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MEDICARE TRANSMITTALS – RECURRING UPDATES

International Classification of Diseases 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2020 Update

• Article Release Date: February 21, 2020
• What You Need to Know: CR11655 informs providers about ICD-10 updates to specific NCDs. “Note: Coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria. Revisions to codes within an NCD are carefully and thoroughly reviewed and vetted by CMS and are not intended to change the original intent of the NCD. The exception to this is when coding revisions are released as official implementation of new or reconsidered NCD policy following a formal national coverage analysis…MACs will adjust any claims processed in error associated with CR 11491 that you bring to their attention.”
• MLN MM11655: https://www.cms.gov/files/document/mm11655.pdf

April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Change Request Release Date: March 3, 2020
• What You Need to Know: CR 11691 is a recurring update notification describing changes to and billion instructions for various payment policies implemented in the April 2020 OPPS update.
• CR 11691: https://www.cms.gov/files/document/r4544cp.pdf

April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1

• Article Release Date: March 6, 2020
• What You Need to Know: CR 11680 providers the I/OCE instructions and specifications for the I/OCE that is being updated April 1, 2020. The two new codes for COVID lab tests (U0001 and U0002) are included in this update.
• MLN MM11680: https://www.cms.gov/files/document/mm11680.pdf

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

• Change Request (CR) Release Date: March 6, 2020
• What You Need to Know: CR 11681 is a Recurring Update Notice (RUN) providing instructions for the quarterly update the clinical laboratory fee schedule with an effective date of April 1, 2020.
• CR 11681: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/document/r4541cp.pdf

April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: March 13, 2020
• What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implements in the April 2020 ASC payment system update.
• MLN MM11694: https://www.cms.gov/files/document/MM11694.pdf

 

OTHER MEDICARE TRANSMITTALS

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

• Provider Types Affected: Physicians, Providers and Suppliers
• Change Request (CR) Release Date: February 21, 2020
• What You Need to Know: CR 11638 updates RARC and CARC lists and instructs ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print Software.
• MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf

NCD 20.4 Implantable Cardiac Defibrillators (ICDs)

• Article Release Date: March 3, 2020
• Provider Types Affected: Physicians, Providers, and Suppliers
• What You Need to Know: This special edition article updated providers on Medicare coverage rules and policies for NCD20.4 and outlines the coding requirements (including heart failure codes) are not more restrictive than the NCD.
• MLN SE20006: https://www.cms.gov/files/document/se20006.pdf

Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare

• Article Release Date: March 3, 2020
• What You Need to Know: This special edition article reinforces existing Medicare policy allowing non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.
• MLN SE20009: https://www.cms.gov/files/document/se20009.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits

• Article release date: March 9, 2020
• What You Need to Know: CR11640 informs MACs about new HCPCS codes for 2020 that are subject to and excluded from CLIA edits.
• MLN MM11640: https://www.cms.gov/files/document/mm11640.pdf

The Supplemental Security Income (SSI)/Medicare Beneficiary data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term care Hospitals (LTCHs)

• Article Release Date: March 13, 2020
• What You Need to Know: Specific to hospitals, CR 11679 provides updates for determining Disproportionate Share (DSH) adjustment.
• MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf

 

REVISED MEDICARE TRANSMITTALS

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update

• Article Revised: February 27, 2020
• Change Request Revised: new Transmittal number R4540CP
• What You Need to Know: The MLN article was revised to reflect the revised change request date and change an MP RVU code in Table 2.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Proper Use of Modifier 59

• Special Edition MLN Article Revised March 2, 2020
• What You need to Know: This article was revised to include modifiers –X{EPSU}. All other information is unchanged.
• MLN SE1418: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf

New Medicare Beneficiary Identifier (MBI) Get It, Use It

• Special Edition MLN Article Revised March 19, 2020
• What You Need to Know: This article was revised to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool.
• MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

 

MEDICARE COVERAGE UPDATES

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Change Request: 11660
• What You Need to Know: The purpose of this Change Request (CR) is to inform MACs that effective June 21, 2029, CMS will continue to cover TAVR under Coverage with Evidence Devlopment (CED) when the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA approved indication for use with an approved device, in addition to the coverage criteria outlined in the NCD manual.
• CR 11660: https://www.cms.gov/files/document/r217ncd.pdf

 

 

MEDICARE PRESS RELEASES AND FACT SHEETS

February 20, 2020: Comprehensive Care for Joint Replacement Model Three Year Extension and Changed to Episode Definition and Pricing (CMS 5529 P)

CMS issued a proposed rule in the Federal Register proposing a three year extension, changes to the  definition of an episode, and changes in pricing in the Comprehensive Care for Joint Replacement (CJR) Model. This model began April 1, 2016 and has a current end date of December 31, 2020. Since this model began total hip and total knee procedures have been removed from the Medicare Inpatient Only Procedure List. Consequently, one proposal being made is to incorporate outpatient hip and knee replacements in the episode of care definition. Comments on the proposed rule must be received no later than 5 p.m. EST on April 24, 2020.

• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/comprehensive-care-joint-replacement-model-three-year-extension-and-changes-episode-definition-and
• Proposed Rule: https://www.federalregister.gov/documents/2020/02/24/2020-03434/medicare-program-comprehensive-care-for-joint-replacement-model-three-year-extension-and-changes-to
• CJR Model webpage on CMS Innovation Center: https://innovation.cms.gov/initiatives/CJR

CMS Press Release: CMS Administrator Seema Verma at the 2020 CMS Quality Conference

https://www.cms.gov/newsroom/press-releases/speech-remarks-cms-administrator-seema-verma-2020-cms-quality-conference

https://www.beckershospitalreview.com/patient-safety-outcomes/cms-revamps-quality-strategy-5-things-to-know.html?origin=QualityE&utm_source=QualityE&utm_medium=email&oly_enc_id=1461H5080234E6F

 

MEDICARE EDUCATIONAL RESOURCES

MLNconnects March 19, 2020 Newsletter: Provider Minute Video: The Importance of Proper Documentation

CMS has med this Provider Minute video available discussing how proper documentation affects items/services, claim payment and medical review by discussing the following:

• Top five documentation errors,
• How to submit documentation for a Comprehensive Error Rate Testing (CERT) review, and
• How your Medicare Administrative Contractor (MAC) can help.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-19-mlnc#_Toc35426083

 

OTHER MEDICARE UPDATES

February 19, 2020: Medicare Advantage Denial Notice

CMS has posted the following information to the CMS MA Denial Notices webpage:

“The Office of Management and Budget (OMB) has approved revisions to the Notice of Denial of Medical Coverage (or Payment), also known as the Integrated Denial Notice (IDN). The expiration date is different on this renewed notice. Plans should begin using the revised IDN as soon as possible, but no later than April 1, 2020. Both the previous and new versions of the notice are acceptable for use through March 31, 2020. Significant revisions made to the notice and instructions include:

• Addition of adjudication timeframes for Part B drugs.
• Removal of language regarding State Fair Hearing as first level of appeal.
• Removal of option to add state specific Medicaid appeal filing timeframe.
• New determination option if an item, service, Part B drug, or payment is partially approved.
• New language notifying enrollees they cannot request an expedited appeal for a request for payment.
• New language informing enrollees they may ask for a good cause extension and should include their reason for being late.
• Option to add information for submitting appeal via plan website.”

March 9, 2020: HHS Finalized Two Transformative Rules Giving Patients Unprecedented, Safe, Secure Access to Their Health Data

Two rules issued by the HHS Office of the National Coordinator for Health information Technology (ONC) and CMS implement interoperability and patient access provisions of the bipartisan 21st century Cures Act (Cures Act) and support the MyHealthEData initiative. 

“The CMS final rule established a new Condition of Participation (CoP) for all Medicare and Medicaid participating hospitals, requiring them to send electronic notifications to another health care facility or community provider or practitioner when a patient is admitted, discharge, or transferred.”  For More Information:

• ONC Cures Act Final Rule website: View the rule,
• CMS Interoperability and Patient Access Final Rule webpage: View the rule,
• CMS Interoperability and Patient Access Fact Sheet,
• Register for Medicare Learning Network call on April 7,
• See the full text of this excerpted CMS Press Release (issued March 9).

March 2020: New OIG Work Plan Item: Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-care Transfer Policies

The OIG indicated they will review Medicare hospital discharges that were paid a full DRG payment when the patient was transferred to a facility covered by the acute and post-acute transfer policies where Medicaid paid for the service. Under the acute- and post-acute transfer policies, these hospital inpatient stays should have been paid a reduced amount. Additionally, we will assess the transfer policies to determine if they are adequately preventing cost shifting across healthcare settings.

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000445.asp

Timeline to a New Code

The CDC announced the release of a new code specifically for reporting COVID-19 during the March 18th ICD-10-CM Coordination and Maintenance Committee Meeting. This code will be available for use on April 1st, 2020. Following is a timeline of events prompting the speed with which this code is being made available for use:

• January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
• January 31, 2020: Emergency meeting convened by WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC). A new ICD-10 emergency code was established by the WHO.
• 1 – 2019-nCoV acute respiratory disease
• February 11, 2020: During the January 31st meeting, the team noted “2019-nCoV” was a temporary name and likely to change. On February 11th the WHO announced the official name of the virus: COVID-19.
• March 11, 2020: The Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization (WHO).
• March 13, 2020: A National Emergency was declared in the United States concerning the COVID-19 Outbreak.
• March 18, 2020: The Coordination and Maintenance Committee Meeting met virtually. It was announced that the COVID-19 code effective date was changed from October 1, 2020 to April 1, 2020 due to the national health emergency. The code that will be effective is U07.1.

U07.1 Coding Instructions

• This code is classified to Chapter 22: Codes for Special Purposes.
• Coding Instructions:
• Use additional code to identify pneumonia or other manifestations
• Excludes 1:
• Coronavirus infection, unspecified (B34.2)
• Coronavirus as the cause of diseases classified to other chapters (B97.2-)
• Severe acute respiratory syndrome [SARS}, unspecified (J12.81)

You can read the entire CDC announcement at: https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-3-18-2020.pdf

March 13, 2020: AMA Announces New CPT Code to Report Novel Coronavirus Test

The CPT editorial panel expedited approval of a unique CPT code to report laboratory testing services that diagnose the presence of the novel coronavirus.

• CPT code and long descriptor: 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
• Note, the code is effective immediately for use for reporting of tests for the novel coronavirus.

Press Release: https://www.ama-assn.org/press-center/press-releases/new-cpt-code-announced-report-novel-coronavirus-test

Link to further guidance from the AMA regarding the CPT including a CPT Fact Sheet: https://www.ama-assn.org/practice-management/cpt/cpt-releases-new-coronavirus-covid-19-code-description-testing

Q:

When Medicare changes the status indicator for separately payable drugs, do we have to revise the related modifiers assigned to these drugs in the chargemaster (CDM) / pharmacy system?

A:

Yes. If your hospital purchased the drug through the 340B Program, you must bill the applicable modifier JG or TB for the drug to Medicare. This is specific to drugs / biologicals assigned status indicator G or K in Addendum B under the Outpatient Prospective Payment System (OPPS).

If the drug is assigned status indicator K, Medicare wants to reduce your reimbursement for the drug if it was purchased through 340B.  In that scenario, it is your responsibility to bill the drug to Medicare with modifier JG. If you purchase a status indicator K drug through the 340B program, but do not bill the drug with modifier JG, you will be overpaid.

Modifier TB should be billed for drugs assigned status indicator G which are purchased through the 340B program.  Even though modifier TB is for informational purposes, it is still required, just like modifier JG. This modifier does “not” trigger a reduced payment from Medicare.

If a drug /biological was “not” purchased through a 340B program, modifier JG / TB should not be billed.

This creates a challenge for CDM coordinators, because this type of CDM maintenance is absolutely essential to compliant Medicare billing of these items. You should expect some status indicator changes quarterly. We acknowledge some hospitals manage pharmacy modifiers in a pharmacy system separate from the CDM.

Take a look at the upcoming status indicator changes listed in the  April 2020 OPPS Update, excerpted below – effective April 1, 2020. Keep in mind, modifiers JG and TB must be date specific to match the status indicator assigned for respective dates of service on the outpatient Medicare claim.

New CY 2020 HCPCS Codes Effective April 1, 2020 for Certain Drugs, Biologicals, and Radiopharmaceuticals

Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals receiving pass-through status Effective April 1, 2020

HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals with Pass-Through Status Ending Effective March 31, 2020

For more information about billing 340B modifiers under the OPPS, refer to the CMS FAQ document published April 2018. 

Getting to Know the MACs

Welcome to the third edition of MMP’s MAC Talk article. Before jumping in to “The Local Scene” I wanted to provide general information about MACs in the form of questions and answers.

Question: What is a MAC?
Answer: A CMS contractor that processes Medicare Part A and Part B (A/B) benefit claims or Durable Medical Equipment (DME) claims for a designated jurisdiction. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare Fee-for-Service (FFS) program and the health care providers and suppliers enrolled in the FFS program.

Question: What types of claims does an A/B MAC process?
Answer: A/B MACs process claims for both institutional and non-institutional providers for a designated geographic jurisdiction. Currently, there are 12 A/B MACs that process about 95% of all FFS claims. Four of the twelve MACs also specialize in handling claims for home health and hospice providers.  Seven different companies hold the prime contracts (CGS, FCSO, NGS, Noridian, Novitas, Palmetto and WPS).

Question: What are the primary functions of the MACs?
Answer: MACs perform the following functions:

• Process Medicare FFS claims,
• Enroll providers in the Medicare FFS program,
• Respond to provider inquiries,
• Handle Redetermination requests (1st stage of the appeals process),
• Review medical records for selected claims,
• Perform provider reimbursement services,
• Review and audit institutional provider cost reports,
• Educate providers about Medicare FFS billing requirements,
• Establish Local Coverage Determinations (LCDs) and Articles,
• Support CMS demonstration projects (e.g., prior authorization, new payment models), and
• Coordinate with CMS and other FFS contractors.

 

March MAC Talk: The Local Scene

February 18, 2020 Palmetto GBA Article for No Orders for Inpatient Admission (5J503)

In this article, Palmetto GBA offers tips to preventing a denial for lack of an inpatient order. The first tip in the article is as follows:

• “Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.”

https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers"JJ%20Part%20A"Medical%20Review"Medical%20Review%20Denials"BLWHMM2865?open

 

February 26th, 2020: Palmetto GBA Posts FAQs from February 13th Part A Ask the Contractor Teleconference

The transcript includes a welcome and brief discussion about Medicare Comprehensive Error Rate Testing (CERT) Program. Specific questions ranged from interrupted stays to waiving a Medicare patient’s coinsurance, deductible and copays to asking if Medicare Advantage Plans adhere to local and national coverage determinations.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BM5SZ43042?opendocument

February 26, 2020: National Government Services (NGS) Posts Guidance for Amending Medical Records

NGS reminds providers that “occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” The post goes on to provide guidance on how to comply with amending a medical record as outlined in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.

https://tinyurl.com/vz8sahe

March 2nd, 2020: NGS Posts News Alert about QIO Improvement Initiatives

In this Alert, NGS encourages providers to reach out to your Quality Improvement Networks – Quality Improvement Organization (QIN-QIO) to see if what resources may be available “to assist you with your local healthcare priorities and needs.”

https://tinyurl.com/yx6zav5n

March 4th, 2020: Palmetto GBA Posts JJ and JM Part B Ask the Contractor Teleconference Q&As

Even though in general MMP focuses on Part A Services, there were a couple of interesting Q&A’s in this release, for example:

• Question: If we have questions regarding a national coverage determination, is there anyone to contact for additional information and/or a better understanding of the criteria that is required?
• Answer: As a Medicare contractor, Palmetto GBA interprets national coverage determinations (NCD) as outlined by CMS. Your first call should be to the Palmetto GBA provider contact center for general information. If you disagree with the NCD and would like to request CMS to consider making changes, you should send your request to NCDrequest@CMS.hhs.gov.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B"BMDJKB7554?opendocument

 

March 9th, 2020: WPS Posts Notice about Expiring ABN Form CMS-R-131

“The Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 expiration date is March 2020. CMS has not notified us of a new form. In addition, CMS has not instructed us to assess errors for the current form during medical review. The form is still acceptable until CMS notifies us otherwise, even after March 2020. We will publish more information when it becomes available.”

https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/form-cms-r-131/

March 9th, 2020: WPS Post Notice about Procedure Code 94762 – Are You Billing Correctly?

Procedure code 94762 represents a continuous overnight pulse oximetry service. WPS GHA recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. We encourage all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) – Evaluate Use.

https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/procedure-code-94762-are-you-billing-correctly/

March 10th, 2020: Noridian Posts Notice Regarding Improper Payment for IMRT

In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance. Use the following resources to bill correctly:

• IMRT Planning Services Editing  MLN Matters Article
• July 2016 Update of the Hospital Outpatient Prospective Payment System  MLN Matters Article
• Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services  OIG Report
• Medicare Claims Processing Manual, Chapter 4 , Section 200.3.1

Source: CMS MLN Connects dated September 19, 2019

https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/improper-payment-for-intensity-modulated-radiation-therapy-planning-services

MMP Note: Palmetto GBA JM recently added a Review of Outpatient Claims for CPT Codes 77301 and 77338 IMRT Planning and MLC Devices to their TPE Medical Review list. You can view the entire Medical Review list at: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers"JM%20Part%20A"Medical%20Review"General"9NNJBX6701?open.

March 10th, 2020: NGS Posts their March 2020 Provider Education: Social Determinants of Health

This three page document defines Social Determinants of Health (SDOH), discusses effort within the government to increase the understanding and impact of SDOH on healthcare and healthcare outcomes, and provides resources for Provider to help identify and address gaps in SDOHs for Medicare beneficiaries.

https://www.ngsmedicare.com/ngs/wcm/connect/ngsmedicare/905372ca-f30a-477e-8aa7-837625f11f82/2222_sd_mar2020_final_508.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_69MIG982N05UD0QGR5I7CS2000-905372ca-f30a-477e-8aa7-837625f11f82-n2s35TX

March 16th, 2020: WPS Posts CERT Denials for Laboratory Services

Claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted error findings for insufficient documentation for laboratory services. Documentation to support medical necessity, a valid physician order (or note of intent), and laboratory report(s) were often missing.

The following will help providers responding to CERT claim reviews. Documentation should include:

• The ordering physician or non-physician (physician assistant, nurse practitioner, or clinical nurse specialist) progress note that documents the medical necessity for the laboratory services.
• A signed and dated physician or non-physician order (a registered nurse (RN) cannot sign an order) or progress notes documenting intent.
• All laboratory reports to support the procedure code(s) billed. 

For more information, refer to the Medicare Learning Network (MLN) Fact Sheet, "Complying with Documentation Requirements for Laboratory Services."

“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”

• Source:   18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.

 

CMS Office of Minority Health January 2020 Data Highlight

The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.

Z codes Background

• Z codes first became available with the implementation of ICD-10-CM codes in 2015.
• Z codes in categories Z55-Z65 are related to SDOHs.
• Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
• Z codes apply to all health settings.

This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:

• Reducing reliance on clinicians to capture SDOH,
• Improving provider and medical code education, and
• Filling gaps in codes.

Study Findings

The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:

• Z-codes were present in approximately 1.4% of 33.7 million claims,
• Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
• Z590 Homelessness was the only Z code with higher utilization in males than females, and
• Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.

Data Highlight Conclusion: Lack of Awareness and Confusion

In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”

RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee

After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.

RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.

 

Moving Forward

Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.

Following are a few available resources about SDOH available to provide education:

• CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
• American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
• American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
• April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
• This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
• Coding Clinic advice is available in the following quarters:
• First Quarter 2018: Page 18,
• Fourth Quarter 2019: Page 66, and
• Fourth Quarter 2019: Page 67. 

Additional Code for Coronavirus Lab Test

Included in MMP’s February Coding Corner was news about CMS developing a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2.

In a March 5th Press Release, CMS announced a second HCPCS code has been developed “that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children’s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well.”

• February 2020 HCPCS code U0001 is to be used specifically for CDC testing laboratories to test patients for SARS-CoV-2.
• March 2020 HCPCS U0002 allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).

The Press Release also notes the Food and Drug Administration issued a new, streamlined policy on February 29th for certain laboratories to develop their own validated COVID-19 diagnostics. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare and health insurers.

The Medicare claims processing systems will be able to accept these codes starting April 1, 2020 for dates of service on or after February 4, 2020.

Medicare Fact Sheet: Inpatient Hospital Quarantines

As mentioned above, included in the press release about a second HCPCS code were fact sheets. Following is an excerpt from the Medicare Fact Sheet specifically about Inpatient Hospital Quarantines:

“There may be times when beneficiaries with the virus need to be quarantined in a hospital private room to avoid infecting other individuals. These patients may not meet the need for acute inpatient care any longer but may remain in the hospital for public health reasons. Hospitals having both private and semiprivate accommodations may not charge the patient a differential for a private room if the private room is medically necessary. Patients who would have been otherwise discharged from the hospital after an inpatient stay but are instead remaining in the hospital under quarantine would not have to pay an additional deductible for quarantine in a hospital.

If a Medicare beneficiary is a hospital inpatient for medically necessary care, Medicare will pay hospitals the diagnosis-related group (DRG) rate and any cost outliers for the entire stay, including any the quarantine time when the patient does not meet the need for acute inpatient care, until the Medicare patient is discharged. The DRG rate (and cost outliers as applicable) includes the payments for when a patient needs to be isolated or quarantined in a private room.”

https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests

Cigna Adopts Sepsis-3

Cigna announced in their First Quarter 2020 Cigna Network News that “As part of our effort to promote the accurate diagnosis and treatment of sepsis, and use the appropriate billing and coding, we have adopted the Third International Consensus Definitions or Sepsis and Septic Shock (Sepsis-3), effective immediately.” https://www.cigna.com/sites/email/2020/937483-2020-q1-network-news.pdf

What this means to you

“If after reviewing a patient’s medical record and the Sepsis-3 criteria a Cigna Medical Director determines that sepsis was not present, a diagnosis-related group (DRG) claim assignment may be adjusted because sepsis treatment services should not have been included as part of the claim. In these cases, covered claims will be processed with the appropriate revised DRG supported in the medical record.”

March is National Professional Social Work Month. This year’s the National Association of Social Workers (NASW) is celebrating its 65th anniversary with the theme “Social Workers: Generations Strong.” The NASW notes that “as we enter a new decade it is important to look back and honor the powerful, positive impact the social work profession has had on our society for generations.”

A few of the highlights available on NASW’s website for your 2020 Social Work Campaign include:

• A Social Work Month 2020 video highlighting who social workers are;
• Several different Infographics that can be used to educate people about the different types of Social Work; and
• A document highlighting the theme and rationale for Social Work Month.

I want to acknowledge and thank all of the wonderful social workers that I have worked with or who have been an invaluable resource in my own life when family members have been hospitalized.

The transition of care from a hospital to a post-acute setting can be a very stressful time. As MMP has done in years past, we are providing an updated list of resources to assist with discharge planning.

• Resources for You:
• Medicare Costs at a Glance for 2020
• Medicare and Medicaid Basics MLN Booklet
• Long-Term Care Hospital Prospective Payment System MLN Booklet
• Inpatient Rehabilitation Facility Prospective Payment System MLN Booklet
• Skilled Nursing Facility Prospective Payment Fact Sheet Booklet
• Swing Bed Services Fact Sheet
• The Medicare Home Health Benefit
• Home Health Prospective Payment System
• Hospice Payment System Fact Sheet
• Medicare Ambulance Transports
• Home Oxygen Therapy
• Power Mobility Devices MLN Booklet

• Resources for your patients
• Taking Care of Myself: A Guide for When I Leave the Hospital
• Discharge Planning Protects You
• Your Discharge Planning Checklist

From all of us at MMP, Happy Social Work Month!

Background

MMP first wrote about Palmetto GBA publishing articles about various DRGs in June of 2019. The first article released was about DRG 460: Spinal Fusion. Since then, DRG 460 has been added to the Jurisdiction J list of Active Medical Reviews under the Targeted Probe and Educate (TPE) Program.

​DRG specific articles can be found under General Information on the CERT Topics webpage on either JJ Part A CERT General Information or JM Part A CERT General Information. Information found in past and the most recent articles ranges from information about documentation requirements to information on assignment of principal and secondary diagnoses to coverage requirements to consideration of an alternate DRG.

On February 23, 2020, Palmetto GBA published an article about DRG 552 (Medical Back Problems with MCC) and DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC respectively).

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‍DRG 552: Medical Back Problems without MCC

In this article, Palmetto GBA focuses on two common denial reasons associated with DRG 552 as well as claims processing tips and suggestions to prevent denials.

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Common Denial Reasons

• Requested Records Not Submitted: Reminder, when an Additional Documentation Request (ADR) is generated, the provider has 45 days to respond with medical records.
• Need for Service/item Not Medically and Reasonably Necessary

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Tips to Prevent Not Medically and Reasonably Necessary Denials

All tips reiterate the need to include documentation. Following are two tips from the article:

• Documentation supporting the need for inpatient care,
• Documentation provided to Palmetto GBA should include all clinical information available for the dates of services being billed.

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DRGs 981, 982, 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC

Annually, CMS reviews procedures assigned to MS-DRGs 981 through 982 based on volume by procedure to see if it would be more appropriate to move procedures codes into one of the surgical MS-DRGs for the Major Diagnostic Category (MDC) into which the principal diagnosis falls. This article serves as a reminder of changes in the FY 2020 IPPS Final Rule. Following is a table of the ICD-10-PCS codes that would no longer group to DRGs 981, 982 and 983:

‍Potential Financial Impact

I was curious to see what the potential impact would be from these changes and turned to our sister company, RealTime Medicare Data (RTMD) to crunch the numbers. The following findings are based off paid Medicare fee-for-service claims in FY 2019 in Alabama.

All DRG 981, 982 and 983 Claims

• Volume: 1,126 claims
• Average LOS: 10.556
• National Average Payment Total: $22,488,788.40

DRGs with a Procedure No Longer Grouping to DRGs 981, 982, and 983

• Volume: 105 claims
• Average LOS: 10.99 days
• National Average Payment Total when Grouped to DRGs 981, 982, and 983: $2,276,263.87
• National Average Payment Total when Grouped into MDC based on Principal Diagnosis: $1,993,041.13
• Average Decrease per claim: -$2,697.36.

Top ICD-10-PCS Procedures Performed Now Grouping within an MDC

• 31 of 105 Claims: 0WPG03Z - Removal of Infusion Device from Peritoneal Cavity, Open Approach
• 24 of 105 Claims: 0QB10ZZ - Excision of Sacrum, Open Approach
• 16 of 105 Claims: 0WHG03Z - Insertion of Infusion Device into Peritoneal Cavity, Percutaneous Endoscopic Approach

In general, payment was lower when a procedure sequenced to an MDC. However, there were a few instances where the payment was higher. Either way, this is one more way that hospital reimbursement changed in FY 2020.

Last week in our Coding Corner article, we shared guidance regarding a new code for a Coronavirus Lab Test.  On February 21, 2020, announcements about a new Emergency ICD-10-CM Code for the 2019 Novel Coronavirus and Coding Advice were posted on the CDC’s ICD-10-CM webpage. Both documents have an effective date of February 20, 2020.

Announcement: Developing an Emergency Code

Following are highlights from the announcement:

• January 30, 2020: The World Health Organization (WHO) declared the 2019 Novel Coronavirus (2019-nCoV) disease outbreak a public health emergency of international concern.
• January 31, 2020: An emergency meeting of the WHO Family International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) met to create a specific code for this new coronavirus.
• Emergency Code (U07.1, 2019-nCoV acute respiratory disease) was established.
• February 11, 2020: COVID-19, the official name of the virus was announced.
• March 2020 ICD-10 Coordination and Maintenance Committee Meeting: A new ICD-10-CM diagnosis code will be implemented for reporting, effective with the next update, October 1, 2020. Full addenda information regarding the new code and the final title is to be presented at this March meeting.
• Interim coding guidance can be found at: https://www.cdc.gov/nchs/icd/icd10cm.htm

COVID-19 ICD-10-CM Official Coding Guideline Supplement

Clinical Picture

A patient with a confirmed diagnosis of COVID-19 can fall at both ends of the spectrum of little to no symptoms to being severely ill and even dying. Symptoms may appear from 2 to 14 days after exposure. Confirmed COVID-19 infections can include the following symptoms:

• Fever,
• Cough, and
• Shortness of Breath.

General Guidance

The CDC notes this information is to be used in conjunction with the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019) and will be updated as new clinical information becomes available. General guidance is provided for the following situations:

Pneumonia confirmed as due to COVID-19

• Assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of disease classified elsewhere

Acute Bronchitis confirmed as due to COVID-19

• Assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Bronchitis not otherwise specified (NOS) due to COVID-19

• Assign code J40 Bronchitis, not specified as acute or chronic, along with code B97.29, Other coronavirus as the cause of disease classified elsewhere

Lower Respiratory Infection

• If COVID-19 is documented as being associated with a Lower Respiratory Infection, not otherwise specified (NOS), or Acute Respiratory Infection, NOS
• Assign code J22, Unspecified acute lower respiratory infection, with code B97.29, Other Coronavirus as the cause of disease classified elsewhere.

• If COVID-19 is documented as being associated with a Respiratory Infection, NOS, it would be appropriate to:
• Assign J98.8, Other specified respiratory disorders, with cod B97.29, Other coronavirus as the cause of diseases classified elsewhere.

ARDS

Acute Respiratory Distress Syndrome (ARDS) may develop with the COVID-19 infection. If ARDS is due to COVID-19:

• Assign codes J80, Acute Respiratory Distress Syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

The Coding Guidance also includes information regarding how to code exposure to COVID-19, signs and symptoms codes and what to do if a provide documents “suspected”, “possible” or “probable” COVID-19.