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CMS has released a revised version of MLN Matters Article SE1138 . This transmittal explains that when a non-specific procedure code is reported on a 5010 institutional or professional claim, a corresponding description of the service is required. The original transmittal incorrectly stated that "simply using Not Otherwise Classified as the description does not pass editing and the claim will be rejected". The claim will not be rejected if “Not Otherwise Classified” is submitted as the description. If the corresponding non-specific procedure code description is not submitted, the transaction does not comply with the implementation guide and is not, therefore, HIPAA compliant.

The transmittal does not specific where on the claim the description should be entered but refers readers to the 837I and 837P implementation guides for detailed information regarding this new requirement.

A complete listing of Not Otherwise Classified (NOC) Code Set is available at http://www.cms.gov/ElectronicBillingEDITrans/40_FFSEditing.asp on the Centers for Medicare & Medicaid Services (CMS) website.

The Medicare Quarterly Compliance Newsletter provides guidance to Fee-for-Service providers, suppliers and billing staff by:

• Describing an identified problem and the issues that may occur as a result of the problem,
• Detailing the steps taken by CMS to make providers aware of the problem, and
• Guidance on how to avoid the identified problem.

Who else is looking at the specific DRGs identified as problems in the Newsletter?

MMP, Inc. strongly encourages our clients to review your PEPPER Report for possible outliers.

All prior Medicare Quarterly Compliance Newsletters have been archived and can be accessed at: https://www.cms.gov/MLNProducts/downloads/MedQtrlyCompNL_Archive.pdf

 

In 2009, CMS transitioned Part A inpatient medical review responsibility from Quality Improvement Organizations (QIOs) to Medicare Administrative Contractors (MACs) and Fiscal Intermediaries (FIs).

Along with this transition, CMS has made the reduction of combined Part A/Part B inappropriate claims payments through the Comprehensive Error Rate Testing (CERT) program a high priority for the Medicare program.  

So, what does this mean? For the first time one entity (MACs) have the ability to review Part A and Part B claims.

This past fall this ability became a reality for TrailBlazer (the MAC for Colorado, New Mexico, Oklahoma, Texas and the Indian Health Service), when they posted Notice ID 14572: "Part A/B Cross-Claim Medical Review: The Impact It Will Have on Physicians announcing that “to increase consistency in Medicare reimbursement, effective November 1, 2011, TrailBlazer will begin cross-claim review” of services. Two other notices were referenced in this announcement that Hospitals and Physicians should pay close attention to (Notice ID 14561: "Part A/B Cross-Claim Medical Review" and Notice ID 14362: "Joint Replacement Documentation").

Key Points from the TrailBlazer Notices:

• For the first time a MAC will be looking at the physician’s related outpatient claims when inpatients stay/service is denied.
• Physician documentation for inpatient services should be as robust and complete as their clinic/office (outpatient documentation).
• Hospitals may need to request and include physician clinic notes in their medical records to help support the medical necessity and other requirements of hospital procedures.

MACs are no longer simply looking at the medical necessity of the admission but also whether or not the procedure was medically necessary.

Description Required for Non-Specific Procedure Codes,

HIPAA Version 5010

 

Although the Office of E-Health Standards and Services (OESS) has deferred enforcement of compliance with HIPAA Version 5010 until March 31, 2012, the official compliance date remains January 1, 2012. CMS encourages providers to implement use of the 5010 version as soon possible. MLN Matters Article SE1138 describes the HIPAA compliance requirement when reporting non-specific procedure codes. When a non-specific procedure code is reported on a 5010 institutional or professional claim, a corresponding description of the service is required. Detailed information regarding this new requirement can be found in the 837I and 837P implementation guides. Non-specific procedure codes are codes that include, in their descriptor, terms such as: “Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug Generic; or Prescription Drug, Brand Name”. These terms included in the descriptors are not sufficient to meet the HIPAA compliance requirements. For example, using a description of “not otherwise classified” will not pass editing and the claim will be rejected.

 

A complete listing of Not Otherwise Classified (NOC) Code Set is available at http://www.cms.gov/ElectronicBillingEDITrans/40_FFSEditing.asp on the Centers for Medicare & Medicaid Services (CMS) website.

Question:
A patient is discharged from our facility (disposition code 01) and is to go to a doctor’s appointment the same day. The patient is then admitted to another hospital after seeing the doctor. What disposition code is appropriate, 01 or 02?

Answer:
Based on the information the hospital had at discharge, the patient was discharged to home (01).  If your facility was unaware of the planned admission at the second facility, it is likely that you will have to modify/adjust your previously submitted claim to indicate a disposition code 02, which reflects where the patient was later admitted on the same date.

Resource: MLN Matters Number: SE0801 / NUBC FAQs

 

Through review of hospital 835 remittances and communication with our clients, MMP, Inc. has become aware of an increasing number of Medicare denials for units exceeding a Medically Unlikely Edit (MUE) limit. MUEs were implemented in 2007 by CMS to reduce paid claim error rates. Per the CMS MUE webpage “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” The MUE list is available on the above webpage; it is updated quarterly but CMS considers some MUEs confidential and does not publish these. Remember that MUE and CCI edits apply to both Medicare and Medicaid claims.

We are seeing a large number of MUE denials for drugs. We have also heard from providers concerning recent denials for additional infusion services, such as for CPT codes 96366 (IV infusion, each additional hour) and 96361 (Hydration, each additional hour). Since these MUEs are unpublished, the MUE limits for these CPT/HCPCS codes are not known.

MMP, Inc. encourages our clients to determine if they are having issues with MUE denials. Line items exceeding an MUE limit will deny with a Claim Adjustment Reason Code (CARC) of B5 (Coverage/program guidelines were not met or were exceeded.) Note that CARC B5 is also used for denials involving Correct Coding Initiative (CCI) edits and for inpatient-only procedures billed on an outpatient claim.  Also look for Remittance Advice Remark Code N362 (The number of Days or Units of Service exceeds our acceptable maximum) to identify MUE denials.

If you are having MUE denials, determine if you are indeed trying to bill the appropriate number of units. The MUE limits for drugs are likely based on the manufacturer’s package insert for recommended dosage amount. To address drug MUE denials, providers should:

• ensure that conversion factors in the CDM are correct for the drug HCPCS description,
• verify that charges are being entered correctly,
• determine if there is a medically necessary reason to exceed the recommended dosage, and
• contact your Medicare contractor if you believe an MUE is unreasonable.

Once you verify that the units you are billing are correct and you determine the MUE value (either the MUE limit is published or you are able to determine it by a trial and error process), you can by-pass the MUE by using an appropriate CPT modifier to report the same code on separate lines of a claim. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, no single line should be reported with units that exceed the MUE limit. For example, if an MUE value is 6 and you provided 18 medically necessary units, you should report three lines each with units of 6 and the appropriate CPT modifier on the additional lines. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service), will accomplish this purpose. Providers/suppliers should use Modifier 59 only if no other modifier describes the service.

If you receive denials for MUEs, you may appeal the denial. Documentation in the medical record should clearly support the number of units and the medical necessity for the quantity of services. If a drug dosage exceeds the package insert amount, you will want to provide medical literature to support the dosage amount as part of your appeal.

One last point to consider – a number of the drugs that are being denied for exceeding the MUE value are not separately reimbursed by Medicare but are instead “packaged” drugs. Providers likely will not want to put in time and effort to appeal these denials, but MMP, Inc. encourages providers to ensure that for future claims the units billed are accurate and submitted correctly to by-pass the MUE limits when appropriate. This will prevent the submission of any “false” claim information.

For more information on MUEs, see the link on the CMS MUE webpage to MUE FAQs. And although CMS Transmittal 9490 addresses a technical correction it also contains good information on the MUE process.

Consumers are increasingly using the internet to direct where they seek health care services. Therefore, it is more important than ever for healthcare providers to be aware of what data is available to the public. 

This past Friday, August 5th, CMS issued a press release announcing a “new tool” and “enhanced initiatives” that will help “empower consumers to make informed choices about their health care, and to help improve the quality of care in America’s hospitals, nursing homes, physician offices, and other health care settings.” The new tool and enhanced initiatives include:

• A Quality Care Finder providing consumers a single online site to all of Medicare’s Compare tools. Below is a “snap shot” of this site that can be accessed at www.Medicare.gov/QualityCareFinder;

• The Hospital Compare site has been updated and now includes:

1.  
2.  
3. New Outpatient outcomes for surgical infections and treatment for patients with suspected hear attacks;
4. Updated data for the Patient Experience, 30 Day Mortality Measures and 30 Day Readmission rates for inpatients admitted with heart attack, heart failure and pneumonia; and

Enhancements to the Quality Improvement Organization (QIO) program.

·         The Hospital Compare  site has been updated and now includes:

o   New Outpatient outcomes for surgical infections and treatment for patients with suspected hear attacks;

o   Updated data for the Patient Experience, 30 Day Mortality Measures and 30 Day Readmission rates for inpatients admitted with heart attack, heart failure and pneumonia; and

Enhancements to the Quality Improvement Organization (QIO) program.

CMS recently released MLN Matters Article SE1117 that describes significant changes in the reporting of the Admission Date and Statement Covers Period (from/through dates) on the UB-04.

Effective October 1, 2011, providers should use the following definitions for these form locators (FLs):

• Admission Date (FL12) – the date the patient was admitted as an inpatient to the facility. (This is the date the patient is formally admitted, i.e. the day an order is written to admit the patient as an inpatient).
• Statement Covers Period (“From” and “Through” dates in FL 6) – span of service dates included on the claim. The “From” Date is the earliest date of service on the bill.

Medicare Fiscal Intermediary Shared System (FISS) edits will be changed to accommodate these new definitions so that:

• These two data elements are not required to match, and
• The number of days in the Statement Covers Period will not be compared to any other data element (e.g. total accommodation days reported in the revenue code section).

Providers should review this information carefully and make sure practices and systems are changed as needed to meet these new definitions October 1, 2011. For complete information, please refer to the MLN Matters article.

CMS recently released a special MLN Matters® Article for inpatient hospitals, in regards to Recovery Auditors having reviewed a significant number of records for DRG Validation that had an incorrect principal diagnosis. This article focuses on assisting hospitals in identifying key steps to take to avoid unnecessary denials of claims.

CMS has noted that Recovery Auditors review the entire medical record when performing DRG Validation while some hospitals possibly choose to code the record before all documentation is completed. There is a risk when hospitals choose to do this “since they are responsible for reporting codes that accurately reflect the patient’s conditions and procedures. Therefore hospitals may increase their chance of errors by choosing to code the case prior to receiving the complete medical record. Recovery Auditors will not take this into consideration.”

Hospitals are reminded that when there is conflicting or contradictory information in the medical record the attending physician should be queried to clarify the principal and secondary diagnoses. Further, “Coding Clinic, First Quarter 2004 states, if there is conflicting physician documentation, and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician’s version. However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict. So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it.”

The entire article can be viewed at: http://www.cms.gov/MLNMattersArticles/downloads/SE1121.pdf.

CMS continues to provide information to help providers understand and avoid common billing errors and other improper activities identified through claim review programs, such as the Recovery Audit Contractor (RAC) program.

CMS recently released the April 2011 Medicare Quarterly Provider Compliance Newsletter. This edition contains the following information relevant to hospitals:

• Improper Coding of MS-DRG 813 Coagulation Disorders (Inpatient Hospital): Hospitals should ensure that their billing staffs are up to date on the guidelines for coding diagnoses for patients with coagulation disorders, adverse effects of anticoagulants in therapeutic use and coagulation profile.
• HIV – Wrong Diagnosis Code or Wrong Principal Diagnosis Code Billed (Inpatient Hospital): The “ICD-9 CM Official Guidelines for Coding and Reporting” states that, if a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(a), page 13.) Once a patient has developed an HIV-related illness, the patient should always be assigned the code 042 on every subsequent admission/ encounter. However, this does not mean that 042 must be the principal diagnosis. If the condition responsible for the admission is AIDS related (on the MDC 25 list or tied to AIDS by the physician in documentation), 042 is the appropriate principal diagnosis. If the admission was prompted by an unrelated illness, the principal diagnosis is that illness, and 042 is a secondary diagnosis. (Refer to “Human Immunodeficiency Virus (HIV) Infections,” Section I.C.1.a.2.(b), page 14.)
• Extensive OR Procedure Unrelated to Principal Diagnosis MS-DRGs 981, 982, and 983 (previously DRG 468) (Inpatient Hospital): RAC auditors found many errors in the assignment for MS-DRG 981, MS-DRG 982, and MS-DRG 983 that resulted in overpayments to hospitals.
• Oxaliplatin – Dose vs. Billed Units (Outpatient Hospital): Due to the vast difference for certain time periods in the amounts used (5.0 mg or 0.5mg) to calculate the number of service units being billed, Recovery Auditors found that many hospitals incorrectly calculated the number of service units billed, resulting in overpayment.
  Oxaliplatin HCPCS codes and units are:
• Before July 1, 2003 – J3490 – 0.5 mg
• July 1, 2003 to December 31, 2005 – C9205 – 5 mg
• On and after January 1, 2006 – J9263 – 0.5 mg
• Untimed Codes – Excessive Units (Outpatient Hospital): No matter how long the evaluation or service, providers can bill only one unit of untimed codes for a patient per date of service with some exceptions. Certain services are limited to certain numbers of units per day for physical therapy, occupational therapy and speech-language pathology, separately to control inappropriate billing. Specifically, the HCPCS codes involved are: 90901, 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92609, 92610, 92611, 92612, 92614, 92616, 95833, 95834, 96110, 97001, 97002, 97003, 97004, 97010, 97022, 97026, 97597 and 97598.

The Newsletter also includes information on Inpatient Rehabilitation Facility (IRF) over- and under-payments related to incorrect discharge status codes and OIG findings related to physician billing of Transforaminal Epidural Injection Services. Although this article concerns physician billing, hospitals may find some of the information helpful in their coding and billing of transforaminal injections.

CMS has also added a quick tips feature to the MLN Provider Compliance webpage. A new “fast fact” will be added monthly to this webpage, so be sure to check it often. This month’s fast fact is:

Issue: Physician Orders

Solution: A physician's order is not valid without a legible signature. The physician must authenticate the order. If the order is not signed or authenticated, the physician's intent must be clearly established in the medical records.

The CMS RAC webpage was recently updated with the addition of a downloadable 2011 FFS Newsletter (RAC). This newsletter contains RAC overpayment and underpayment amounts as of March 2011. Providers should note the increase in activity for the last quarter versus the two previous quarters of the National RAC program. Through March 2011, the corrections of the permanent RAC program totals $365.8M. The newsletter also includes the top issues per Recovery Auditor.

Clients of Medical Management Plus can also find the above referenced documents in the Resource section of our website.