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Did You Know?

When a patient has bi-level positive airway pressure (BiPap) delivered through an endotracheal tube (ETT), the procedure code is different that BiPap (5A09x57), and the case groups to a different DRG.

Why It Matters

When BiPap is delivered through an ETT or tracheostomy, the PCS alpha index sends us to see Performance, Respiratory (5A19###).

Alphabetic Index:

BiPAP – see Assistance, Respiratory 5A09

Via

Endotracheal Tube or Tracheostomy –see Performance, Respiratory

Example: If a patient has a principal diagnosis of pneumonia, unspecified (J18.9), with a secondary diagnosis of acute respiratory failure with hypoxia (J96.01), and the patient is placed on Bipap without an ETT, the case groups to DRG 193 (Simple pneumonia and pleurisy with MCC) with a relative weight of 1.3107.

However, if this same patient is placed on BiPap, via an ETT or tracheostomy, the case groups to DRG 208 (Respiratory system diagnosis with ventilator support) with a relative weight of 2.5423.

Accurate coding of BiPap, via an ETT or tracheostomy, will not only group to a higher-weighted DRG, realizing more appropriate reimbursement, but it will also help to support the resources your facility spends on a patient. p>

What Should I Do?

Thoroughly review the record:

• Watch for words like “intubation” or “successfully intubated”
• Review any procedure reports
• Review all respiratory sheets
• Review nursing notes

References:

• ICD-10-PCS Official Coding Book
• Coding Clinic for ICD-10-CM/PCS, 2014, page 3

Question

We do ultrasound guided prostate biopsies in Radiology and report the ultrasound guidance with CPT code 76742. To report CPT code 76942, should we maintain permanently recorded images?

Answer

Yes, per the parenthetical guidelines in the Diagnostic Ultrasound section of the CPT book, permanently recorded images must be maintained for ultrasound guidance. The physician should also document the use of ultrasound guidance. This documentation can be included in the biopsy report or can be documented as a separate report. Typically, we see only one physician’s report that describes both the prostate needle biopsy as well as the ultrasound guidance.

September is Prostate Cancer Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to screening for Prostate Cancer.

Did You Know?

According to the CDC:

• 13 out of every 100 American men will get prostate cancer during their lifetime, and
• 2 to 3 men will die from prostate cancer,
• If you are African American or have a family history of prostate cancer you are at increased risk for getting or dying from prostate cancer.

The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.

Why Does this Matter? Know the Symptoms

The CDC advises that if you are having any of the following symptoms, you need to see your doctor right away:

• Difficulty starting urination.
• Weak or interrupted flow of urine.
• Frequent urination, especially at night.
• Difficulty emptying the bladder completely.
• Pain or burning during urination.
• Blood in the urine or semen.
• Pain in the back, hips, or pelvis that doesn’t go away.
• Painful ejaculation.

The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.

What You Can Do About It? Screening for Prostate Cancer

There are two tests commonly used to screen for prostate cancer:

• A blood test called a prostate specific antigen (PSA) test and
• A digital rectal examination (DRE).

The U.S. Preventive Services Task Force recommendation is that men aged 55 to 69 years should participate in a shared decision making process with their physician by discussing the potential benefits and harms of screening with a PSA test and incorporating their values and preferences in the decision.

This recommendation applies to men who:

• Are at average risk for prostate cancer,
• Are at increased risk for prostate cancer,
• Do not have symptoms of prostate cancer, and
• Have never been diagnosed with prostate cancer.

Medicare Preventive Service: Prostate Cancer Screening – Coverage & Coding

HCPCS & CPT Codes

• G0102 (Prostate cancer screening; digital rectal exam): A patient’s copayment or coinsurance, and deductible will apply.
• G0103 (Prostate cancer screening; prostate specific antigen test): there is no copayment, coinsurance, or deductible for the patient.

Resources:

• CDC website: https://www.cdc.gov/cancer/prostate/
• NIH National Cancer Institute Cancer Stat Facts: Prostate Cancer: https://seer.cancer.gov/statfacts/html/prost.html
• U.S. Preventive Services Task Force Final Recommendation Statement for Prostate Screening: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
• CMS MLN Educational Tool (MLN006559 May 2021): Medicare Preventive Services at https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html#PNEUMO

COVID-19 Updates

August 12, 2021: FDA Authorized Additional Vaccine Dose for Certain Immunocompromised Individuals

The FDA has amended the emergency use authorization (EUA) for the Pfizer-BioNTech COVID- 19 Vaccine and the Moderna COVID-19 Vaccine to allow for additional doses “in certain immunocompromised individuals, specifically, solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.” (link). CMS updated their COVID-19 webpage on August 13, 2021 (link), to reflect that they will pay the same amount to administer this additional dose as they did for the other doses (approximately $40 each). .

August 16, 2021: Actemra® (Tocilizumab) Supply Shortage

Genentech released a statement (link) indicating that due to “the unprecedented surge in worldwide demand and supply constraints driven by Delta variant spikes in much of the rest of the world that preceded the current situation in the U.S., has led to a global shortage of Actemra® (tocilizumab) supply for at least the next several weeks…This new wave of the pandemic has led to Genentech experiencing an unprecedented demand for Actemra IV-- well-over 400% of pre-COVID levels over the last two weeks alone and it continues to increase.”

August 18, 2021: COVID-19 Booster Shots

The U.S. Department of Health and Human Services (HHS) published a Press Release (link) regarding the need for COVID-19 booster shots. Specifically, data has shown that protection from vaccination begins to decrease over time and they have a plan to begin offering booster shots “subject to FDA conducting an independent evaluation and determination of the safety and effectiveness of a third dose of the Pfizer and Moderna mRNA vaccines and CDC’s Advisory Committee on Immunization Practices.”

Other Updates

July 19, 2021: CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule (CMS-1753-P) – Hospital Price Transparency

The September 17, 2021 deadline to comment on the CY 2022 OPPS and ASC Payment System Proposed Rule is fast approaching. In a related CMS Fact Sheet (link), CMS noted several proposed “modifications designed to increase compliance and reduce hospital burden beginning January 1, 2022.” One key proposal for hospitals to be aware of is the proposed increase in Civil Monetary Penalties (CMP) for non-compliance with the Hospital Price Transparency rule. Specifically, CMS has proposed the following:

• Set a minimum CMP of $300/day that would apply to smaller hospitals with a bed count ≤30, and
• Apply a penalty of $10/bed/day for hospitals with a bed count >30, not to exceed a maximum daily dollar amount of $5,500.

Under the proposed increases, the new penalty for a full year of noncompliance would be a minimum of $109,500 per hospital and a maximum total penalty of $2,007,500 per hospital.

August 11, 2021: Hospital Price Transparency Stakeholder Webinar

This CMS webinar focused on how to meet the requirements of the Hospital Price Transparency Final Rule (link) for posting standard charge information in a comprehensible machine-readable file (link). CMS experts reviewed 8 steps to a Machine-Readable File of All & Services and provided hospital compliance examples. For those that missed this event, a pdf copy of this presentation is available on the Hospital Price Transparency Resources web page (link). (link)

Medicare MLN Articles & Transmittals – Recurring Updates

New Waived Tests

• Article Release Date: August 9, 2021
• What You Need to Know: This MLN article lists the six latest tests approved by the FDA as waived tests under CLIA. CMS reminds you that the CPT codes for the new tests must have the modifier QW to be recognized as a waived test.
• MLN MM12381: (link)

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2022

• Article Release Date: August 12, 2021
• What You Need to Know: This article highlights key changes in the FY 2022 IPF PPS.
• MLN MM12417: (link)

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2022

• Article Release Date: August 10, 2021
• What You Need to Know: This article provides information related to the SNF payment for rates for FY 2022.
• MLN MM12366: (link)

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2022

• Article Release Date: August 12, 2021
• What You Need to Know: This article includes information regarding rate updates for PPS IRFs for FY 2022.
• MLN MM12364: (link)

Other Medicare MLN Articles & Transmittals

Modifications/Improvements to Value-Based Insurance Design (VBID) Model – Implementation

• Article Release Date: August 9, 2021
• What You Need to Know: This article alerts you to Change Request (CR) 11754 – Transmittal 10170, which replaces the May 8, 2020, Transmittal 10127. This was done to add a note to the effective date and to revise the background section and business requirements, 11754.3. All other information remains the same.
• MLN MM 12349: (link)

Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims

• Article Release Date: August 9, 2021
• What You Need to Know: This article provides a quick summary of updates to the Medicare Claims Processing Manual, Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims. Complete reviews can be found in related Change Request (CR) 12079.
• MLN MM12079: (link)

Internet Only Manual Updates to Publication (Pub.) 100-02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF))

• Article Release Date: August 9, 2021
• What You Need to Know: This article tells you about updates to Chapter 1, Section 110 (IRF Services) of the Medicare Benefit Policy Manual.
• MLN MM12353: (link)

Internet Only Manual Updates to Pub. 100-01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF)

• Article Release Date: August 9, 2021
• What You Need to Know: Changes made clarify existing content. CMS notes in this MLN article that no policy, processing, or system changes are anticipated.
• MLN MM12009: (link)

Implementation of the GV Modifier for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for Billing Hospice Attending Physician Services

• Article Release Date: August 11, 2021
• What You Need to Know: Effective January 1, 2022, an RHC or FQHC can bill and receive payment under the RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS), respectively, when their employed and designated attending physician provides services during a patient’s hospice election. This article provides detail regarding the required modifier to receive payment in both settings.
• MLN MM12357: (link)

Skilled Nursing Facility (SNF) Claims Processing Updates

• Article Release Date: August 11, 2021
• What You Need to Know: This article highlights changes to correct claims processing edits applicable to the FISS and CWF in CR 12344.
• MLN MM12344: (link)

Revised Medicare MLN Articles & Transmittals

National Coverage Determination (NCD) Removal

• Article Release Date: Initial article May 24, 2021 – 3rd Revision August 3, 2021
• What You Need to Know: The MLN Article was revised to reflect the CR 12254 revisions made to the spreadsheet for NCD 20.5 and NCD 220.6.16.
• MLN MM12254: (link)

Medicare Coverage Updates

August 11, 2021: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

The CMS released Proposed Decision Memo CAG-00457R (link) proposing to remove the NCD for Transvenous Pulmonary Embolectomy (NCD 240.6) and allow for Medicare coverage determinations to be made by Medicare Administrative Contractors (MACs). The public comment period ends on September 10, 2021. You can follow the progress of this proposed decision memo on the related National Coverage Analysis (NCA) tracking sheet (link).

CMS Resumes Targeted Probe & Educate Program

In response to the COVID-19 Public Health Emergency (PHE), CMS suspended medical review activities on March 30, 2020. In August 2020, Recovery Auditors, Comprehensive Error Rate Testing Program, and Medicare Administrative Contractor post-payment reviews were resumed. At that time, the Targeted Probe and Educate (TPE) program remained on hold.

On May 8, 2019, CMS put a temporary hold on SSRs and HWDRG reviews as they planned to procure a new contractor to review both types of reviews on a national basis. The expectation was to award the contract by the 3rd quarter of calendar year 2019.

According to a CMS TPE Q&A document (link), when performing medical review as a part of this program, Medicare Administrative Contractors (MACs):

• Focus on specific providers/suppliers who, through data analysis, have been identified as varying significantly from their peers,
• Typically review 20-40 claims per provider/supplier, per item or service (round),
• Provide individualized education based on review results after a round, and
• Perform up to three rounds of reviews per item or service.

The CMS announced in the Thursday August 12, 2021, edition of MLN Connects (link) that the TPE Program is restarting “to help educate providers and reduce future denials and appeals.”

Livanta to Begin Short Stay Reviews and Higher Weighted DRG Reviews

Kepro and Livanta are the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) that serve all regions across the nation. The BFCC-QIO scope of work, among other things includes performing certain types of medical record reviews. Two specific reviews are Short Stay Reviews (SSRs) and Higher Weight Diagnosis-Related Group (HWDRG) review.

It wasn’t until April of 2021, that Livanta announced they had been awarded this contract. On August 11, 2021, Livanta released a Provider Bulletin (link) to announce the official start of claims reviews. The bulletin includes information on the following topics:

• What Hospitals Can Expect,
• Hospital Inpatient Claim Review Types,
• HWDRG Review Process,
• SSR Process, and
• Questions and Education.

The review process for each type of medical review includes the timing of when they will begin requesting records. For HWDRG reviews, they expected to send the first medical record request the week of August 16th. For SSRs, Livanta anticipated sending the first individual medical record requests on or about the week of September 20, 2021. Note, record requests will be sent to your Medical Record point of contact via fax when possible or U.S. mail if fax is not possible. A hospital sample will consist of 30 claims reviewed within a rolling 3-month period and records must be submitted electronically.

I encourage you to visit Livanta’s webpage (link), read the Provider Bulletin and share this information with appropriate staff at your facility.

Did You Know?

It is common for a surgeon to perform a fusion on the anterior column and the posterior column of the spine through a single incision.

Why It Matters

The codes for anterior and posterior spinal column fusion will group to the higher-weighted DRG group (453-455). You could be under-coding and losing out on thousands of dollars of reimbursement for your facility.

What Can I Do?

First, make sure you are familiar with the anatomy and the terms describing the anterior and posterior columns.

The anterior column consists of:

• Anterior longitudinal ligament
• Vertebral body
• Intervertebral Disc
• Annulus Fibrosus
• Posterior Longitudinal Ligament

The posterior column consists of:

• Pedicles
• Transverse Process (gutter)
• Lamina
• Facets
• Spinous Process

The anterior column fusion is usually what is described first in the Operative Report and is often coded correctly. However, the posterior fusion is typically overlooked and not reported. One of the reasons may be the unfamiliarity with the terms describing the posterior column. For example, a surgeon may document that bone graft was placed in the “gutters”. Gutters is another term to describe the Transverse Process, so bone graft placed in the gutters is a posterior spinal fusion.

Based on the above information, there should be a code for fusion of the anterior column and a code for the posterior column in order for the claim to group to the appropriate higher-weighted DRG.

Question

I am a new chargemaster (CDM) coordinator at my facility, and my current to-do list involves trying to verify the CPT / HCPCS code assignment for vaccines. How can I determine if the CPT codes assigned in the CDM for pneumonia and influenza vaccines are correct?

Answer

Don’t try to figure it out on your own – you really need the expertise of one of your hospital pharmacists to help you with this. Fortunately, there are only 2 CPT codes to choose from for the pneumonia vaccines, but 20 CPT codes and 6 HCPCS Q codes to choose from for the influenza vaccines. In our experience with pharmacy CDM reviews, hospital pharmacists are usually able to easily tell you which CPT or HCPCS code should be used.

Thursday August 12, 2021

The FDA has amended the emergency use authorization (EUA) for the Pfizer-BioNTech COVID- 19 Vaccine and the Moderna COVID-19 Vaccine to allow for additional doses “in certain immunocompromised individuals, specifically, solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.” (link).

Friday August 13, 2021

The CMS updated their COVID-19 webpage on August 13, 2021 (link), to reflect that they will pay the same amount to administer this additional dose as they did for the other doses (approximately $40 each). They go on to note in the announcement that they will be sharing information in the coming days related to billing and coding.

Monday August 16, 2021

The CMS released a Special Edition MLN Connects noting that “effective August 12, 2021, CMS will pay to administer additional doses of COVID-19 vaccines consistent with the FDA EUAs, using CPT code 0003A for the Pfizer vaccine and CPT code 0013A for the Moderna vaccine (link). We’ll pay the same amount to administer this additional dose as we did for other doses of the COVID-19 vaccine (approximately $40 each).

We’ll hold and then process all claims with these codes after we complete claims system updates (no later than August 27).”

August is National Immunization Awareness Month (NIAM). A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to the treatment costs of Pneumonia.

Did You Know?

According to CDC data for the United States in 2017

• 3 million people were diagnosed with pneumonia in an emergency department, and
• Approximately 50,000 people died from pneumonia.

Why Does this Matter?

In general, people affected by pneumonia in the United States are adults. Per the CDC, vaccines, and appropriate treatment (like antibiotics and antivirals) could prevent many of these deaths.

What You Can Do About It? Wash Your HandsWhy Does this Matter?

In general, people affected by pneumonia in the United States are adults. Per the CDC, vaccines, and appropriate treatment (like antibiotics and antivirals) could prevent many of these deaths.

What You Can Do About It? Wash Your Hands

Handwashing is one of the most important things you can do. In fact, it’s so important that annually there is a Global Handwashing Day on October 15th and the first week of December in the U.S. is National Handwashing Week. You can download a CDC poster educating people on knowing when and how to wash your hands (link).

When to Wash Your Hands?

• After using the bathroom,
• Before, during, and after preparing food,
• Before eating food,
• Before and after caring for someone at home who is sick with vomiting or diarrhea,
• After changing diapers or cleaning up a child what has used the toilet,
• After blowing your nose, cough, or sneezing,
• After touching an animal, animal feed, or animal waste,
• After handling pet food or pet treats, and
• After touching garbage.

How to Wash Your Hands? Wet, Lather, Scrub, Rinse and Dry

• Wet your hands with clean running water (warm or cold), turn off the tap and apply soap,
• Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails,
• Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice,
• Rinse hands well under running water, and
• Dry hands using a clean towel or air-dry time.

What You Can You Do About It? Get Your Pneumonia Vaccine(s)

Did you know that there are two different pneumonia vaccines? Further, did you know they cannot be given at the same time?

According to the CDC (link), if you are recommended to or want to receive both vaccines get Prevnar13® first and talk to your doctor about when to come back to get the Pneumovax23. If you’ve already received the Pneumovax23 vaccine, wait at least a year after that shot to get the Prevnar13® vaccine.

Prevnar13® Pneumococcal conjugate vaccine (PCV13)
This vaccine was approved in 2010. It is approved for adults 18 years of age and older for the prevention of pneumococcal pneumonia and invasive disease caused by 13 Streptococcus pneumoniae strains.

Pnuemovax23 (Pneumococcal Vaccine Polyvalent)
This vaccine was approved by the FDA in 1983 and has been available for over 35 years. It helps protect against 23 types of pneumococcal bacteria, some of which are common and often cause serious illness.

The CDC recommends this vaccine for:

• All adults 65+, even if you already had a different pneumococcal vaccine, and
• Those 19-64 years old who have certain chronic conditions such as diabetes, heart disease or COPD.

Pneumococcal Shot Administration Coverage
As of September 19, 2014, Medicare Part B covers:

• All adults 65+, even if you already had a different pneumococcal vaccine, and
• Those 19-64 years old who have certain chronic conditions such as diabetes, heart disease or COPD.

There is no copayment, coinsurance, or deductible for Medicare beneficiaries.

HCPCS & CPT Codes

• CPT 90670 – Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use
• CPT 90732 – Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
• HCPCS G0009 – Administration of pneumococcal vaccine.

Medicare covers all patients receiving pneumonia vaccines and there is no copayment, coinsurance, or deductible.

What Vaccines are Recommended for You?

In addition to pneumonia vaccines, there are additional immunizations that all adults need. Do you know what vaccines you have had or should have? If not, the CDC offers an Adult Vaccine Assessment Tool for all adults 19 years or older (link).

Resources:

• CDC website: https://www.cdc.gov/handwashing/index.html
• CMS MLN Educational Tool (MLN006559 May 2021): Medicare Preventive Services at https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html#PNEUMO
• MerckVaccines.com®: https://www.pneumovax23.com/
• Prevnar13® website: https://adult.prevnar13.com/about-prevnar13