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Sometimes providers do not pay as much attention to the Medicare documentation requirements for diagnostic tests as they do for therapeutic services. There are several reasons for this. Diagnostic tests generally do not pay as much as therapeutic services, they are less likely to have a coverage policy, the documentation required is not as extensive as the documentation requirements for therapeutic services, and they are less likely to be reviewed by Medicare contractors. Therefore, the financial risk, even if some claims are reviewed, is not that significant for an individual provider. For Medicare however, due to the large volumes of diagnostic services, overpayments could result in significant costs.

The Medicare Comprehensive Error Rate Testing (CERT) program contractor audits random claims to determine if the Medicare Administrative Contractors (MACs) are paying claims appropriately. This means the CERT contractor looks at all types of claims, including those for diagnostic tests. WPS, the MAC for Jurisdictions 5 and 8, recently published an article containing documentation reminders related to CERT denials of diagnostic tests. Those documentation reminders are:

• “Only the treating physician, nurse practitioner, clinical nurse specialist or physician assistant can sign and date an order.
• The order must specify the exact test(s) ordered. Stating “x-ray” is not sufficient.
• The physician or non-physician must document the medical necessity in a signed and dated progress note.
• Medicare will not consider unsigned and/or undated orders; this includes laboratory requisition forms.
• Providers cannot use a signature attestation statement used in place of an unsigned order.”

These are the basics of which every provider should already be aware. But the article states the CERT contractor has “noted significant error findings for diagnostic services.” So, where do providers go wrong? First, nurses in a physician’s office cannot sign an order. Physicians and non-physician practitioners may delegate the writing of orders to others in the office, but they have to actually be the ones to validate and sign the orders. Remember that Medicare contractors do not accept late signatures or signature attestations for orders. Unsigned orders are “ignored” by Medicare reviewers – an unsigned order is the same as a non-existent order. Orders and progress notes describing the orders must be specific – for example, a progress note that states “labs ordered” or “x-rays ordered” is not sufficient.

The other big issue for diagnostic tests besides signed and dated orders is documentation supporting the medical necessity of the test. Years ago, if you had a signed and dated order that included a diagnosis or a diagnosis code, that was sufficient for medical necessity. These days, most Medicare reviewers want to also see the documentation from the physician, such as an office progress note, describing the medical necessity for the test. And remember any physician progress notes submitted to a Medicare contractor also have to be signed and dated by the practitioner. The good thing about CERT reviews is that the CERT contractor generally communicates the need for any additional documentation needed and gives the provider several chances to submit that before denying the claim.

Some other diagnostic services are also being targeted by other Medicare reviewers and entities. For example, Novitas (JH/JL MAC) is looking at cardiovascular nuclear medicine testing, sleep testing is part of the OIG Work Plan, and the Recovery Auditors (RACs) have complex reviews involving the medical necessity/coding of chest x-rays and the medical necessity of transthoracic echocardiography.

One new complex issue recently approved by all of the Recovery Auditors is for the diagnostic test Computed Tomography (CT) Coronary Angiography. The issue details reiterate the documentation reminders discussed above -

“All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage.”

How can hospitals ensure compliance with the signature and medical necessity requirements of diagnostic tests without undue effort? Train hospital personnel who first encounter orders for diagnostic testing to reject or obtain corrected orders when order requirements are not met – unsigned orders, orders not dated, orders lacking diagnoses, non-specific orders, etc. This could be the Scheduling, Registration, or Ancillary departments, for example. Hopefully, the practice of only accepting appropriate orders will encourage your physicians and practitioners to get it right the first time. On the back end, if a Medicare reviewer requests claims for diagnostic tests ensure all the required documentation is sent to the reviewer. The request for records should detail the specific medical record elements the reviewer needs. If required, contact the ordering physician’s office to obtain office progress notes for submission to the Medicare contractor.

With a little effort, denials of diagnostic tests can be eliminated or at least, minimized. Though not always a large financial impact, every penny helps and proactive processes also reduce the costs of additional time and effort.

There are no MAC Medical Review Activity updates for this month.

Another good resource for Providers is the CMS YouTube presentation Provider Minute: The Importance of Proper Documentation at https://www.youtube.com/watch?v=10pmw4czf08.

Way back in January 2017, CMS published two transmittals (MM9613 and MM9907) that described the requirement for hospitals’ service addresses reported on claims to be an exact match to the facility’s practice locations reported on their CMS 855A enrollment form. The correct reporting of service addresses to Medicare is required to allow accurate payments based on service location. Per the Background information in MLN Matters Article SE19007,

“Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare Physician Fee Schedule (MPFS) and OPPS payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.”

Although the requirements for correct service address reporting became effective back in 2017, Medicare did not put systematic validation edits in place at that time. With the release of MLN Matters Article SE18023 in October 2018, edits were scheduled to go into place on April 1, 2019. CMS had already conducted one round of “behind-the-scenes” testing and concluded that “many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments.” Most of the discrepancies had to do with spelling variations (Road vs Rd, for example). After a second round of testing in November 2018, CMS decided to:

• delay implementation until July 2019,
• provide further guidance to hospitals,
• make the practice location address screen available to providers in DDE beginning April 2019, and
• conduct additional round(s) of testing “to ensure that we have a smooth implementation of the edits.”

This resulted in the March 2019 release of SE19007 referenced above with link provided. For more details on the reporting requirements of service locations, read SE19007 and see this prior Wednesday@One article. 

Hospitals must finally be paying attention to the requirement because a recent updated version of SE19007 “discovered no major issues during round 3 testing” conducted in June 2019. However, CMS is still being cautious so in response to stake-holder comments and to further evaluate the results of round 3 testing, they are again delaying the claim edits, this time until October 1, 2019.

Unless there are more delays, at that time, CMS will direct the Medicare Administrative Contractors (MACs) to permanently turn on the edits. Claims with service location addresses that do not exactly match the address in PECOS will Return-to-Provider (RTP). Per the article, “Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing practice location address will still need to submit a new 855A enrollment application in PECOS.”

In the final sentence of the article, CMS states they think 2 ½ years has been ample time for providers to prepare for these edits and get their systems in order. I have to agree with CMS on this one – 2 ½ years to get an address correct is plenty of time.

Q:

In ICD-9-CM, hemorrhagic was listed as one of the modifiers for pneumonia so it couldn’t be coded separately; however, it has been removed as a modifier for ICD-10-CM.  Can we now code hemoptysis in addition to a diagnosis of pneumonia?

A:

Yes.  Since hemorrhagic is no longer a non-essential modifier for pneumonia, coders can assign an additional code for it.  Even though hemoptysis is a sign and/or symptom, it may be reported in addition to a code for pneumonia, because it is not routinely associated with the diagnosis.

 

References:

Coding Clinic, Fourth Quarter 2013: Page 118

Transcatheter Aortic Valve Replacement (TAVR) is for the treatment of symptomatic aortic valve stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. In 2012, when CMS first published a National Coverage Determination (NCD) for TAVR, it was considered a new technology. Under that current NCD (NCD 20.32), TAVR is covered under Coverage with Evidence Development (CED) according to certain criteria detailed in the NCD. Coverage under CED means that the service is only covered in the context of a clinical trial (such as a national registry or a clinical study). This allows limited coverage for Medicare beneficiaries in a controlled environment while determining the efficacy, risks, and outcomes of the procedure.  Once a new technology or procedure is proven to be safe and effective, CMS may remove the CED requirement and cover the procedure outright within set criteria.

TAVR is not there yet. In a recently released (June 21, 2019) new TAVR Coverage Decision Memo, the requirement for Coverage under Evidence Development remains.

1. TAVR is covered according to CMS criteria when the procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system's FDA approved indication and the heart team and hospital are participating in a prospective, national, audited registry.
2. TAVR is covered for uses that are not expressly listed as an FDA-approved indication when performed within a clinical study that fulfills criteria set forth in the decision memo.

Other requirements that did not change from the current NCD to the new Decision Memo include:

• The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals;
• The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR; and
• TAVR must be furnished in a hospital with the appropriate infrastructure.

What did change with the Final Decision Memo and why? First the Why - TAVR now has 7 years of study since the original 2012 NCD and the incidence of and experience with performing the procedure has greatly increased. When the Proposed Decision Memo was released in March of this year, my fellow writer for this newsletter, Beth Cobb, included a table in her article about the memo that looked at the volumes of hospital services coding to MS-DRGs 266 and 267. These DRGs include TAVR and other valve replacements. From 2015 though 2018, the volumes of these DRGs increased around 160% in Alabama and approximately 80-85% in Tennessee and Georgia, respectively.

The major changes in the Final Decision Memo include a change in the pre-procedure patient evaluation requirements and changes in the volumes of services required for the hospital and the heart team to meet criteria for performing the TAVR procedure.

The current TAVR NCD required face-to-face evaluation of the patient’s suitability for TAVR surgery by two cardiac surgeons. The new Decision Memo changes the two cardiac surgeons to a cardiac surgeon and an interventional cardiologist. This makes more sense as these are the two physicians that jointly participate in the intra-operative technical aspects of TAVR. This requirement is addressed in the composition of the heart team as quoted here from the Final Decision Memo:

1. “The heart team includes the following:
2. Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
3. independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
4. documented and made available to the other heart team members the rationale for their clinical judgment.
5. Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.”

Both the current NCD and the new Final Decision Memo require certain volumes of procedures for the hospital and the heart team based on whether they have previous TAVR experience or not. Here is a brief summary of the new and old requirements, but be sure to read the new Decision Memo for full details.

Hospitals – no previous TAVR experience

Current NCD (Old requirements)

1. ≥ 50 total AVRs in the previous year prior to TAVR, including ≥ 10 high-risk patients, and;
2. ≥ 2 physicians with cardiac surgery privileges, and;
3. ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.

New Decision Memo (New Requirements)

1. ≥ 50 open heart surgeries in the previous year prior to TAVR program initiation, and;
2. ≥ 20 aortic valve related procedures in the 2 years prior to TAVR program initiation, and;
3. ≥ 2 physicians with cardiac surgery privileges, and;
4. ≥ 1 physician with interventional cardiology privileges, and;
5. ≥ 300 percutaneous coronary interventions (PCIs) per year.

Heart Teams – no previous TAVR experience

Current NCD (Old requirements)

1. Cardiovascular surgeon with:
2. ≥ 100 career AVRs including 10 high-risk patients; or,
3. ≥ 25 AVRs in one year; or,
4. ≥ 50 AVRs in 2 years; and which include at least 20 AVRs in the last year prior to TAVR initiation; and,
5. Interventional cardiologist with:
6. Professional experience with 100 structural heart disease procedures lifetime; or,
7. 30 left-sided structural procedures per year of which 60% should be balloon aortic valvuloplasty (BAV). Atrial septal defect and patent foramen ovale closure are not considered left-sided procedures; and,
8. Additional members of the heart team such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social workers; and,
9. Device-specific training as required by the manufacturer.

New Decision Memo (New Requirements)

1. Cardiovascular surgeon with:
2. ≥ 100 career open heart surgeries of which ≥ 25 are aortic valve related; and,
3. Interventional cardiologist with:
4. Professional experience of ≥ 100 career structural heart disease procedures; or, ≥ 30 left-sided structural procedures per year; and,
5. Device-specific training as required by the manufacturer.

Hospital with previous TAVR experience

Current NCD (Old requirements)

1. ≥ 20 AVRs per year or ≥ 40 AVRs every 2 years; and,
2. ≥ 2 physicians with cardiac surgery privileges; and,
3. ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.
4. Heart team - cardiovascular surgeon and an interventional cardiologist whose combined experience maintains the following:

1. ≥ 20 TAVR procedures in the prior year, or,
2. ≥ 40 TAVR procedures in the prior 2 years.

New Decision Memo (New Requirements)

1. ≥ 50 AVRs (TAVR or SAVR) per year including ≥ 20 TAVR procedures in the prior year; or,
2. ≥ 100 AVRs (TAVR or SAVR) every 2 years, including ≥ 40 TAVR procedures in the prior 2 years; and,
3. ≥ 2 physicians with cardiac surgery privileges; and,
4. ≥ 1 physician with interventional cardiology privileges, and
5. ≥300 percutaneous coronary interventions (PCIs) per year.

What does all of this mean for hospitals? Here is a checklist for hospitals that perform the TAVR procedure:

• The patient must have symptomatic aortic valve stenosis;
• The patient is under the care of a heart team and the heart team's interventional cardiologist(s) and cardiac surgeon(s) jointly participate in the intra-operative technical aspects of TAVR;
• The hospital has the appropriate infrastructure for the procedure;
• Your medical record contains documentation of the face-to-face patient examinations by a cardiac surgeon and an interventional cardiologist (experienced in the care and treatment of aortic stenosis) evaluating the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
• Assess your hospital and heart team volumes to be sure you meet the requirements for performing the procedure under the new Decision Memo; and
• Read the new Decision Memo carefully and make sure you are following all of Medicare’s requirements.

As always with Decision Memos, the requirements are not yet effective until the NCD is updated and implemented. However, NCD revisions generally revert to the effective date of the Decision Memo, which is in this case June 21, 2019. This means hospitals need to know the new requirements now and be preparing now to meet those new requirements.

My first thought when I hear the word “smorgasbord,” in keeping with its primary definition, is a large well-stocked buffet meal. Can’t you just see and smell the seafood, soups, salad bars, meats, vegetables, side dishes and of course, desserts? It is hard to know where to begin and when to stop. The word “smorgasbord” has also come to mean any extensive array or variety. Recently, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published a smorgasbord of articles about various DRGs. These 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.

As a reminder, CERT, which stands for Comprehensive Error Rate Testing (program), was established by CMS to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. CERT contractors select random claims out of the total claims’ submissions for a contractor for review. This random review of claims differs from that of other Medicare review entities who review selected topics based on risk and data analysis of aberrant utilization and/or billing patterns. A random review results in lower error rates since high-risk areas are not targeted, but it is also able to identify a broader array of issues.

CERT findings are used by other Medicare contractors, especially the MACs, to select topics for targeted reviews. According to Palmetto’s CERT webpage, “The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for our Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).” This means the CERT is sort of a report card on the MACs and in order to make a better “grade” the MACs educate providers based on the errors identified by the CERT. This can be accomplished through targeted reviews as mentioned above or through educational articles such as those that are the topic of this article.

The Palmetto articles offer a variety of information from documentation requirements to information on assignment of principal and secondary diagnosis to coverage requirements to consideration of an alternate DRG. Below is a listing of the DRGs featured in a Palmetto article so far, at the time of the writing of this article. It is possible Palmetto may be adding other articles, so check the links above to watch for more articles.

DRG 266 - Endovascular Cardiac Valve Replacement with MCC

• Addresses Transcatheter Aortic Valve Replacement (TAVR) and Tricuspid Valve Replacement
• Provides requirements for and a listing of ICD-10-PCS procedure codes
• “The correct procedure code must depict: Initial placement, Replacement, Removal, or Adjustment”
• TPE review topic for Jurisdiction N MAC, First Coast.

DRG 460 – Spinal Fusion

• Provides documentation requirements and strategies to support payment for spinal fusion-related hospital care, to reduce audit errors, and to substantiate the medical necessity of the procedure for a particular patient
• “The most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: “Failed outpatient therapy, admit for spinal fusion” are simply not sufficient evidence of medical necessity for the admission or the surgery.”
• Palmetto recently released a new LCD for Spinal Fusion services.
• TPE review topic for CGS, J15; new 2019 topic for Supplemental Medical Review Contractor (SMRC); and PEPPER target.

DRG 193, 194, and 195 - Simple Pneumonia and Pleurisy

• Addresses appropriate assignment of the principal and secondary diagnoses
• “Abnormal billing practices are seen when the principle and secondary diagnoses are improperly assigned, which can result in overpayments. The most common areas were related to sequencing of the principal diagnosis and improper coding of secondary diagnosis. Secondary diagnoses errors are related to selecting the improper code based on physician documentation or the addition of a secondary diagnosis that was not documented within the medical record.”
• DRGs 193 and 194 are PEPPER targets.

DRG 313 – Chest Pain

• Includes a listing of the principal diagnoses, a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• “The Principal Diagnoses are:
• R072 Precordial pain
• R0782 Intercostal pain
• R0789 Other chest pain
• R079 Chest pain, unspecified”
• Palmetto has an LCD that addresses Chest Pain

DRG 884 – Organic Disturbances and Mental Retardation and DRG 885 - Psychoses

• Provides information on coverage/benefits and documentation/billing requirements including the most common errors and reasons for denials
• The most common CERT errors are insufficient documentation and medically unnecessary service or treatment
• DRG 885 is currently a topic of review for both Palmetto JJ and JM Targeted Probe and Educate (TPE) program

DRG 092: Other Disorders of Nervous System with Complication or Comorbidity (CC) 

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 493 – Lower Extremity and Humerus Procedures except Hip, Foot, Femur w/CC)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also addresses medical record documentation requirements such as H&P, evidence of prior conservation treatment, outpatient records supporting medical necessity of procedure, imaging reports and operative reports.

DRG 682 - Renal Failure with Major Complication or Comorbidity (MCC)

• Contains a listing of the documentation required to support the principal and secondary diagnoses.
• This includes signs and symptoms, elevated urine protein, documented treatment, potential underlying cause, and specificity of whether acute or chronic failure
• Palmetto recently added this DRG as a TPE review topic for both JJ and JM

DRG 057 – Degenerative Nervous System Disorders W/O MCC

• Describes situations that can cause a neuropathic condition
• “The most common medical condition to cause peripheral neuropathy is diabetes mellitus. … Other medical conditions, such as HIV, kidney disorders, hormonal imbalances and cancers may also damage nerve cells. Heredity can play a role, as can traumatic situations such as a crush injury or fractured bone, which can result in compression, stretching, or severing of the nerve cell, leading to a neuropathic condition.”
• Also includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 227 – Cardiac Defibrillator Implant W/O Cardiac Catheterization w/o MCC

• Reviews the covered indications for implantation of a cardiac defibrillator
• “Medicare defines the requirements for coverage of an implantable cardioverter-defibrillator (ICD) insertion in National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators.”
• All MACs have a coverage article that addresses “Implantable Automatic Defibrillators – Coding and Billing” which can be found on the Medicare Coverage Database or your MAC’s website.

DRG 518 (Back and Neck Procedures except Spinal Fusion w/ Major Complications or Comorbidity (MCC) or Disc Device or Neurostimulator)

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.

DRG 312 – Syncope and Collapse

• Addresses the causes and clinical considerations of syncope, process and approach of key components, and principal diagnosis.
• Clinical considerations include other DRGs that might be more appropriate if the cause and underlying conditions can be determined.
• Consideration of appropriate patient status - “People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present.”
• PEPPER target

DRG 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis

DRG 556 (Signs and Symptoms of Musculoskeletal System and Connective Tissue without CC/MCC

• Includes a link to the MS-DRG Definition Manual, and the FY 2019 Final Rule and Correction Notice Table 5 – List of MS-DRGs, Relative Weighting Factors and Geometric & Arithmetic Mean Length of Stay.
• Also includes top ICD diagnosis codes, top ICD procedure code, and Charge Capture Analysis
• “Do not use this DRG if the signs and symptoms are attributable to a specific condition:
• DRG 542 — Fatigue, stress or pathological fracture, initial encounter
• DRG 557 — Tendonitis, Myositis and Bursitis with MCC”

A smorgasbord indeed – lots to choose from and lots to digest. Happy reading!

CMS posted the FY 2020 ICD-10-PCS procedure codes updates on their website on May 31, 2019. At that time downloads posted on the 2020 ICD-10 PCS webpage included the following:

• 2020 ICD-10-PCS Code Tables and Index [ZIP, 8MB]
• 2020 ICD-10-PCS Codes File [ZIP, 605KB]
• 2020 ICD-10-PCS Order File (Long and Abbreviated Titles) [ZIP, 1MB]
• 2020 ICD-10-PCS Addendum [ZIP, 921KB]
• 2020 ICD-10-PCS Conversion Table [ZIP, 1MB]

This past Friday CMS added two new downloads:

• 2020 Official ICD-10-PCS Coding Guidelines (Updated 6/13/19) [PDF, 180KB]
• 2020 Version Update Summary [PDF, 124KB]

ICD-10-CM Diagnosis Codes

CMS indicated in their June 6, 2019 edition of MLNconnects that the ICD-10-CM diagnosis codes would be posted in June. True to their word, the 2020 ICD-10-CM code downloads were posted on their website on June 21, 2019:

• 2020 Code Descriptions in Tabular Order [ZIP, 2MB]
• 2020 Code Tables and Index [ZIP, 20MB]
• 2020 Addendum [ZIP, 664KB]

MMP will continue to watch and report to our readers when the ICD-10-CM Coding Guidelines are released.

MEDICARE TRANSMITTALS – RECURRING UPDATES

July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11298.pdf

July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Describes changes to and billing instructions for various payment policies implemented in the July 2019 OPPS update.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11318.pdf

 

OTHER MEDICARE TRANSMITTALS

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment

Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and adds information on E&M code that may be billed with superficial radiation treatment.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11273.pdf

New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs

Adds Appendix X to the SOM to outline the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R189SOMA.pdf

Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters

Every demand letter, regardless of the cause of the overpayment or the status of the provider, shall meet certain requirements as to form and content.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R316FM.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions

Updated reporting instructions for CAR T-Cell Therapy.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19009.pdf

 

MEDICARE COVERAGE UPDATES

Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R)

The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=293

 

MEDICARE PRESS RELEASES

CMS Seeks Public Input on Patients over Paperwork Initiative to Further Reduce Administrative, Regulatory Burden to Lower Healthcare Costs

https://www.cms.gov/newsroom/press-releases/cms-seeks-public-input-patients-over-paperwork-initiative-further-reduce-administrative-regulatory

 

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements
• Bill Correctly for Device Replacement Procedures

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf

OTHER MEDICARE UPDATES

April-June 2019 Quarterly Provider Updates

CMS publishes this Update to inform the public about the following:

• Regulations and major policies completed or cancelled.
• New/Revised manual instructions

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html

Kepro BFCC-QIO FAQs for Healthcare Providers

Frequently asked questions (FAQs) related to KEPRO’s services.

https://www.keproqio.com/media/1279/bfccqiofaq_508.pdf

Remember when you were young and there were some positives in having a broken bone. You got to wear a flashy cast in the color of your choice and all your friends and family signed your cast. Another positive was that broken bones generally heal quickly and effectively in the young. Recovering from broken bones when you are older is harder and you could have lasting effects such as ongoing pain, especially if you have osteoporosis. According to the Centers for Disease Control (CDC) website, osteoporosis “affects about 25% (1 in 4) of women aged 65 and over and about 5% (1 in 20) of men aged 65 and over. Many people with osteoporosis do not know they have it until they break a bone. Screening is important to find these people before this happens, so they can take steps to decrease the effects of osteoporosis.” The website also contains steps you can take to improve your bone health and strengthen weak bones. The good news for older Americans is that Medicare covers bone mass measurements to screen for osteoporosis as one of their preventive services. This means the beneficiary co-pay and deductible are waived so Medicare bears all the cost of these screenings.

The coverage guidelines for bone mass measurements (BMM) can be found in Chapter 15 of the Medicare Benefits Policy Manual, section 80.5. Medicare pays for a screening BMM once every 2 years with a few exceptions for more frequent testing. Section 80.5.6 of the above referenced manual, states that Medicare covers the screening for the following:

1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis, based on her medical history and other findings.

NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an “adequate” dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.
4. An individual with primary hyperparathyroidism.
5. An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

For healthcare providers, it is helpful to have a current list of the covered ICD-10 diagnosis codes. The BMM coverage is under National Coverage Determination (NCD) 150.3. CMS makes frequent updates to the NCD diagnosis codes as a result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Providers should watch for these periodic updates through transmittals or you can find them listed by NCD number at this website –

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html

Notice there were revisions to the NCD 150.3 as late as May 2019. You will need to open the transmittal and then locate the link within the transmittal to access the latest updates. There will be a spreadsheet for each updated NCD that includes the revisions and a complete list of covered codes.

Another thing to bear in mind about BMMs is the different CPT and diagnosis codes required for screening versus monitoring tests. From section 140.1 of the Medicare Claims Processing Manual, Chapter 13, contractors will pay claims for screening tests that contain CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or G0130 when reported with an appropriate diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.

Dual-energy x-ray absorptiometry (axial) tests are covered when used to monitor FDA-approved osteoporosis drug therapy subject to the 2-year frequency standards. Contractors will pay claims for monitoring tests when coded as follows:

• Contains CPT procedure code 77080 or 77085, and
• Contains ICD-10- CM diagnosis code M81.0, M81.8, M81.6 or M94.9.

Single photon absorptiometry tests are not covered. Contractors will deny CPT procedure code 78350.

As you age take care of your bone health by taking your calcium and vitamin D, eating well, and doing strength exercises. As a Medicare provider, avoid denials by including the correct diagnosis codes on your claims for bone mass measurements.

I have really good intentions. I plan to do this and plan to do that, but sometimes “the best-laid plans of mice and men often go awry.” This is often simply a failure on my part to follow through, but other times, things happen that impede my plans. This can happen to anyone – rain on the day of a planned outdoor outing, an injury that prevents a planned activity, or extenuating circumstances that prevent a planned medical procedure.

The problem with planned medical procedures that have to be canceled is that the hospital often has already invested resources into preparing for the planned service. Thankfully, Medicare has a means to report canceled services that allows the hospital to recoup some or all of their expenses through the use of modifiers. It is incumbent on the hospitals to appropriately use these modifiers and maintain documentation in their medical records that support their use. As with all reimbursements, there is a risk that payments may be made when not appropriate. A couple of weeks ago, Medicare approved a new issue for the Recovery Auditors (RACs) regarding “Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements.” This is to be a complex review, meaning the RACs will request and review medical record documentation to determine if payment was appropriate. The review is for Ambulatory Surgical Centers (ASCs) and outpatient hospitals. As of the date of this article, none of the RACs have posted this issue on their Approved Issues websites. Also note that at this time, the link for the details of the issue on the CMS RAC Approved Issues webpage is not working.

However, the instructions for the use of modifiers for discontinued services can be found in Chapter 4 of the Medicare Claims Processing Manual, section 20.6.4. There are two modifiers for services which require the use of anesthesia and one modifier for services that do not require anesthesia. According to the manual reference above, “Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued.”

For the modifiers for services requiring anesthesia (modifiers -73 and -74), anesthesia is defined as:

• Local anesthesia,
• Regional blocks,
• Moderate sedation/analgesia (“conscious sedation”),
• Deep sedation/analgesia, or
• General anesthesia.

Modifier -73 is used when procedures requiring anesthesia are terminated prior to administration of anesthesia.  Other considerations for using modifier -73 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Termination occurs after the patient had been prepared for the procedure (including procedural pre-medication when provided), and has been taken to the room where the procedure was to be performed.
• Procedures reported with modifier -73 will be paid at 50% of the full OPPS payment amount.
• Payment for device-intensive procedures (device offset amount exceeds 30% of the procedure’s mean coast) reported with modifier -73 will be reduced by 100% of the device offset amount prior to applying the additional payment adjustments.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.

Modifier -74 is used when procedures requiring anesthesia are terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). Other facts about modifier -74 include:

• Termination is due to extenuating circumstances or to circumstances that threatened the well-being of the patient.
• Modifier -74 may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia.
• Procedures reported with modifier -74 will be paid at the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient received anesthesia and include the progress of the procedure.

Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. For modifier -52,

• The patient has been prepared and taken to the room where the procedure is to be performed.
• Procedures reported with modifier -52 will be paid at 50% of the full OPPS payment amount.
• Documentation should clearly indicate the reason the procedure is being canceled and support that the patient was prepped and taken to the procedure room.
• This modifier is often used for radiologic procedures that cannot be completed as planned.

NOTE: The elective cancellation of a procedure should not be reported.

When things do not work out as planned, it is good to have a back-up plan, or in the case of medical procedures, a way to recoup your cost. Just make sure you code, document, and bill appropriately.

Social Determinants of Health (SDOH) are economic and social conditions (i.e., food insecurity, homelessness) that can impact an individual’s health status. As the number of Social Determinants of Health (SDOH) increases the potential for a patient to have poorer health and increased healthcare utilization also increases.

In the May 2, 2019 issue of mlnconnects, CMS included the following tools that organizations can use to measure these factors to help achieve health equity:

• Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
• Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
• Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window  : Collect the data needed to better understand and act on patients’ social determinants of health
• Health Leads Screening Toolkit - Opens in a new window  : Comprehensive way to assess patients for adverse social determinants

In the newsletter, CMS went on to indicate they are proposing that some data elements specific to SDOH’s has been proposed in several post-acute care provider settings to help “strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services.”

As a reminder, the SDOH Z-code Z59.0 Homelessness is being proposed for a CC severity designation in the FY 2020 IPPS Proposed Rule. You can read more about this in a related article at: http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-proposed-rule.