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The CMS Review Choice Demonstration for Inpatient Rehabilitation Facility (IRF) Services is set to begin in Alabama in August 2023. You can read more about the program and choices that Alabama IRF providers will need to make in a related article in this week’s newsletter.

This article looks back at past IRF claims reviews and resources available to providers on Palmetto GBA’s website, the Medicare Administrative Contractor (MAC) for Alabama.

Prior IRF Claims Reviews

Office of Inspector General (OIG)

In September 2018, the OIG published the report “Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements” (A-01-15-00500). The audit covered $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays. The objective was to determine if IRFs complied with Medicare coverage and documentation requirements for claims for services provided in 2013. Based on sample results, the OIG estimated that Medicare paid IRF’s $5.7 billion for care to beneficiaries that was not reasonable and necessary.

 

The OIG noted errors occurred because many IRFs did not have adequate internal controls to prevent inappropriate admissions; Medicare Part A FFS lacked a prepayment review for IRF admissions and CMS’ extensive educational efforts and post payment reviews were unable to control an increasing improper payment rate reported by CERT.

https://oig.hhs.gov/oas/reports/region1/11500500.asp

 

Supplemental Medical Review Contractor (SMRC)

Based on the 2018 OIG report findings, CMS tasked Noridian, the current SMRC, to complete a review of Medicare Part A IRF claims for CY 2018 claims. Noridian published their review results in October 2021 and reported a 33% error rate. I encourage you to read their review results as it includes common reasons for denial and references and resources.

https://noridiansmrc.com/completed-projects/01-025/

 

Comprehensive Error Rate Testing (CERT)

The OIG noted in the above 2018 report the CERT program found that the error rate for IRFs had increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. Although the error rate has decreased in subsequent years, the Improper Payment Rate remained high at 19.3 percent in 2022 with close to $7M projected improper payments.

https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

 

Active OIG Work Plan Item: Inpatient Rehabilitation Facility Nationwide Audit

In this active issue description, the OIG notes that in fiscal year 2021, Medicare paid approximately $8.7 billion for 373,000 IRF stays nationwide. The CERT has consistently found high error rates, and their Hospital Compliance audits also frequently include IRF claims and have similarly found high error rates.

 

“In response to these findings, IRF stakeholders have stated that Medicare audit contractors and OIG have misconstrued the IRF coverage regulations. To better understand which claims IRFs believe are properly payable by Medicare, OIG needs more information from the IRF stakeholders. We plan to determine whether there are areas in which CMS can clarify Medicare IRF claims payment criteria. In addition, we will follow up on recommendations from our prior IRF audit, A-01-15-00500. We believe data and input from IRF stakeholders are critical to identifying any specific areas that might require clarification and will result in more meaningful recommendations and a greater positive impact on the program.”

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000729.asp

 

Palmetto GBA IRF Education Resources

 

IRF Avoiding Common Billing Issues Module

Palmetto notes their goal with this module is to ensure providers are in compliance with Medicare coverage, coding, and billing rules so that payments will not be delayed.

https://www.palmettogba.com/palmetto/jja.nsf/DID/HBEIF25RPF#ls

 

Did You Miss It? Jurisdictions J, M Current Year 2023 IRF Webinar

Palmetto has made available a webinar on demand where Palmetto discusses IRF documentation requirements, Targeted Probe and Educate (TPE), CERT and the FY 2023 IRF Final Rule.

https://www.palmettogba.com/palmetto/jja.nsf/DID/000GWG3K8O#ls

 

Inpatient Rehabilitation Facility (IRF) Resources

This Palmetto GBA article provides links to the CMS IRF Prospective Payment System educational tool and a Medicare Learning Network web-based training course that includes information about IRF services, documentation requirements and the CERT program.

 

Moving Forward

If you are an IRF provider, I encourage you to share this information with key stakeholders.

Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.   

My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.  

 

While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.

 

In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.

 

The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.

 

My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.

 

I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.

 

With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.

 

As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:

• Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
• Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.

• Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
• Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.

 

Resources

National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/

NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf

National Institute on Aging: https://www.nia.nih.gov/health/osteoporosis

Intermittent Use of Continuous Positive Airway Pressure (CPAP)

Effective date:  April 1, 2020

 

 

Question:

How do you calculate total hours for a patient that is placed on CPAP intermittently during the daytime, but uses it continuously throughout the night?

 

Answer:

Code assignment depends on the number of consecutive hours that a patient receives CPAP.  The CPAP system is a noninvasive ventilation support system designed only to augment a patient’s breathing, not take over their breathing, as does a ventilator. 

Assign code 5A09357 (Assistance with ventilation, less than 24 consecutive hours, continuous positive airway pressure) since the patient received CPAP for less than 24 hours at a time.

 

Facilities may develop their own internal guidelines, as to whether they code and report CPAP one-time, multiple times or not at all. 

 

Note:  Do not assign code Z99.89 (Dependence on other enabling machines and devices) to describe a patient’s CPAP status.  ICD-10-CM does not specifically classify CPAP dependence or status. 

 

References:

ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020:  Page 10

Did You Know?

According to the National Cancer Institute, bladder cancer:

• Is the fourth most commonly diagnosed malignancy in men in the United States,
• Occurs about four times higher in men than in women,
• Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
• The incidence of bladder cancer increases with age.

   

  Bladder Cancer Symptoms

  Although symptoms can vary from person to person, the most common symptom is blood in the urine, called hematuria. Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer. Other common symptoms include:

• Frequent urination,
• Pain or burning during urination,
• Feeling as if you need to urinate even if your bladder is not full, and
• Frequent urination during the night.

   

  If the cancer has grown large or spread beyond the bladder, symptoms may include:

• Being unable to urinate
• Lower back pain on one side of the body
• Pain in the abdomen
• Bone pain or tenderness
• Unintended weight loss and loss of appetite
• Swelling in the feet, and
• Feeling tired.

   

  April 3, 2023: FDA Grants Accelerated Approval for Patients

  The FDA granted accelerated approval to enfortumab vedotin-ejfv (Padcev, Astellas Pharma) with pembrolizumab (Keytruda, Merck) for patients with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy. Note, this cancer primarily arises in the bladder.

   

  In an April 3^rd, Merck news release, Dr. Eliav Barr, senior vice president, head of global clinical development and chief medical officer, Merck Research Laboratories notes “This approval is a major milestone in the treatment of patients with locally advanced or metastatic urothelial carcinoma because it is the first approved combination of an immunotherapy and an antibody-drug conjugate for these patients…This expands the use of KEYTRUDA-based regimens to more patients with advanced urothelial carcinoma and demonstrates the value of collaboration in creating new combination approaches for patients in need of more options.”

   

  Why it Matters?

  There are risk factors related to developing bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

• Having a family history of bladder, cancer,
• Having certain changes in the genes that are linked to bladder cancer,
• Being exposed to paints, dyes, metals, or petroleum products in the workplace,
• Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
• Taking Aristolochia fangchi, a Chinese herb,
• Drinking water from a well that has high levels of arsenic,
• Drinking water that has been treated with chlorine,
• Having a history of bladder infections, and
• Using urinary catheters for a long time.

 

What Can I Do?

First, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with your physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current 5-year relative survival rate is 77.9%.

 

Resources:

National Cancer Institute Cancer Stat Facts: Bladder Cancer: https://seer.cancer.gov/statfacts/html/urinb.html

National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq

FDA April 3, 2023 News Release: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-enfortumab-vedotin-ejfv-pembrolizumab-locally-advanced-or-metastatic

Merck April 3, 2023 New release: https://www.merck.com/news/fda-approves-mercks-keytruda-pembrolizumab-in-combination-with-padcev-enfortumab-vedotin-ejfv-for-first-line-treatment-of-certain-patients-with-locally-advanced-or-metastatic/

Did You Know?

Livanta, the National Medicare Claim Review Contractor, is actively reviewing two types of reviews monthly.  

Higher weighted diagnosis-related groups (HWDRG) Reviews: When a hospital resubmits a claim with a higher weighted DRG as a correction to the original claim, this “is a trigger for a potential review of an inpatient claim. This review activity helps ensure that the patient’s diagnostic, procedural, and discharge information is coded and reported properly on the hospital’s claim and matches documentation in the medical record.”  

Short Stay Reviews (SSRs): For SSRs, “reviewers at Livanta obtain and evaluate the medical record to ensure that the patient’s admission and discharge were medically appropriate based on the documentation of the patient’s condition and treatment rendered during the stay, and that the corresponding Part A Medicare claim submitted by the provider was appropriate.” 

Why It Matters? 

HWDRG Reviews: When a hospital’s HWDRG claim is subject to a post-payment review, in addition to DRG validation of the adjusted claim, the review will include validation of medical necessity of the inpatient admission. 

SSRs: Short Stays are a high volume and high-cost review focus for more contractors than Livanta. RealTime Medicare Data’s (RTMDs) database includes Medicare Fee-for-Service paid claims for the nation. The following RTMD data represents paid short stay claims in CY 2022:

• 874,104: The volume of short stay claims,
• $47,043,865,852: The total charges by hospitals for short stay claims, and
• $10,052,743,324: The total payment by Medicare to hospital for short stays.

Discharge disposition codes expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with a planned acute care hospital inpatient admission (82), left against medical advice (07), and hospice election (50 & 51) are excluded from the short stay RTMD data as CMS considers them to be unforeseen circumstances. 

Office of Inspector General (OIG)

Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. The OIG had previously stated they would not audit short stays after October 1, 2013; however, their current work plan includes a review of CMS’ Oversight of the Two-Midnight Rule for Inpatient Admissions.

Comprehensive Error Rate Testing (CERT)

Since the October 1, 2013 implementation of the Two-Midnight Rule, as part of their annual report, the CERT review contractor has reported hospital inpatient review findings by length of stay. The improper payment rate for “0 or 1 day” claims is consistently higher than other lengths of stay. In fact, the improper payment rate for short stay claims increased from 16.8% in 2021 to 20.1% in 2022 with a projected improper payment of $1.5B.

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

One-Day stays for medical and surgical DRGs are review targets in the short-term acute care PEPPER. The suggested intervention for high outliers is that “this could indicate that there are unnecessary admissions related to the inappropriate use of admission screening criteria or outpatient observation. A sample of one-day stay cases should be reviewed to determine whether inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation).”

What Can I Do?

Livanta provides several education resources on their website. For example, the Livanta Claims Review Advisor newsletter alternates between SSRs and HWDRG reviews. Examples of newsletter topics includes: 

HWDRG Review Topics: Physician Queries, Sepsis DRGs, Encephalopathy, Anemia and GI Bleeding, and Malnutrition, and Short Stay Review Topics: Chest Pain, Atrial Fibrillation, Congestive Heart Failure, and Transient Ischemic Attack Case Scenarios.

I encourage you to share this information with your HIM, Case Management, and Clinical Documentation Integrity staff.

Resources

Livanta website: https://www.livantaqio.com/en/ClaimReview/index.html

RealTime Medicare (RTMD): https://www.rtmd.org/

OIG Workplan: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

CERT Reports: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports

36^th Edition of Short-Term Acute Care Hospitals Users Guide at https://pepper.cbrpepper.org/

 

Did You Know?

CMS published Change Request (CR) 12471 in October 2021 to:

• 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 laterality could not be determined.

This new edit became effective for hospital inpatient discharges occurring on or after 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.”

 

Code Edit 20- is 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.

 

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports 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-

Enter one of the following in the Remarks Field to enable your MAC to systematically bypass the edit and process your claim:

• UNABLE TO DET LAT 1 to show you are unable to obtain additional information to specify laterality, or
• UNABLE TO DET LAT 2 to show the physician is clinically unable to determine laterality.

   

  “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.”

   

  Table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule contains the initial list of 3,432 ICD-10-CM unspecified codes.

   

  In the FY 2024 IPPS Proposed Rule, CMS has proposed the addition of new ICD-10-CM diagnosis codes that will be effective October 1, 2023 to the list of codes subject to Code Edit 20-.  Specifically, CMS has proposed adding:

• Twelve new ICD-10-CMS age related and other osteoporosis codes with current pathological fracture diagnosis codes (M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S), and
• Four unspecified pressure ulcer codes that CMS identified as being inadvertently omitted from this list effective with discharges on or after April 1, 2022 (L89.103, L89.104, L89.93, and L89.94).

 

Why It Matters by the Numbers?

RealTime Medicare Data (RTMD), our sister company, maintains a database of Medicare Fee-for-Service paid claims data for all states and Washington, D.C. While I am unable to identify how many claims were returned to the provider, based on claims data, it appears that hospitals have significantly decreased the volume of claims that includes one of the 3,432 unspecified codes.

 

Six months Prior to implementation of Code Edit 20- (October 1, 2021 – March 2022 Data)

• 26,892: The volume of claims including one of the 3,432 unspecified codes,
• $485,063,597: The total payment for this group of claims.

   

  Six months Post April 1, 2022 Implementation of Code Edit 20- (April 1 – September 30, 2022)

• 2,244: The volume of claims including one of the 3,432 unspecified codes,
• $32,653,438: The total payment for this group of claims.

 

What Can I Do?

Share this information with key stakeholders at your facility (i.e., billing, coding, clinical documentation integrity specialists and watch for the release of the FY 2024 final rule later in the year to confirm that CMS finalized this proposal.

 

Resource: MLN Matters MM12471: April 2022 Update to the Java Medicare Code Editor (MCE) for New Edit 20 – Unspecified Code Edit: https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf

Medicare Transmittals & MLN Articles

 

March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update – Article Revised April 3, 2023

This article was revised to reflect a revision to Change Request (CR) 13136 which changed a reference to average sales price (ASP) calculations based on sales price submissions from the third quarter of CY 2022 to the fourth quarter. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf

 

April 6, 2023: MLN MM13162: New Waived Tests

CMS advises that your billing staff know about Clinical Laboratory Improvement Amendments (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13162-new-waived-tests.pdf

 

April 21, 2023: Transmittal 11995, Change Request (CR) 13181: Medicare Policy Updates for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (MPFS) Final Rule

The purpose of CR 13181 is to update the Internet Only Manual (IOM) Medicare benefit policy for dental services as finalized in the CY 2023 MPFS final rule. CMS provides four scenarios in which Medicare payment for dental services is not excluded. They also note these policies do not prevent a MAC from deciding that payment can be made for dental services in other circumstances under which the dental services are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services, but are not specifically addressed in final rules, manual provisions, and the finalized amendment to §411.14(i). https://www.cms.gov/files/document/r11995bp.pdf

 

April 21, 2023: MLN MM13149: Skilled Nursing Facility Prospective Payment System: Updates to Current Claims Editing

Information in this article is for SNFs and hospital swing bed providers. Action needed is to make sure your staff knows about improved editing of claims that have interrupted stays that span two months and modified editing for occurrence span code (OSC) edits allowing for proper claims decisions.

https://www.cms.gov/files/document/mm13149-skilled-nursing-facility-prospective-payment-system-updates-current-claims.pdf

 

 

Compliance Education Updates

 

February 2023: MLN Booklet: Information for Critical Access Hospitals

CMS has updated the MLN Booklet. Changes to the booklet are highlighted in dark red, for example, information about the new provider type call rural emergency hospitals (REHs) starting January 1, 2023 has been added to this document. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CritAccessHospfctsht.pdf

 

April 13, 2023: MLN Connects: Hospital Outpatient Departments: Prior Authorization for Facet Joint Interventions Starts July 1

CMS reminds hospitals in the April 13^th edition of MLN Connects that hospital outpatient departments must submit prior authorization requests for facet joint interventions starting on or after July 1, 2023. The Prior Authorization CMS webpage was updated on April 12, 2023 with the addition of this notice and access to a complete list of all HCPCS codes requiring prior authorization as part of this initiative. In general, the Medicare Administrative Contractors (MACs) will begin accepting prior authorization requests for facet joint interventions on or around June 15^th. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-13-mlnc#_Toc132203902

 

April 27, 2023: New OMB approved Medicare Outpatient Observation Notice

Reminder

The Medicare Outpatient Observation Notice (MOON) and Important Message from Medicare (IM)/Detailed Notice of Discharge (DND) forms received OMB approval on January 23, 2023. The new versions must be used no later than April 27, 2023. All updated forms are available on the CMS Beneficiary Notices Initiative webpage at https://www.cms.gov/Medicare/Medicare-General-Information/BNI.

 

MLN Fact Sheet: Intravenous Immune Globulin Demonstration Fact Sheet

This demonstration began in October 2014 and will end on December 31, 2023. A related MLN Fact Sheet has been updated this month with updated 2022 and 2023 payment rates for Q2052 and claims adjustment language for updated payment rates. https://www.cms.gov/files/document/mln3191598-intravenous-immune-globulin-demonstration.pdf

COVID-19 Updates

 

March 29, 2023: FAQs Issued on Coverage of COVID-19 Testing and Vaccines by Health Plans After the Public Health Emergency Ends

A set of FAQs were issued to help group health plans and health insurance issuers in the private market understand their obligations under the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act) related to coverage for COVID-19 diagnostic testing and vaccines following the expiration of the PHE. The FAQs were issued jointly by HHS, the Department of Labor, and the Department of Treasury.

https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-58

 

April 10, 2023: New COVID-19 Treatments Add-On Payment (NCTAP)

This webpage was updated to let providers know Medicare will provide an enhanced payment through September 30, 2023, for eligible inpatient cases using certain new products with current FDA approval or emergency use authorization (EUA) to treat COVID-19.

https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap

 

April 5, 2023: COVID-19 Over the Counter (OTC) Test Coverage Ends May 11, 2023

“Effective May 12, 2023, COVID-19 OTC tests (HCPCS K1034) are no longer a covered benefit for Medicare. Any providers or suppliers providing monthly supplies to their patients should notify their patients of this change before providing further services.”

https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/covid-19-over-the-counter-otc-test-coverage-ends-may-11-2023

 

Other Updates

 

April 4, 2023: Special Edition MLN Connects: Proposed Rules

CMS announced the release of the FY 2024 proposed rules for Hospice, Medicare Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities. Included in the announcement are links to related Fact Sheets. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-04-oce

 

April 6, 2023: Advance Beneficiary Notice of Noncoverage: Form Renewal         

CMS posted a notice in the March 6, 2023 edition of MLN Connects letting providers know the OMB has approved the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) for renewal. The expiration date is the only change to the form and must be used beginning June 30, 2023.

 

April 17, 2023: New Resources to Address Rising Threat of Cyberattacks in Health and Public Health Sector

HHS issued a Press Release announcing new resources made available by the U.S. HHS 405(d) Program to address cybersecurity concerns in the Healthcare and Public Health (HPH) sector including a Knowledge on Demand – platform offering free educational cybersecurity trainings, the 2023 edition of the Health Industry Cybersecurity Practices (HICP) report, and a Hospital Cyber Resiliency Initiative Landscape Analysis reporting on the current state of domestic hospitals’ cybersecurity preparedness.

 

The HICP report indicates that “healthcare records continue to be one of the most lucrative items on the underground market, ranging from $250 to $1,000 compared to other items like credit cards only selling for an average of $100,” driver’s license an average of $20, and SSN’s average of $1.

   

April 21, 2023: CMS Issues Two More Civil Monetary Penalties for Failure to Meet Hospital Price Transparency Requirements

On April 21, CMS updated the hospital’s price transparency enforcement actions webpage by adding two more hospitals subject to civil monetary penalties for noncompliance with the hospital price transparency requirements (https://www.cms.gov/hospital-price-transparency/enforcement-actions). 

For the CMS FY 2024, CMS has proposed several changes to the Major Diagnostic Category (MDC) 05: Diseases and Disorders of the Circulatory System. This article focuses on these proposed changes. You can read about proposed changes in other MDCs in a related article in this week’s newsletter.

Surgical Ablation

A request was made for CMS to review the MS-DRG assignment of cases involving open concomitant surgical ablation procedures, recommending that open concomitant surgical ablation procedures for atrial fibrillation (AF) be reassigned from MS-DRGs 219, 220, and 221 (Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 216, 217, and 218 or create new MS-DRGs for all open mitral or aortic valve repair or replacement procedures with concomitant surgical ablation of AF.

CMS analysis found these cases require greater resources, have higher average costs and generally longer lengths of stay compared to all other cases in their assigned MS-DRG. CMS is proposing to create new base MS-DRG 212 (Concomitant Aortic and Mitral Valve Procedures) for cases reporting an aortic valve repair or replacement procedure, a mitral valve repair or replacement procedure, and another concomitant procedure in MDC 05.

External Heart Assist Device

Currently, the three ICD-10-PCS procedure codes describing the insertion of a short-term heart assist device are recognized as extensive O.R. procedures assigned to MS-DRG 215 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC-05. One of the codes is for an open approach (02HA0RZ: Insertion of short-term external heart assist system into heart, open approach). The other two codes describe a percutaneous approach.

CMS is proposing to reassign the open approach code when reported as a standalone procedure from MS-DRG 215 in MDC-05 to Pre-MDC MS-DRGs 001 and 002. Under this proposal, this code will no longer need to be reported as a part of a procedure code combination or procedure code “cluster” to satisfy the logic assigned to MS-DRGs 001 and 002.

Ultrasound Accelerated Thrombolysis for Deep Vein Thrombosis

A request was made to reassign cases reporting USAT of peripheral vascular structures procedures with the administration of thrombolytic(s) for deep venous thrombosis from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 270, 271, and 272 (Other Major Cardiovascular Procedures with MCC, with CC, and without CC/MCC, respectively).

Although CMS found this subset of cases does not clinically align with patients undergoing surgery for acute myocardial infarction, the difference in resource consumption does warrant creating a new MS-DRG to reflect more appropriate payment for USAT and standard CDT procedures of peripheral vascular structures. CMS is proposing to create new MS-DRGs 278 and 279 (Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structures with MCC and without MCC, respectively).

Coronary Intravascular Lithotripsy

A request was made to review MS-DRG assignment of cases describing percutaneous intravascular lithotripsy (IVL) involving the insertion of drug eluting and non-drug eluting stents. According to the requestor, cases involving IVL are more complex as this is a therapy deployed exclusively in several calcified coronary lesions that are associated with longer procedure times and increased resources.

CMS analysis showed that cases reporting percutaneous coronary IVL, with or without a stent had higher average costs and lengths of stay. CMS is proposing to create two new MS-DRGs:

• MS-DRGs 323 and 324 (Coronary Intravascular Lithotripsy with Intraluminal Device with MCC and without MCC, respectively), and
• MS-DRGs 325 (Coronary Intravascular Lithotripsy without Intraluminal Device).

Eliminating Distinction Between Bare Metal and Drug Eluting Stent (DES)

CMS notes it appears to no longer be necessary to subdivide the MS-DRGs for percutaneous cardiovascular procedures based on the type of coronary intraluminal device inserted. Therefore, they are proposing to delete MS-DRGs 246, 247, 248, and 249, and are proposing new MS-DRG 321 (Percutaneous Cardiovascular Procedures with Intraluminal Device with MCC or 4+ Arteries/Intraluminal Devices) and MS-DRG 322 (Percutaneous Cardiovascular Procedures with Intraluminal Device without MCC).

CMS is also proposing to revise the titles for MS-DRGs 250 and 251 from “Percutaneous Cardiovascular without Coronary Artery Stent with MCC, and without MCC, respectively” to “Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC, and without MCC, respectively” to better reflect the ICD-10-PCS terminology of “intraluminal devices” versus “stents” as used in the procedure code titles within the classification.

Cardiac Defibrillators and Shock

During a review of cardiogenic shock, CMS noted data analysis shows the average costs and length of stay are generally similar for cardiac defibrillator cases without regard to the presence of AMI, Heart Failure (HF), or shock. CMS is proposing to delete MS-DRGs 222, 223, 224, 225, 226, and 227, and create three new MS-DRGs:

• MS-DRG 275 (Cardiac Defibrillator Implant with Cardiac Catheterization and MCC, and
• MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC, and without MCC, respectively).

Specific to MS-DRG 275, CMS is proposing to designate procedure codes describing cardiac catheterization as non-O.R. procedures affecting the MS-DRG.

CMS is accepting comments through June 9, 2023.

Resource: CMS-1785-P; FY 2024 IPPS Proposed Rule at https://www.cms.gov/medicare/acute-inpatient-pps/fy-2024-ipps-proposed-rule-home-page

The FY 2024 IPPS Proposed Rule (CMS-1785-P) was issued by CMS April 10, 2023. This article focuses on proposed changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications in Major Diagnostic Categories (MDCs) 02, 04, and 06 (Diseases and Disorders of the Eye, Respiratory System, and Digestive System, respectively).

MDC 02: Diseases and Disorders of the Eye: Retinal Artery Occlusion

A request was made to review the MS-DRG assignment of cases involving central retinal artery occlusion (CRAO). The assertion was that CRAO is a form of acute ischemic stroke which occurs when a vessel supplying blood to the brain is obstructed and there is growing recognition of this diagnosis as a vascular neurological problem. New evidence outlines treatment of patients with CRAO with acute stroke protocols, specifically with intravenous thrombolysis or hyperbaric oxygen therapy, to improve outcomes.

Based on this request, data analysis and examining clinical considerations, CMS is proposing to:

• Reassign ICD-10-CM diagnosis codes H34.10, H34.11, H34.12, H34.13, H34.231, H34.232, H34.233, and H34.239 from MDC 02 MS-DRG 123 to MS-DRGs 124 and 125,
• Add procedure codes describing the administration of a thrombolytic agent listed in this section of the proposed rule to MS-DRG 124,
• As part of the logic for MS-DRG 124, designate the administration of thrombolytic agent codes as non-O.R. procedures affecting the MS-DRG, and
• Change the titles of MS-DRGs 124 and 125 from “Other Disorders of the Eye, with and without MCC, respectively,” to “Other Disorders of the Eye with MCC or Thrombolytic Agent, with without MCC, respectively” to better reflect the assigned procedures.

MDC 04: Diseases and Disorders of the Respiratory System: Ultrasound Accelerated Thrombolysis for Pulmonary Embolism

A request was made to reassign cases reporting ultrasound accelerated thrombolysis (USAT) with administration of thrombolytic(s) for the treatment of pulmonary embolism (PE) from MS-DRGs 166, 167, and 168 (Other Respiratory O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 163, 164, and 165 (Major Chest Procedures with MCC, with CC, and without CC/MCC, respectively).

CMS believes clinical and data analyses support creating a new base MS-DRG for cases reporting a principal diagnosis of PE and USAT or standard catheter directed thrombolysis (CDT) procedures with or without thrombolytics and are proposing new base MS-DRG 173 (Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis of Pulmonary Embolism).

MDC 04: Respiratory Infections and Inflammations Logic

There are two logic lists for case assignment to MS-DRGs 177, 178, and 179 (Respiratory Infections and Inflammations with MCC, with CC, without CC/MCC, respectively). All diagnosis codes in the first logic list are designated as MCCs.

Currently, if the principal diagnosis is from the second logic list and any of the diagnoses from the first logic list are also on the claim, the case would be assigned to MS-DRG 177. This is inconsistent with how other similar logic lists function in the ICD-10 grouper software. Therefore, CMS is proposing to correct the logic for cases assigned to MS-DRG 177 by excluding the 15 diagnosis codes in the first logic list from acting as an MCC when reported as a secondary diagnosis when the principal diagnosis is from the second logic list.

MDC 06: Diseases and Disorders of the Digestive System: Appendicitis

ICD-10-CM diagnosis codes K35.20 (Acute appendicitis with generalized peritonitis, without abscess) and K35.21 (Acute appendicitis with generalized peritonitis, with abscess) will no longer be effective October 1, 2023. At that time, six new diagnosis codes describing acute appendicitis with generalized peritonitis, with and without perforation or abscess will become effective. The new codes are proposed for assignment to MS-DRGs 371, 372, and 373 (Major Gastrointestinal Disorders and Peritoneal Infections with MCC, with CC, and without MCC/CC, respectively).

CMS notes that clinically both localized and generalized peritonitis in association with an appendectomy require the same level of patient care and believe the distinction between “complicated” versus “uncomplicated” is no longer meaningful regarding resource consumption. Therefore, CMS is proposing to delete MS-DRGs 338, 339, 340, 341, 342, and 343 and proposing to create new MS-DRGs 397, 398, and 399 (Appendix Procedures with MCC, with CC, and without CC/MCC, respectively). The new MS-DRGs would no longer require a diagnosis in the definition of the logic for case assignment.

CMS is accepting comments through June 9, 2023.  

Resource: FY 2024 IPPS Proposed Rule Home Page