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In a November 16^th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”

White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)

HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:

• Pillar 1: Expanding Data Gathering and Sharing,
• Pillar 2: Support Flexible Funding to Address Social Needs,
• Pillar 3: Support Backbone Organization.

   

  HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework

  In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”

   

  HHS Resource: HHS’s Call to Action to Address Health Related Social Needs

  The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”

   

  Z-Codes: Identifying and Coding Social Determinates of Health

  Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:

• Z59.00: Homelessness, unspecified,
• Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
• Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.” 

To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.

A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.

Question

A patient was admitted to the hospital with acute renal failure and has a history of a kidney transplant.  Is acute renal failure a complication of the kidney transplant?

Answer

Acute renal failure is affecting the function of the transplanted kidney, but it doesn’t mean that the transplant itself has failed.  Assign T86.19 (Other complication of kidney transplant) along with N17.9 (Acute renal failure) to correctly code this case.

• Pre-existing conditions or conditions that develop after an organ transplant are not coded as complications unless it affects the function of the transplanted organ.

References:

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019:  Page 7

AHA Coding Handbook

The OIG released its semiannual report to Congress on December 1^st. In a related fact sheet they indicated the report highlights over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations conducted during fiscal year (FY) 2023.

This report “describes OIG’s work on significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations during the reporting period. In this report, we present OIG expected recoveries, criminal and civil actions, and other statistics as a result of our work for the semiannual reporting period of April 1, 2023-September 30, 2023. We also provide data for accomplishments for fiscal year (FY) 2023 and highlight some of our work completed during this semiannual reporting period.”

For this article, we will focus on one report completed by the OIG that impacts inpatient claims in acute care hospitals. In September 2023, OIG released the report Medicare Improperly Paid Acute-Care Hospitals for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy Over a 4-Year Period, but CMS’s System Edits Were Effective in Reducing Improper Payments by the End of the Period (A-09-23-03016), September 2023.

About the Post-Acute-Care Transfer Policy

Medicare makes the full Medicare Severity Diagnosis-Related Group (MS‑DRG) payment to an acute‑care hospital that discharges an inpatient to home or certain types of health care institutions but pays an acute-care hospital that transfers an enrollee to post-acute care a per diem rate for each day of the enrollee’s stay in the hospital.

Post-acute care settings that are subject to this policy includes transfers to:

• Inpatient rehabilitation facilities and units (Patient discharge status code 62 or planned acute care hospital inpatient readmission patient status code 90),
• Long-term care hospitals (Patient Status Code 63 or planned acute care hospital inpatient readmission Patient Status Code 91),
• Psychiatric hospitals and units (Patient discharge status code 65 or planned acute care hospital inpatient readmission patient status code 93),
• Cancer hospitals (Patient discharge status code 05 or planned acute care hospital inpatient readmission patient status code 85),
• Children’s hospitals (Patient discharge status code 05 or planned acute care hospital inpatient readmission patient status code 85),
• Skilled nursing facility (Patient discharge status code 03 or planned acute care hospital inpatient readmission patient status code 83),
• Hospice care at home (Patient status code 50) or Hospice Medical Facility (Certified) providing hospice level of care (Patient status code 51)
• Home under a written plan of care for the provision of home health (HH) services from a HH agency and those services occurs within 3 days after the date of discharge (Patient discharge status code 06 or planned acute care hospital inpatient readmission patient status code 86).

MS-DRGs Subject to the Post-Acute-Care Transfer Policy in the CMS FY 2024

• 764: The overall number of MS-DRGs for FY 2024
• 282: The number of MS-DRGs subject to this policy
• 148: The number of surgical MS-DRGs subject to this policy
• 134: The number of medical MS-DRGs subject to this policy

Specific regulations regarding the transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, section 40.2.4.

Why OIG Did The Audit

OIG notes that compliance with the transfer policy has been an issue for a long time and this audit was conducted to evaluate whether Medicare properly paid acute-care hospital claims subject to the policy for claims with dates of service from January 1, 2019, through December 31, 2022.

About the Audit

• $198 million: The Medicare Part A payments covered in the audit.
• 12,133: the number of inpatient claims subject to the transfer policy.
• Claims included in the audit had a discharge status code to home or certain types of health care institutions on the claim.
• OIG used Medicare enrollee information to identify post-acute services settings that began on the same day as discharge for SNF claims, and within 3 days of inpatient discharge for home health claims.

What OIG Found

Medicare improperly paid $41.4 million to acute-care hospitals for inpatient claims subject to the post-acute-care transfer policy. This amount of money represents the difference between the amount of the full MS-DRG payments and the amount that would have been paid if the per diem rates had been applied.

These improper payments were made because CMS’s system edits were not effective in detecting inpatient claims subject to the transfer policy in October and November 2019 and from October 2020 through March 2022. However, after CMS fixed the edits in April 2022, improper payments significantly decreased through the end of the audit period.

Coverage Updates

October 30, 2023: MLN MM13017: Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening – Revised

The initial release of this MLN article was February 2, 2023. Now in it’s third iteration, CMS has added clarifying information about the -KX modifier for screening colonoscopy claims in the context of a complete colorectal cancer screening. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

November 20, 2023: MLN MM13429: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease

On October 13, 2023 CMS published a Final Decision Memo announcing a final decision to remove this NCD and now permitting Medicare coverage determinations to be made by the MACs. Removing the NCD also removes the current limitation of one PET beta-amyloid scan per lifetime from the coverage requirements.

CMS notes in MLN article MM13429 that “your MAC will adjust any PET beta amyloid claims processed incorrectly that you bring to their attention, effective for claims with DOS on or after October 13, 2023. https://www.cms.gov/files/document/mm13429-beta-amyloid-positron-emission-tomography-dementia-and-neurodegenerative-disease.pdf

Compliance Education Updates

MLN Educational Tool: Medicare Payment Systems

CMS has updated this tool to include FY 2024 updates to the:

• Acute Care Hospital Inpatient Prospective Payment System,
• Hospice Payment System & Coverage,
• Inpatient Psychiatric Facility Prospective Payment System,
• Inpatient Rehabilitation Facility Prospective Payment System,
• Long-Term Care Hospital Prospective Payment System, and
• Skilled Nursing Facility Prospective Payment System.

Substantive changes to this tool are in dark red. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html

October 2023: MLN Booklet: Independent Diagnostic Testing Facility

CMS has updated this booklet to include more information on several topics, including supervising physicians, interpreting physicians, and technicians. https://www.cms.gov/files/document/mln909060-independent-diagnostic-testing-facility.pdf

New and Updated CMS National Training Program (NTP) Products

• Medicare & the Health Insurance Marketplace^®
• Medicare: Getting Started
• Medicare & Home Health Care

You can order CMS products in bulk by visiting our product ordering website.

October 30, 2023: MLN MM13390: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 1 of 2)

CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information.  https://www.cms.gov/files/document/mm13390-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-1-2.pdf

October 30, 2023: MLN MM13391: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 2 of 2)

CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13391-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-2-2.pdf

November 3, 2023: MLN MM13244: Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Claims

Effective January 1, 2024, Medicare will make separate payment for HCPCS code A9272 on type of bill (TOB) 032x, instead of 034x. Also, Medicare Administrative Contractors (MACs) will apply deductible and coinsurance.

https://www.cms.gov/files/document/mm13244-separate-payment-disposable-negative-pressure-wound-therapy-devices-home-health-claims.pdf

November 6, 2023: MLN MM13055: Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order – Revised

Initially published June 1, 2023, this article was revised on November 6, 2023 to add two new CPT codes effective January 1, 2024, based on Change Request (CR) 13279.

Did You Know?

On November 6, 2023, the Office of Inspector General (OIG) released General Compliance Program Guidance (GCPG).

Per the OIG’s announcement, “the GCPG is a reference guide for the health care compliance community and other health care stakeholders. The GCPG provides information about relevant Federal laws, compliance program infrastructure, OIG resources, and other items useful for understanding health care compliance. The GCPG is voluntary guidance that discusses general compliance risks and compliance programs. The GCPG is not binding on any individual or entity.”

You can download the complete guidance or  individual sections.

Why it Matters?

The OIG first published compliance program guidance documents (CPGs) in 1998. Historically, guidance has been published in the Federal Register. However, moving forward, updates or new guidance will no longer be published in the Federal Register.

GCPG

The GCPG guidance applies to all individuals and entities involved in the health care industry and addresses:

• Key Federal authorities for entities engaged in health care business.
• The seven elements of a compliance program,
• Adaptations for small and large entities, other compliance,
• Other compliance considerations, and
• OIG processes and resources.

Moving forward, the OIG anticipates updating the GCPG as changes in compliance practices or legal requirements may warrant.

ICPGs

Starting in 2024, the OIG will begin publishing industry specific CPGs (ICPGs) that “will be tailored to fraud and abuse risk areas for each industry subsector and will address compliance measures that the industry subsector participants can take to reduce these risks. ICPGs are intended to be updated periodically to address newly identified risk areas and compliance measures and to ensure timely and meaningful guidance from the OIG.”

Moving Forward

Ultimately, the goal of both guidance documents (GCPG and ICPGs) “has been, and will continue to be, to set forth voluntary compliance guidelines and tips and to identify some risk areas that OIG believes individuals and entities engaged in the health care industry should consider when developing and implementing a new compliance program or evaluating and updating an existing one.”

I encourage you to take the time to read this latest guidance, pay close attention to the information in the blue boxes and tips throughout this document. For example, in the “Auditing and Monitoring” section of this document an OIG tip reminds providers that “Medicare requires, as a condition of payment, that items and services be medically reasonable and necessary. Therefore, entities should ensure that any claims reviews and audits include a review of the medical necessity of the item or service by an appropriately credentialed clinician. Entities that do not include clinical review of medical necessity in their claims audits may fail to identify important compliance concerns relating to medical necessity.”

Finally, if you are not already signed up for the OIG newsletter, I encourage you to do so. You can sign up on the website by scrolling to the bottom of page and clicking “Subscribe to Our Newsletter.”  

Did You Know?

CMS announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024 that they are pausing their efforts to implement the Appropriate Use Criteria (AUC) Program for reevaluation and rescinding the AUC regulations at 42 CFR 414.94, reserving this section for future use.

Why It Matters?

On November 3, 2023, CMS posted the following notice on the AUC Program webpage:

“Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. Additionally, CMS will no longer qualify PLEs or CDSMs and will remove this information from the AUC website. The claims processing instructions and guidance for the educational and operations testing period will also be removed.”

What Can I Do?

Share this information with the appropriate stakeholders at your facility and consider this an early Thanksgiving blessing that CMS acknowledged the challenges to implementing the regulations at 42 CFR 414.94.

Did You Know?

Effective October 1, 2023, the Alphabetic Index to the code book changed how we are to code elevated Troponin level again.

Why It Matters?

Prior to October 1, 2023, the Alphabetic Index led coders to assign R77.8, Other Specified Abnormalities of Plasma Protein, for an elevated Troponin level, while the advice from Coding Clinic, 2Q 2019, page 6 instructed coders to use R79.89, Other Specified Abnormal Lab Findings of Blood Chemistry. Even though the code book instructions take precedence over Coding Clinic advice, this confused many coders and caused coding errors when coding this condition.

What Can I Do?

Inform coders that the Alphabetic Index has now changed and that R79.89, Other Specified Abnormal Lab Findings of Blood Chemistry is the correct code for an elevated Troponin level.

Resources:

Coding Clinic, 2Q 2019, page 6

Alphabetic Index from the code book, 10/01/2023

CMS issued the CY 2024 OPPS/ASC Final Rule on November 2, 2023. This article highlights changes to the Medicare Inpatient Only (IPO) Procedure list and the ASC Covered Procedure List (CPL)

Medicare IPO Procedure List

Although CMS received several requests recommending services for removal from the IPO list, CMS did not find sufficient evidence that met the criteria, and no services were removed from the IPO list for CY 2024. CMS finalized their proposals to add nine services with newly created codes by the AMA CPT Editorial Panel which will be in effect January 1, 2024 to the list and to reassign CPT code 0646T (Transcatheter tricuspid valve implantation (ttvi)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed) from status indicator “E1” (not payable by Medicare) to status indicator “C.” Changes to the IPO list are in table 103 of the final rule.

ASC Covered Procedures List (CPL)

In regard to expanding the ASC CPL, CMS notes in the final rule that “while expanding the ASC CPL offers benefits, such as preserving the capacity of hospitals to treat more acute patients and promoting site neutrality, we also believe that any additions to the CPL should be added in a carefully calibrated fashion to ensure that the procedure is safe to be performed in the ASC setting for a typical Medicare beneficiary. We expect to continue to gradually expand the ASC CPL, as medical practice and technology continue to evolve and advance in future years.” 

In the CY 2024 proposed rule, CMS proposed to update the ASC CPL by adding 26 dental surgical procedures.

Before we find out what was finalized. It is relevant to share information from the CY 2023 and CY 2024 Physician Fee Schedule (PFS) final rules where CMS provides greater clarity to current policies related to dental services. Specifically, in the CY 2023 final rule CMS provided:

1. A clarification of our interpretation of section 1862(a)(12) of the Act to permit payment for dental services that are inextricably linked to other covered services.
2. clarification and codification of certain longstanding Medicare FFS payment policies for dental services that are inextricably linked to other covered services.
3. that, beginning for CY 2023, Medicare Parts A and B payment can be made for certain dental services inextricably linked to Medicare-covered organ transplant, cardiac valve replacement, or valvuloplasty procedures; and,
4. beginning for CY 2024, that Medicare Parts A and B payment can be made for certain dental services inextricably linked to Medicare-covered services for treatment of head and neck cancers (87 FR 69670 and 69671).

CMS also clarified that adding dental procedures to the ASC CPL does not serve as a coverage determination for dental services under anesthesia.

The CY 2024 Physician Fee Schedule Final Rule was also issued on November 2, 2023. In a related Fact Sheet CMS notes for CY 2024 they are building up on their efforts and for CY 2024 are finalizing the following:

1. A codification of the previously finalized payment policy for dental services for head and neck cancer treatments, whether primary or metastatic.
2. The codification to per Medicare Part A and Part B payment for dental or oral examination performed as part of a comprehensive workup prior to medically necessary diagnostic and treatment services, to eliminate an oral or dental infection prior to, or contemporaneously with, those treatment services, and to address dental or oral complications after radiation, chemotherapy, and/or surgery when used in the treatment of head and neck cancer; and
3. The proposal to permit payment for certain dental services inextricably linked to other covered services used to treat cancer prior to, or during chemotherapy services, Chimeric Antigen Receptor (T (CAR-T) Cell therapy, and the use of high-dose bone modifying agents (antiresorptive therapy).

CMS has finalized the addition of 37 procedures to the ASC CPL. In addition to the proposed 26 dental surgical procedures, CMS finalized adding 11 of 235 procedure recommendations received during the public comment period. They note that “these 11 codes correspond to procedures that are frequently performed in outpatient settings and increasingly show lower risks of serious complications and inpatient admissions.” The procedures are listed in Table 123 of the CY 2024 OPPS/ASC final rule.

Resources

CY 2024 OPPS/ASC Final Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1786-fc

CY 2024 OPPS/ASC Final Rule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2024-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0

CY 2024 Medicare Physician Fee Schedule Final Rule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule

CMS issued the CY 2024 OPPS/ASC Final Rule on November 2, 2023. You can read about changes to the Inpatient Only (IPO) Procedure List and ASC Coverage Procedure List (CPL) in a related article in this week’s newsletter. This article highlights additional topics that historically our clients have reached out to us to learn about.

OPPS Remedy for 340B-Acquired Drug Payment Policy

On July 7, 2023, CMS published a proposed rule, referred to as “remedy proposed rule” to address reduced payment amounts to 340B hospitals for CYs 2018 through 2022 and to comply with the statutory requirement to maintain budget neutrality. The “remedy proposed rule” proposed changes to the calculation of the OPPS conversion factor beginning in CY 2025.

The 340B final remedy was also issued on November 2^nd. In this final rule, CMS finalized their proposed methodology of estimating the reduction in drug payments to affected 340B covered entity hospitals in CY 2018 through September 27, 2022, and will make total lump sum payments in the amount of $9.004 billion.

CMS will be issuing instructions to the MACs to issue a one-time lump sum payment to the affected hospitals within 60 calendar days of the MAC’s receipt of the instructions.

Based on updated analyses, the final rule Addendum AAA was updated with new hospital-specific payment amounts and accounts for all payment activity that has happened since the proposed rule was issued. Updated claims data reflects that affected hospitals received approximately $10.6 billion less in 340B drug payments (including money that would have been paid by Medicare and money that would have come from the beneficiaries as copayments) than they would have for drugs provided in CY 2018 through September 27, 2022, had the 340B policy not been implemented.

“The amounts included in Addendum AAA are the amounts that hospitals will receive, except that payment amounts may be affected by MACs continuing to follow normal accounting processes for collecting repayment amounts stemming from provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process described below, as well as other unique situations such as provider bankruptcy or payment suspension, any of which may impact the provider’s net payment amount.”

Unfortunately, the lump sum payments do not include interest and CMS is following budget neutrality requirements to make these payments. This means that “beginning in CY 2026, we will reduce all payments for non-drug items and services to all OPPS providers, except new providers (hospitals with a CMS CCN effective date of January 2, 2018, or later), by 0.5 percent each year until the total estimated offset of $7.8 billion is reached. We currently estimate that the payment decrease will be completed after approximately 16 years. To implement this reduction and exception for new providers, we are finalizing the proposed regulation text changes at § 419.32(b)(1)(iv)(B) as proposed, except for changing the implementation date of the 0.5 percent reduction from CY 2025 to CY 2026.”

CMS notes in the 340B remedy final rule that “generally the impact of that annual 0.5 percent reduction to the OPPS conversion factor on individual providers, as well as categories of providers, will depend on the percentage of their OPPS payments that are conversion factor-based, and in most cases will be a decrease of slightly less than 0.5 percent of overall OPPS payments.”

Beneficiary Cost Sharing

CMS noted in the final rule that commenters overwhelmingly supported their proposed approach and rationale for accounting for beneficiary cost sharing. They finalized their “policy to account for beneficiary cost sharing as proposed. We will exercise our authority under section 1833(t)(2)(E) of the Act (42 U.S.C. 1395l(t)(2)(E)) to make adjustments “as necessary to ensure equitable payments,” to pay the full $9.0 billion difference, including $1.8 billion, an amount that is approximately equivalent to what affected 340B covered entity hospitals would have collected from beneficiaries for these 340B-acquired drugs if the 340B Payment Policy had not been in effect from CY 2018 through September 27, 2022, so that affected 340B covered entity hospitals are paid the approximate amount they would have been paid in full without application of the 340B Payment Policy.”

340B Modifiers “JG” and “TB”

The Inflation Reduction Act of 2022 expanded the provider types that must report one of these modifiers no later than January 1, 2024, to now include critical access hospitals, Maryland All-Payer or Total Cost of Care Model Hospitals, and Non-excepted off-campus provider-based departments (PBD).

In the CY 2023 OPPS/ASC final rule, CMS maintained the requirements that 340B hospitals report one of two modifiers, “JG” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes, or “TB” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes for select entities.

In the CY 2024 OPPS/ASC proposed rule, CMS notes they “now believe utilizing a single modifier will allow for greater simplicity, especially because both modifiers are used for the same purpose: to identify separately payable drugs and biologicals acquired under the 340B program.”

CMS is proposing that all 340B covered entity hospitals would report the “TB” modifier effective January 1, 2025, even if the hospital previously reported the “JG” modifier. The “JG” modifier will remain effective through December 31, 2024. Beginning January 1, 2025, the “JG” modifier would be deleted.

CMS notes hospitals currently using the “JG” modifier could choose to continue to use it in CY 2024 or choose to transition to the “TB” modifier during that year.