Knowledge Base - Full Library

Did You Know?

The advice from Coding Clinic, First Quarter 2021, page 12 advises that medications prescribed on a “PRN” or “as needed” basis are not considered to be long term drug therapy. This means that Z79, Long Term Drug Therapy would not be assigned for these medications.

Why It Matters?

Coding long term medication use for a drug that is given only on an “as needed” basis would be contradictory to the Z79 code description as it implies continuous use of a drug for an extended period of time.

What Can I Do?

Review Coding Clinic, 1ST Quarter 2021, page 12. Read the medication list, determine the medications to be coded and then look to see how they are prescribed.

Coding Clinic, 1ST Quarter 2021, page 12.

The federal government has penalized 764 hospitals — including more than three dozen it simultaneously rates as among the best in the country — for having the highest numbers of patient infections and potentially avoidable complications.

The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The punishments, which the Affordable Care Act requires be assessed on the worst-performing 25% of general hospitals each year, are intended to make hospitals focus on reducing bedsores, hip fractures, blood clots, and the cohort of infections that before covid-19 were the biggest scourges in hospitals. Those include surgical infections, urinary tract infections from catheters, and antibiotic-resistant germs like MRSA.

This year’s list of penalized hospitals includes Cedars-Sinai Medical Center in Los Angeles; Northwestern Memorial Hospital in Chicago; a Cleveland Clinic hospital in Avon, Ohio; a Mayo Clinic hospital in Red Wing, Minnesota; and a Mayo hospital in Phoenix. Paradoxically, all those hospitals have five stars, the best rating, on Medicare’s Care Compare website.

Eight years into the Hospital-Acquired Condition Reduction Program, 2,046 hospitals have been penalized at least once, a KHN analysis shows. But researchers have found little evidence that the penalties are getting hospitals to improve their efforts to avert bedsores, falls, infections, and other accidents.

“Unfortunately, pretty much in every regard, the program has been a failure,” said Andrew Ryan, a professor of health care management at the University of Michigan’s School of Public Health, who has published extensively on the program.

“It’s very hard to capture patient safety with the surveillance methods we currently have,” he said. One problem, he added, is “you’re kind of asking hospitals to call out events that are going to have them lose money, so the incentives are really messed up for hospitals to fully disclose” patient injuries. Academic medical centers say the reason nearly half of them are penalized each year is that they are more diligent in finding and reporting infections.

Another issue raised by researchers and the hospital industry is that under the law, the Centers for Medicare & Medicaid Services each year must punish the quarter of general care hospitals with the highest rates of patient safety issues even if they have improved and even if their infection and complication rates are only infinitesimally different from those of some non-penalized hospitals.

In a statement, CMS noted it had limited ability to alter the program. “CMS is committed to ensuring safety and quality of care for hospital patients through a variety of initiatives,” CMS said. “Much of how the Hospital-Acquired Condition (HAC) Reduction Program is structured, including penalty amounts, is determined by law.”

In allotting the penalties, CMS evaluated 3,124 general acute hospitals. Exempted from the evaluation are around 2,000 hospitals. Many of those are critical access hospitals, which are the only hospitals serving a geographic — often rural — area. The law also excuses hospitals that focus on rehabilitation, long-term care, children, psychiatry, or veterans. And Maryland hospitals are excluded because the state has a different method for paying its hospitals for Medicare patients.

For the penalized hospitals, Medicare payments are reduced by 1% for each bill from October 2021 through September 2022. The total amount of the penalties is determined by how much each hospital bills Medicare.

A third of the hospitals penalized in the list released this year had not been punished in the previous year. Some, like UC Davis Medical Center in California, have gone in and out of the penalty box over the program’s eight years. Davis has been penalized four years and not punished four years.

“UC Davis Medical Center is usually within a few points of the [Hospital-Acquired Condition Reduction Program] threshold, so it’s not unusual to move in and out of the program year to year,” UC Davis Health said in an email. It said Davis ranked 38th out of 101 academic medical centers that use a private quality measurement system.

The Cleveland Clinic said that its satellite hospital in Avon has received awards from private groups, such as an “A” grade for patient safety from the nonprofit Leapfrog Group. Both it and Cedars-Sinai touted their five-star ratings. In addition, Cedars said that overall assessment comes even though the hospital deals with large numbers of very sick patients. “This [star] rating is particularly meaningful because of the complexity of the care that many of our patients require,” Cedars said in a statement.

Other hospitals declined to comment or did not respond to emails.

The KHN analysis found that the government penalized 38 of the 404 hospitals that were both included in the hospital-acquired conditions evaluation and had received five stars for “overall quality,” which CMS calculates using dozens of metrics. Those include not just infection and complication rates but also death rates, readmission frequencies, ratings that patients give the hospital after discharge, and hospitals’ consistency in following basic protocols in a timely manner, such as giving patients medicine to break up blood clots in the 30 minutes after they display symptoms of potential heart attacks.

In addition, 138 of 814 hospitals with the next-highest rating of four stars were docked by the program, KHN found.

Lower-rated hospitals were penalized with a higher frequency: Although just 9% of five-star hospitals were punished, 67% of one-star hospitals were.

KHN’s analysis found major discrepancies between the list of penalized hospitals and how Medicare’s Care Compare rated them for virtually the same patient safety infection rates and conditions. On the Medicare site, two-thirds of the penalized hospitals are rated as “no different than average” or “better than average” for the public safety measures CMS uses in assigning star ratings. The major differences center on the time frames for those measures and the structure of the penalty program. The Medicare website, for instance, evaluated only one year of infection rates, rather than the 18 months’ worth that the penalty program examined. And the public ratings are more forgiving than the penalties: Care Compare rates each hospital’s patient safety metric as average unless it’s significantly higher or lower than the scores of most hospitals, while the penalty program always punishes the lowest quartile.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, said the penalties would cause more stress to hospitals already struggling to handle the influx of covid patients, staffing shortages, and the extra costs of personal protective equipment. “It is demoralizing to the staff when they see their hospital is deemed unsafe or less safe than other hospitals,” she said.

Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said it was time for Congress and CMS to reevaluate the penalty program. “When this program had started, the thought was that we would get to zero” avoidable complications, she said, “and that hasn’t proven to be the case despite a really good effort on the part of some of these hospitals.”

She said the hospital-acquired conditions penalty program, along with other quality-improvement programs created by the ACA, feels “very ready for a refresh.”

Subscribe to KHN's free Morning Briefing.

Coverage Updates

National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: September 15, 2021 – Latest Revision January 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12403: (link)

CWF Editing – NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: February 16, 2022
• What You Need to Know: This article provides information about new edits for autologous Platelet-Rich Plasma (PRP) claims for diabetes and chronic ulcers.
• MLN MM12611: (link)

Final Decision Memo: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

CMS posted a Final Decision Memo ((link) for Lung Cancer Screening with LDCT on February 10, 2022. The eligibility age for screening has decreased from 55 years to 50 years. The tobacco smoking history has decreased from thirty packs per year to at least twenty packs per year. Counseling and shared decision-making are required prior to a beneficiary’s first screening test. Shared Decision Making (SDM) shall “include the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

COVID-19 Updates

January 31, 2022: FDA Approves Second COVID-19 Vaccine

The FDA announced the approval of a second COVID-19 vaccine ((link). The vaccine under emergency use authorization has been known as the Moderna COVID-19 vaccine. The approved vaccine will be marketed as Spikevax. Spikevax has the same formulation as the EUA Moderna COVID-19 Vaccine and is administered as a primary series of two doses, one month apart.

February 18, 2022: FDA Authorized Monoclonal Antibody Bebtelovimab

CMS announced in a special edition of MLN Connects ((link) that the FDA has approved the monoclonal antibody Bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when specific criteria apply. CMS has created three new codes for administering this drug. You can find information about this and other monoclonal antibody drugs on the CMS COVID-19 Monoclonal Antibodies webpage (link).

Other Updates

February 1, 2022: DOJ News: False Claims Act Settlements and Judgements Exceed $5.6 Billion in Fiscal Year 2021

In this DOJ announcement ((link) the DOJ reports that over $5 billion of the more than $5.6 billion in settlements in the past fiscal year related to matters involving the health care industry, “including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians.”

Medicare MLN Articles & Transmittals – Recurring Updates

Expedited Review Process for Hospital Inpatients in Original Medicare

• Article Release Date: January 21, 2022
• What You Need to Know: CMS has reformatted the current instructions for delivery of the Important Message from Medicare (IMM) and the beneficiary’s rights to an expedited review. While this MLN article notes in bold to “make sure your staff knows this is a reformatting of the current instructions and there are no policy or instructional changes,” following are three noteworthy clarifications:
• The effective date for the related Change Request is April 21, 2022.
• A new exception of who you would not provide an IMM to is the beneficiary that ends care on their own initiative by electing the hospice benefit.
• A new note indicates “the IM should only be given when an inpatient admission is pending or has occurred. It should not be given ‘just in case,’ such as a hospital delivering to all Medicare patients being treated in a hospital emergency room.”
• CMS has included a statement that “an IM must be delivered even if the beneficiary agrees with the discharge.”
• MLN MM12546: (link)

Internet-Only Manual Updates for Critical Care Evaluation and Management Services

• Article Release Date: January 22, 2022
• What You Need to Know: You will learn about critical care updates for a patient in a global surgical period and the use of modifier FT.
• MLN MM12550: (link)

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

• Article Release Date: January 27, 2022
• What You Need to Know: This article provides instructions for the April 2022 update to the CLFS and new codes effective April 1, 2022.
• MLN MM12612: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022

• Article Release Date: February 10, 2022
• What You Need to Know: This article provides information about newly available codes, separate NCD coding revisions, and coding feedback.
• MLN MM12606: (link)

Gap Billing Between Hospice Transfers

• Article Release Date: February 10, 2022
• What You Need to Know: A new CWF edit will no longer allow gaps of care to occur during a transfer.
• MLN 12619: (link)

Omnibus Change Request to Remove Two NCDs, Updates Medical Nutritional Therapy Policy and Updates to Pulmonary Rehabilitation, (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage

• Change Request 12613/Transmittal 11272 Release Date: February 18, 2022
• What You Need to Know: Updates became effective January 1, 2022, by statute with an implementation date of July 5, 2022. Specific to PR, the CY 2022 MPFS final rule removed the requirements for direct physician-patient contact and expanded coverage of PR for beneficiaries with confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least 4 weeks. The two NCDs being removed are:
• NCD 180.2 Enteral/Parenteral Nutritional Therapy, and
• NCD 220.6 Positron Emission Tomography (PET) Scans.
• Transmittal 11272: (link)

Revised Medicare MLN Articles & Transmittals

April 2022 Update to the MS-DRG Group and Medicare Code Editor Version 39.1 for ICD-10 Diagnosis Codes for 2019 COVID-19 Vaccination Status and ICD-10-PCS codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment

• Article Release Date: Initial article January 19, 2022 – Revised February 8, 2022
• What You Need to Know: This article was revised to add two new procedure codes describing the introduction or infusion of therapeutics including vaccines for COVID-19 treatment, effective April 1, 2022.
• MLN MM12578: (link)

Did You Know?

February is American Heart Month. Per NCD 210.11 (link), cardiovascular disease (CVD):

• Is the leading cause of mortality in the United States,
• Is comprised of hypertension, coronary artery disease (i.e., myocardial infarction and angina pectoris), heart failure and stroke, and
• Is the leading cause of hospitalizations.

Risk Factors for CVD includes:

• Being overweight,
• Obesity,
• Physical inactivity,
• Diabetes,
• Cigarette smoking,
• High Blood Pressure (HTN),
• High blood cholesterol,
• Family history of myocardial infarction, and
• Older age

Why this Matters?

Annually, the CERT publishes a supplemental improper payment data report. Table D4, in the supplemental report (link), highlights the top 20 service types with the highest improper payments for Part A IPPS Hospitals. This table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical necessity.
• Incorrect coding, and
• Other.

In the 2021 supplemental data, nine of the top twenty service types with highest improper payments were DRGs in the major diagnostic category (MDC) 5 Diseases and Disorders of the Circulatory System. Insufficient documentation and medical necessity were the two most common type of errors cited for this group of service types.

The projected improper payment for the circulatory system service types is $714,632,739 representing 36% of the total projected improper payments for the top twenty service types.

What Can You Do?

Be proactive for your patients by becoming familiar with the cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease covered by Medicare and additional resources published in the February 10, 2022 edition of MLN Connects (link):

• Preventive Services webpage (link)
• Achieving Health Equity web-based training (link)
• CMS Office of Minority Health, Health Observances webpage (link)
• Million Hearts® (link): HHS initiative to prevent a million heart attacks and strokes
• Cardiovascular disease screenings coverage (link) & behavioral therapy (link): information for your patients

Become familiar with coverage determinations related to the top services. For example:

• For DRGs 226 and 227 (Cardiac Defibrillator Implant without cardiac catheterization with MCC and without MCC respectively), there is a National Coverage Determination (NCD 20.4) and Medicare Administrative Contractor (MAC) specific Local Coding and Billing Articles.
• Transcatheter Aortic Valve Replacement (TAVR) and TEER (Transcatheter Edge-to-Edge Repair) procedures fall within DRGs 266 and 267. Both procedures have a related NCD (TAVR NCD 20.32 and TEER NCD 20.33).
• Percutaneous Left Atrial Appendage Closure (LAAC) procedures fall within DRGs 273 and 274 and has a related NCD (20.34).
• For DRG 313 (Chest Pain), Palmetto GBA the Jurisdiction J and M MAC, has a Local Coverage Determination (LCD L34551) titled, One Day Stays for Chest Pain.

Finally, respond to requests for documentation in a timely manner, sending adequate documentation to support the medical necessity of the services provided.

Question

Has Palmetto GBA finalized its coverage determination for Cardiac Resynchronization Therapy (CRT)?

Answer

Yes. The coverage determination became effective December 12, 2021 and can be found in Palmetto GBAs’ Local Coverage Article A58821 (link) and Palmetto GBAs’ Local Coverage Determination L39080 (link).

As with most of the other Medicare coverage guidelines, CRT has specific diagnosis codes that must be submitted on the claim to support medical necessity. In addition, the medical record must have documentation of the patient’s QRS duration - reflected in milliseconds - from the EKG, as well as documentation of QRS morphology such as right / left bundle branch block. Check the LCA and LCD for complete coverage requirements.

Question

We have a patient that was admitted through the ED with significant shortness of breath and acute respiratory distress, with the CT scan of the lungs showing bilateral infiltrates. The patient tested negative for COVID-19 on admission. The patient was treated for pneumonia and acute hypoxic respiratory failure. However, four days into the stay, a second COVID-19 test was performed and the results were positive. What POA do we assign in this case?

Answer

Due to the many nuances, complexities, and incubation period of COVID-19, we cannot assume that the infection was POA or occurred after admission, based on the date of the test. Any issues relating signs and symptoms, the timing of test results, or findings, should be referred to the provider for the most appropriate assignment of the POA.

References:

• ICD-10 Official Guidelines
• AHA Coding Handbook
• cdc.gov
• Revenue Cycle Advisor / March 27, 2021

Did You Know?

In October 2021, CMS published Change Request (CR) 12471 (link). There were two stated purposes for this CR noted in the Summary of Changes:

• • Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• • Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason why laterality could not be determined

The effective date for this CR is April 1, 2022.

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

You will find the complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (link).

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the providers responsibility to determine if documentation in the medical record support’s a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.

Mechanism to Bypass new MCE Edit 20-

The provider may enter a remark:

• • Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
• • “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality

However, “if there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

“0 or 1 day” Length of Stay Claims

After reading this CR, my first thought was, how often are one of these codes being included on a claim. To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Following are the numbers for Medicare Fee-for-Service paid claims data with dates of service from October 1, 2020, through August 31, 2021, available in RTMD’s footprint:

• • 57,951 claims included one of the unspecified codes in Table 6P.3a of the FY 2022 IPPS/LTCH Final Rule,
• • The paid claims total for this set of claims was $1,010,178,584.54, and
• • The top five states by claims volume included:
• o California: 5,926 claims - $135,738,052.81
• o Texas: 5,872 claims - $104,453,156.02
• o New York: 3,290 claims - $70,001,125.23
• o Pennsylvania: 3,192 claims - $48,281,839.67
• o Illinois: 2,750 claims - $41,821,442.35

What Can You Do?

This is not a large volume of claims in the world of Medicare Fee-for-Service Inpatient paid claims. However, just over $1 billion in paid claims is a significant amount of money. With a little over a month to prepare, you should make sure that CR 12471 and related MLN Matters article MM12471(link) are shared with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists). You should also work with your IT department to anticipate the potential volume of claims that will be impacted by the new Code Edit 20-.

A related article in this week’s newsletter (link), provides detail from the 2021 Comprehensive Error Rate Testing (CERT) program annual report and annual supplement data to the report. This article provides key facts about the CERT.

About the CERT

• The objective of the CERT program is to monitor and report the accuracy of claims payment in the Medicare Fee-for-Service program.
• CMS uses the CERT error rate to evaluate the performance of the Medicare Administrative Contractors (MACs).
• There are two CERT contractors:
• The CERT Review Contractor (CERT RC), and
• CERT Statistical Contractor (CERT SC).
• The CERT claim selection includes a stratified random sample of approximately 50,000 claims that are chosen by claim type (Part A, Part B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and includes paid and denied claims by the MAC.
• The CERT process is a federally mandated program and not responding to documentation requests will result in a denial of all services billed on the claim.
• CERT request letters are mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS).
• You can submit requested documentation to the CERT via postal mail, fax, Electronic Submissions of Medical Documentation (esMD), via CD or via email attachment(s).
• For short (less than 24 – 48 hours stay) inpatient hospital stay, a discharge summary is not required when a beneficiary is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
• The billing provider is responsible for obtaining medical records from the third-party to substantiate the claim that was billed.
• The CERT makes every effort to obtain the request documentation. Providers have 45 days to respond to the first letter requesting documentation. When the CERT does not receive the requested documentation by the 75th day, a claim is counted as a non-response error and is subject to overpayment recovery by the MAC.
• Claims reviews by the CERT includes program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and provision in the CMS instructional manuals.
• Denied claims as well as overpayments and underpayments are all considered to be an improper payment by the CERT program.
• Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
• The improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements.
• Providers that wish to appeal a CERT contractor’s determination can follow the normal redetermination process to appeal all CERT denials.
• The CERT A/B MAC Outreach & Education Task Force has a goal to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force webpage (link) includes education resources for providers.

Resources:

CERT C3Hub: https://c3hub.certrc.cms.gov/

CMS.gov CERT webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT

Fiscal Year 2021 Estimated Improper Payment Rates

In mid-November 2021, the Comprehensive Error Rate Testing (CERT) program published the Fiscal Year (FY) 2021 Annual CERT Report. A related Press Release, (link) noted that “CMS’ aggressive corrective actions led to an estimated $20.72 billion in reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.”

While CMS cites an impressive reduction in improper payments over seven years, there was only a slight change from 2020 to 2021.

• Improper Payment Rate
• o FY 2020: 6.27%
• o FY 2021: 6.26%
• Improper Payment Amount
• o FY 2020: $25.74 billion
• o FY 2021: $25.03 billion

As I have noted in past articles, CMS noted in the Press Release that “while fraud and abuse may lead to improper payments, it is important to note that the vast majority of improper payments do not constitute fraud, and improper payment estimates are not fraud rate estimates.”

Fiscal Year 2021 Supplemental Improper Payment Data

The 2021 Supplemental Improper Payment Data Report (link) was published on December 12, 2021. This report highlights common causes of improper payments and includes tables allowing you to drill down into the review findings.

COVID-19 Impact

• From March 27, 2020, until August 10, 2020, CERT program activities were suspended,
• CMS reduced the claim sample size for FY 2021 (claims submitted July 1, 2019, through June 30, 2020), and
• Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities.

“0 or 1 day” Length of Stay Claims

Since implementation of the Two-Midnight Rule, the supplemental data report has included a table comparing improper payments rates for Part A hospital claims by length of stay (LOS). The improper payment rate for “0 or 1 Day” stay claims was highest in 2014 at 37.18% and in 2021 hit an all-time low of 16.8%. However, with the project improper payment rate being $1.5 billion, it is not surprising that Two-Midnight Stays are currently on the OIG Work Plan (link) and Livanta as the National Medicare Claim Review Contractor (link), is focusing their review efforts solely on Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews.

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical Necessity,
• Incorrect Coding, and
• Other.

Overall, 58.9% of the errors in this table were due to the error category medical necessity. The CERT places a claim into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. One hundred percent of the errors for the following four DRG Types was attributed to medical necessity:

• DRG 069: Transient Ischemia,
• DRGs 308, 309, 310: Cardiac Arrhythmia & Conduction Disorders,
• DRG 312: Syncope, and
• DRG 313: Chest Pain.

Moving Forward

For the Septicemia DRGs 871 and 872, 37.2% of the errors was attributed to “no documentation.” Unfortunately, denied claims due to no documentation is also a frequent issue reported by the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor (SMRC).

Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:

• Visit the CERT Provider Website (link) to find information about the CERT, how to submit records, sample request letters and much more.
• Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of specific services. For example, DRGs 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity) had the highest projected improper payment in Table D4 at $724,055,597. The CERT attributed 19.5% of the error to insufficient documentation and 80.3% to medical necessity. CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (link) that provides guidance on what to document to avoid denied claims.
• Become familiar with and utilize your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER).
• And finally, take the time to review the CERT’s Supplemental Improper Payment Data report annually.