.

Denials of pulmonary and cardiac rehab from prior MAC reviews were often cited as due to lack of all the required components. Both pulmonary and cardiac rehab require the following components.

• Physician-prescribed exercise,
• Education or training (for cardiac risk factor modification in the case of cardiac rehab)
• Psychosocial assessment
• Outcomes assessment
• Individualized treatment plan

It is unknown how strict a particular Medicare reviewer will be, so best practice is to address each of these elements with the following strategy – 1) what does the patient need, 2) what is the plan for addressing that need, 3) what was done for the patient based on the plan, 4) how did the patient respond and 5) modifications based on patient failure to progress. Years ago, CGS published an article that described the requirements for cardiac rehab. That article is no longer available, but MMP provided details from that publication in a prior Wednesday@One article that you might find helpful.

Cardiac and pulmonary rehabilitation program sessions are limited to a maximum of two (2) 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary. MMP sees Medicare denials of cardiac and pulmonary rehab services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. This could occur when:

• Cardiac/pulmonary rehab services exceed two (2) units for a single day of service
• Cardiac/pulmonary rehab services exceed 36 sessions without a –KX modifier included on the claim line
• Cardiac/pulmonary rehab services exceed 72 sessions

Medicare will assign liability for these services to the provider unless an Advance Beneficiary Notice (ABN) was obtained.

If a patient requires medically necessary cardiac/pulmonary rehab services beyond 36 sessions (up to a maximum of 72 sessions), a –KX modifier should be appended to the claim line. The –KX modifier indicates the services provided meet the medical necessity requirements of the applicable medical policy/regulation and there is supporting the rehab services beyond 36 sessions. For example, a patient may be benefiting from rehab but may not meet exit criteria after the initial 36 sessions. This is an example when use of the –KX modifier would be appropriate.

Also, be sure your documentation specifies the amount of time the patient is participating in cardiac or pulmonary rehab. In order to report one session of cardiac/pulmonary rehabilitation services in a day, the duration of treatment must be at least 31 minutes. Two sessions may only be reported in the same day if the duration of treatment is at least 91 minutes. If several shorter periods of cardiac/pulmonary rehabilitation services are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.

Now is a good time to look at your own cardiac or pulmonary rehab records to verify they meet all the Federal requirements before the OIG, a MAC, or another Medicare reviewer comes calling for those records. Be proactive before it is too late.

Q:

Would you please clarify guidelines for when it is appropriate to code excisional vs non-excisional debridement?

A:

One thing to keep in mind, is the difference between an excisional debridement and a non-excisional debridement. 

An excisional debridement:

• Is a surgical procedure that involves an excisional method of removal, or cutting away tissue, necrosis and/or slough
• Groups to a surgical MS-DRG
• Results in a higher relative weight
• Translates into higher reimbursement
• Is classified to root operation “Excision”

A non-excisional debridement:

• Non-operative procedure involving brushing, scrubbing, irrigating or washing of devitalized tissue, necrosis, slough, and/or foreign material.
• May be classified to root operation “Extraction” (pulling or stripping out or off all or portion of a body part by use of force)
• Use “Extraction” of the specific body part instead of “Irrigation” when coding for debridement of areas other than skin
• May be classified to root operation “Irrigation” when procedure is performed by irrigating the devitalized tissue
• Does not group to a surgical MS-DRG

As stated in 3rd Qtr. Coding Clinic 2015: pages 3-5, "the provider is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the provider when the correlation between the documentation and the defined PCS term is clear.  It is the coder's responsibility to determine what the documentation equates to in the PCS definitions."   

When the physician’s intent of the procedure is to debride the wound, in most cases, he or she is not likely to use the PCS terms “Extraction, Irrigation or even Excisional”, as emphasized in the guideline above”   Documentation in the body of the procedure note should be descriptive enough for the coder to determine which procedure code to assign.

It should also be noted that this same Coding Clinic also emphasizes that a code is assigned for excisional debridement when the provider documents “excisional debridement” “AND / OR” the documentation meets the definition of the Excision root operation.  

Even when the physician states an excisional debridement was carried out; elements must also be documented in the body of the procedure note to support an excisional debridement.  You may find it easier to memorize “TINA D” in order to help with assignment of the more appropriate code for the procedure performed.

T - Technique used by the provider (cutting, scrubbing, trimming)

I - Instruments used (scissors, scalpel, pulse lavage, or curette)

N - Nature of the tissue removed (slough, necrosis, devitalized tissue, or non-viable tissue)

A - Appearance and size of the wound (fresh bleeding tissue or viable tissue)

D - Depth of the debridement (down to and including)

 

Additional things to remember:

1. Use of sharp instrument is not always indicative of excisional debridement.
2. Only one code, for the deepest layer documented is assigned when there are multiple layers involved of the same site
3. Both excisional and non-excisional debridement can be performed by:

• Physician
• Physician assistant
• Nurses
• Therapists

4. The location in which the procedure is performed is no indication of the type of debridement carried out.

Remember:  We cannot assume anything.  Documentation in the record needs to clearly support and reflect the procedure that was performed.   If not, then a query should be sent for clarification.

We often associate the term “it takes a village” with the raising of children. It is true that parents, grandparents, relatives, teachers, coaches, church members, healthcare providers, and/or others often play key roles in bringing up a physically and emotionally healthy, well-adjusted young person. But what brought the “it takes a village” phrase to my mind today was listening to a replay of Palmetto GBA’s webcast on Inpatient Psychiatric Facility (IPF) coverage and documentation requirements.

Palmetto likely offered this educational session in preparation for and in response to their Targeted Probe and Educate (TPE) medical review of DRG 885, Psychoses. This is a target review area for both Palmetto’s Jurisdictions -  J and M. First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, also has a planned TPE review for this DRG. The Palmetto webcast reminded providers that other Medicare review entities such as the CERT contractor, Recovery Auditors, and the Office of Inspector General (OIG) could review inpatient psych or any other Medicare services.

According to the webcast, the “villagers” involved and their concerns and responsibilities for IPF services are listed below. Many tasks will involve the input of multiple staff and are a shared responsibility – more evidence that “it takes a village.”

Physicians

• Patient must be under the care of a physician
• Write admission and other orders for patient’s care
• Perform a psychiatric evaluation of the patient at admission to include
• Medical history and mental status
• Onset of illness and admission circumstances
• Patient attitudes and behaviors
• An estimate of intellectual functioning, memory functioning & orientation; and
• A descriptive inventory of patient’s assets
• Certify/recertify the need (medical necessity) for inpatient care, which includes
• Patient psychiatric condition severe enough to warrant inpatient care
• Need for active treatment
• Intensive, comprehensive, multimodal treatments exceeding the level and intensity of those that may be rendered in an outpatient setting
• Generally, an expectation of improvement of the patient’s condition or for diagnostic purpose
• Establish a treatment plan that includes
• Substantiated diagnosis
• Short-term & long-range goals
• Specific treatment modalities utilized
• Each treatment team member’s responsibilities
• Adequate documentation to justify diagnosis & treatment/rehabilitation activities carried out
• Document H&P, evaluations, examinations, treatment plan, progress notes, and discharge summary

Clinicians (Nurses, Social Workers)

• Perform and document assessments and interviews
• Provide and document treatments including description of service, content and purpose, patient’s response and correlation to treatment plan goals

Utilization Review, Social Services, Discharge Planning

• Appropriate utilization of patient benefit days and lifetime reserve days in appropriate setting

Billing

• Submit correct type of bill (TOB) with appropriate revenue and occurrence codes
• Special considerations for
• Admission source “D” for patients transferred from acute care hospital to their psych distinct part unit (prevents overpayment due to ER adjustment)
• One day payment window
• Interrupted stays and occurrence span code 74
• Services provided by other facilities during IPF stay

Coders

• Assignment of correct primary and secondary diagnosis codes to the highest degree of specificity
• Discharge status code

These are just some of the coverage and documentation requirements to support Medicare inpatient psychiatric services. I recommend providers who offer inpatient psychiatric services listen to this webcast (located on Palmetto’s Past Events webpage) whether you are in Palmetto’s jurisdictions or not. The information applies universally to all Medicare inpatient psych services. Palmetto also shared some of their findings from TPE reviews so far as well as some of the CERT findings. Providers need to pay special attention to make sure their records include:

• Physician’s orders for admission and other services. Be sure all orders include a legible signature, a date, and the author’s credentials. If signatures are illegible, send an attestation log with the documentation upon review.
• Valid and timely certifications and recertifications.
• An initial psychiatric evaluation at the time of admission or no later than 60 hours after admission
• Documentation that services and treatments are related to improving the patient’s condition
• A valid, individualized treatment plan that supports psychotherapy with type, amount, frequency, duration, diagnosis & anticipated goals
• Documentation of active treatments during billing period
• Complete and sufficient documentation

You may want to hold a town hall meeting for all the villagers to communicate, coordinate and understand their individual and shared responsibilities. Sometime it takes a village meeting to guide a village.

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”

• Social Determinants of Health World Health Organization definition

The Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative includes a Social Determinants of Health (SDOH) topic area. They note that “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks…resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”

In general, since the Wednesday@One focuses on topics related to Medicare Rules and Regulations in the acute hospital setting, you may be asking, this is interesting but what does it have to do with the hospital? Well, I am glad you “asked.”

ICD-10-CM codes included in categories Z55-Z65 identify patients with potential health hazards to socioeconomic and psychosocial circumstances. Information represented in this code block is information that would typically be identified by a Social Worker, Case Manager, or admitting nurse as a hospital begins the discharge planning process as soon as the patient is admitted.

In Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, a question was asked to verify whether or not these codes could be assigned based on non-physician documentation. Advice given was that these codes represent social information and it would be acceptable to report them based on documentation from other clinicians following the patient.

To help you begin to understand what information is represented in these codes categories, the following table provides a high-level detail of the code categories and examples of codes within each category.

In MMP’s 2019 IPPS Proposed Rule series of articles, there was a related article discussing CMS’ efforts to account for social risk factors in several of the Hospital Quality Reporting Programs.

The Health People 2020 SDOH topic area has a goal to “create social and physical environments that promote good health for all.” A key to this is analyzing and acting upon data. As a hospital it is important that you begin to identify and utilize these codes.

If you are interested in learning more about SDOH’s, you can visit the Centers for Disease Control and Prevention (CDC) Social Determinants of Health web page at https://www.cdc.gov/socialdeterminants/.

The relationship between physicians and hospitals could be described as a symbiotic partnership, that is, a mutually beneficial relationship between different groups. Physicians need hospitals to provide the resources and personnel to care for their patients and hospitals need physicians to refer patients to the hospitals for such care when medically necessary. Physicians direct a patient’s care and decide when and what services are necessary. It also often falls on the physicians’ documentation to support that services and care provided and paid for by Medicare meet the requirements of being medically necessary. Unfortunately for hospitals, it is often their payment at risk if a physician provides a service in the hospital setting that is not medically necessary or fails to document sufficiently to support the medical necessity of the service. Because directing the patient’s care is the physician’s responsibility, many Medicare education resources about compliance are directed to the physicians. Likewise, hospitals must work with physicians to ensure services are appropriately provided and documented. Such is the case for ophthalmology services.

Though a number of ophthalmology services determined by the Office of Inspector General (OIG) to be at risk of “questionable billing” are more likely to be performed in a physician office setting, there are also services that could be performed in a hospital setting. Hospitals need to be aware of the concerns and requirements for these types of ophthalmology services.

A December 2014 OIG audit found that Medicare paid $22 million for ophthalmology claims in 2012 that were potentially inappropriate, according to national and local coverage requirements. The three eye conditions for which Medicare pays the most each year are cataracts, wet age-related macular degeneration (wet AMD), and glaucoma. The concerns for inappropriate payments related to these conditions are:

• Cataracts
• Medicare has a national requirement stating that it will not routinely cover more than one comprehensive eye examination and scan for beneficiaries whose only diagnosis was cataracts.
• It is medically impossible to perform more than one cataract surgery on the same eye because an eye’s natural lens will never grow back.
• Submitting disproportionately more claims for complex than standard cataract surgery.
• Wet AMD
• Some Medicare Administrative Contractors (MACs) have local coverage determinations (LCDs) limiting the number of wet AMD diagnostic or evaluation services for which a provider may bill annually.
• Medicare paid providers substantially more for treating wet AMD with the expensive biologic Lucentis instead of other biologic treatments that are similarly effective.
• Some MACs have LCDs specifying that Lucentis injections are not covered more frequently than once per month per eye. These guidelines are in keeping with the Food and Drug Administration (FDA)-approved dosing guidelines that Lucentis injections should be administered between once monthly and once every 3 months.
• Medicare has a national requirement that it covers each step of ocular photodynamic therapy only when both steps are performed on the same date. These steps are billed separately, but they must be performed within 30 minutes of one another.
• Glaucoma
• A national requirement states that Medicare covers either of two types of screening services once every 12 months for beneficiaries at high risk for glaucoma.

A September 2015 follow up OIG report found Medicare paid $171 million for services associated with the measures on which certain providers demonstrated questionable billing.

Prior to these OIG reports, the Recovery Auditors identified overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye for the same date of service. CMS published MLN Special Edition Article SE1319 in response to these findings. It reminded providers,

“According to the “National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services,” Chapter 8, Section D #3, cataract removal codes are mutually exclusive of each other and can only be billed once for the same eye. Because CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another, providers may not report multiple codes for the same eye even if more than one technique is used or more than one code could be applicable. Only one code from this CPT code range may be reported for an eye.”

The NCCI Policy Manual chapter and section noted above addresses 25 other correct coding guidelines for ophthalmology services of which providers should be aware.

For another ophthalmology service, CMS clarified in a 2005 ruling that a Medicare beneficiary may request insertion of a presbyopia-correcting intraocular lenses (IOLs) in place of a conventional IOL following cataract surgery. However, if the Medicare patient selects a presbyopia-correcting IOL, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. The MLN Article describing this ruling included payment policies for facilities and physicians.  The policy relevant to hospital services states:

• For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital outpatient prospective payment system (OPPS) or the inpatient prospective payment system (IPPS), respectively;
• Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital for an IOL inserted following removal of a cataract.
• For a presbyopia-correcting IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively;
• The facility will bill for removal of a cataract with insertion of a conventional IOL, regardless of
• whether a conventional or presbyopia-correcting IOL is inserted.
• When a beneficiary receives a presbyopia-correcting IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
• There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.
• There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.

The article also addresses coding requirements, beneficiary liability and notification requirements for these services.

Both hospitals and physicians must be aware of and follow the Medicare requirements for providing and billing ophthalmology services. Working together to “get it right” keeps the relationship between physicians and hospitals mutually beneficial for both parties and for Medicare.  

MEDICARE TRANSMITTALS

Revisions to the Telehealth Billing Requirements for Distant Site Services

Implements requirements for billing modifier GT for Telehealth Distant Site Services. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II.

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

Implementation of Changes to the Pre-Payment Additional Documentation Request (ADR) Letters for Medical Review

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2083OTN.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10642.pdf

Updates to Publication 100-04, Chapters 1 and 27, to Replace Remittance Advice Remark Code (RARC) MA61 with N382

MACs will use N382 in place of MA61 to communicate reject/denials for patient identifiers (HICN or MBI) in all remittance advices and 835 transactions. However, MACs will continue to use RARC MA61 only when/if communicating rejections/denials related to a missing/incomplete/invalid social security number.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10619.pdf

Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Extensions per the Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act Included in the Bipartisan Budget Act of 2018

Information and implementation instructions for:

• Section 50204 – Extension of Increased Inpatient Hospital Payment Adjustment for Certain Low-Volume Hospitals
• Section 50205 – Extension of the Medicare-Dependent Hospital (MDH) Program
• Section 51005 – Adjustments to the LTCH Site Neutral Payment Rate

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10547.pdf

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) – REVISED

The article was revised on May 15, 2018, to clarify that one of the requirements of the SET program is it must be conducted in a hospital outpatient setting or in a physician’s office.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10295.pdf

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

A sentence is added to show that Part B payment for Q9995 includes the clotting factor furnishing fee.

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

Intent to Reopen

Provides instructions for contractors to: provide notification of the reopening process and to notify the provider or supplier of their intent to reopen a specific claim when requested documentation is received after a denial of the claim has been made.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R796PI.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10620.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2018 Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10644.pdf

 

MEDICARE COVERAGE UPDATES

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

CR10622 makes coding and clarifying adjustments to the following NCDs:

• NCD 110.18 Aprepitant
• NCD 150.3 Bone Mineral Density Studies
• NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR)
• NCD 220.6.16 Positron Emission Tomography (PET) for Infection/Inflammation
• NCD 220.6.17 PET for Solid Tumors
• NCD 220.13 Percutaneous Image-Guided Breast Biopsy

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10622.pdf

 

MEDICARE PRESS RELEASES

CMS Announces Agency’s First Rural Health Strategy

The agency’s first Rural Health Strategy intended to provide a proactive approach on healthcare issues to ensure that the nearly one in five individuals who live in rural America have access to high quality, affordable healthcare.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-08.html

CMS Unveils Enhanced “Drug Dashboards” to Increase Transparency on Drug Prices

For the first time, the dashboards include year-over-year information on drug pricing and highlight which manufactures have been increasing their prices.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-15.html

 

MEDICARE EDUCATIONAL RESOURCES

Palmetto JM Provider Contact Center (PCC) Frequently Asked Questions (FAQs): January 2018 - April 30, 2018

https://www.palmettogba.com/palmetto/providers.nsf/ls/JM%20Part%20A"AYKQC62336?opendocument&utm_source=J11AL&utm_campaign=JMALs&utm_medium=email

MLN Fact Sheet Complying with Medicare Signature Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

Targeted Probe and Educate Video

https://my.happify.com/hd/why-gratitude-is-the-best-gift-we-can-give-our-children/?et=e2e969ce-70c2-474e-873b-a6e3fb839cf1

 

MEDICARE RULES

 Hospital IPPS and LTC 2019 FY Proposed Rule

The proposed rule proposes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). Also includes proposal concerning Quality Programs, EHR Incentive Programs, Cost-Reporting and Physician Claim Certifications.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08705.pdf

Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program

This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09015.pdf

Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019

This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08961.pdf

FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 2019)

This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs), which include psychiatric hospitals and excluded psychiatric units of an acute care hospital or critical access hospital.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09069.pdf

 

OTHER MEDICARE UPDATES

Kepro Case Review Connections, Acute Care Edition, Spring 2018

A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

https://www.keproqio.com/providers/spring-2018-acute-newsletter/

Trump Administration Releases Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs

https://www.hhs.gov/about/news/2018/05/11/trump-administration-releases-blueprint-lower-drug-prices-and-reduce-out-pocket-costs.html