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Over the past several weeks, MMP has written about what is being proposed in the FY 2020 IPPS Proposed Rule. Prior to its release, there seemed to be a high probability that the proposed rule would include additional guidance regarding hospital charges transparency. My assumption was based on the following from a March 8, 2019 Kaiser Health News article written by Steven Findlay:   

• This article highlighted the fact that CMS Administrator Seema Verma took to twitter in March by posting a Where’s the Price challenge? Specifically, she challenged consumers to visit the website of their local hospital to see if they could find the hospital’s pricing information posted in an electronic format, if you can’t she wants to know by sending her a tweet with the hashtag #WheresThePrice to help drive #PriceTransparency!
• The article ended by indicating a CMS spokesperson said the agency plans to issue its next regulation on hospital price transparency this year.

While this “next regulation” was not in the Proposed Rule, a May 29th Washington Post article, indicated that President Trump is preparing to issue an executive order regarding greater price transparency that is likely to be announced mid-June. While we wait, this article provides a very high level background of what CMS has required of hospitals in regards to price transparency to date and highlights what the data can tell you by utilizing COPD claims data from our sister company RealTime Medicare Data (RTMD).

Hospital Price Transparency Background

Initially, the Price Transparency requirement was included in the Affordable Care Act. Specifically, section 2718(e) of the Public Health Service Act, required that ‘‘[e]ach hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.’’

CMS reminded hospitals of their obligation to comply with this section of the Act and reiterated the following specific guideline for hospitals in the 2015 IPPS Final Rule:

• “Either make public a list of their standard charges (whether that be the chargemaster itself or in another form of their choice), or have a policy for allowing the public to view a list of those charges in response to an inquiry.” (FY 2015 IPPS/LTCH Final Rule (79 FR 50146)

Four years later in the 2019 IPPS Final Rule, CMS finalized their proposal, that effective January 1, 2019, hospitals will be required “to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.”

Subsequent to the FY 2019 Final Rule, CMS released two FAQ documents answering questions from the health care community. First was an October 2019 FAQ document followed by the December 2018 release of “Additional Frequently Asked Questions Regarding Requirements for Hospitals to Make Public a List of Their Standard Charges via the Internet” document.  

The second FAQ document included a question regarding what will happen if a hospital does not comply with this requirement. CMS answer was to reiterate “as indicated in the FY 2019 IPPS/LTCH PPS final rule (83 FR 41686), specific additional future enforcement or other actions that we may take with the guidelines will be addressed in future rulemaking.”

Analyzing the Data

So, you have posted your chargemaster information on your website, do you know how you compare to your competitors? I turned to our sister company RealTime Medicare Data (RTMD) to take a look at what the average inpatient charges are for patients admitted with COPD. The specific parameters of the data review includes the following:  

• The data is for Medicare fee-for-service claims with a date of service from 10/1/2018 through 12/31/2018.
• The data is focused on one disease type, chronic obstructive pulmonary disease.
• DRG 190: Chronic Obstructive Pulmonary Disease with MCC
• DRG 191: Chronic Obstructive Pulmonary Disease with CC
• DRG 192: Chronic Obstructive Pulmonary Disease without CC/MCC
• Hospitals have been compared to their “Defined Market.” Simply stated, defined markets for a hospital are developed by the facility and all reports are from this perspective. It answers the question: Where did my patients go for treatment?
• Paid claims data was analyzed for five distinct Defined Markets:
• Huntsville Hospital in Huntsville, AL
• Mobile Infirmary in Mobile, AL
• MUSC in Charleston, SC
• UAB Hospital in Birmingham, AL
• University of Kansas Health System, St. Francis Campus

The following table highlights the variation in charges for the care of COPD patients.

For those interested, the links in the above table are to pdf downloads which provide a view of each of these hospital’s defined market average COPD charges.  

Additional Price Transparency Resources:

In November 2018 CMS launched new online tools displaying cost differences for certain surgical procedures (link to CMS press release: https://www.cms.gov/newsroom/press-releases/new-online-tool-displays-cost-differences-certain-surgical-procedures).

AHA Toolkit for Achieving Price Transparency

Guroo.com cost data includes 40M insured individuals and was created with the goal “to give you insight into health care costs and quality so you can be informed and get the most out of every dollar you spend” (www.guroo.com).

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente. 

School is out for the summer and my youngest grandchild graduated from pre-school, where she learned her ABC’s. There is no summer break from learning in real life and if you work with Medicare outpatient claims, you have to learn your A, C, E1, E2, G, J1, etc. status indicators.

Each quarter, CMS issues an update for the Outpatient Prospective Payment System (OPPS). These updates sometimes include policy changes, but generally consist mainly of coding updates, such as new HCPCS codes and revised OPPS status indicator assignments. The status indicators (SI’s) describe how particular HCPCS codes and APCs are paid (or not paid) under OPPS, so it is important for providers to understand what the various status indicators mean. CMS provides a table of the definitions of the status indicators in Addendum D1 of the OPPS Final Rule each year – the 2019 addenda can be found here.

Below are descriptions of the status indicators that appear in the July 2019 OPPS Update.

SI “A” means the service is paid under a fee schedule or payment system other than OPPS. For example, you see this code in the tables below for laboratory services that are paid under the Clinical Laboratory Fee Schedule (CLFS). Another common type of service with this SI is therapy services (PT, OT and SLP services).

SI “C” is an inpatient only procedure. These codes will not be paid when billed on an outpatient claim with limited exceptions. For inpatient only procedures, the patient should be admitted as an inpatient.

SI “E1” are services that are not covered for outpatients and will not be paid when submitted on an outpatient claim. They are services that are not an outpatient benefit, are statutorily excluded, or are not medically necessary for outpatients.

SI “E2” are not paid under OPPS because pricing information and claims data are not yet available.

SI “G” indicates drugs and biologicals that receive pass-through payment.

SI “J1” indicates the primary procedure of a comprehensive APC. The payment for all adjunctive services on the claim with the J1 service is packaged into the payment for the primary J1 service, with only a few exceptions.

SI “K” are drugs and biologicals eligible for separate payment under OPPS because they exceed the per day cost threshold for separately payable drugs.

SI “L” are for flu and pneumonia vaccines. They are paid at reasonable cost and are not subject to deductibles and co-insurance

SI “M” are services that are not billable to the MAC and are not paid under OPPS. Notice in the tables below that these services say “provided by physician” or “interpretation and report” meaning they are professional (physician or other qualified health care professional) services and not to be billed by the hospital.

SI “N” indicates services for which the payment for the service is packaged into the payment of other services. This means there is no separate payment made for this HCPCS code. Even though these services are not paid separately, it is important to report the codes so CMS can know all of the components of a primary service.

SI “Q1” is a conditionally packaged service which means the payment for this service is packaged in certain circumstances. Q1 services are packaged if they appear on the same claim with services with an SI of S, T, or V (visit). If the Q1 service does not meet packaging criteria (no S, T, or V code on the claim), it is separately paid. It defaults to the status indicator of its APC when paid separately.

SI “Q4” is for laboratory services with packaged payment. These lab services are only paid separately if they are the only type of services provided on the claim. Most clinical lab services have been conditionally packaged since 2014 and have this status indicator.

SI “S” are procedures and service paid under OPPS similar to SI “T” but to which a payment reduction for multiple procedures/services does not apply. All S services on a claim are paid at 100% of the OPPS payment rate.

SI “T” are procedures and services paid under OPPS but to which a reduction applies for multiple procedures. The first T procedure on a claim is paid at 100%, but subsequent T procedures on the same claim are paid at 50% of the OPPS payment rate.

Below are tables of the code additions and changes from the July 2019 OPPS Updates. All changes are effective July 1, 2019.

Table A includes some miscellaneous additions and changes such as a temporary new C-code, some status indicator changes, and the reassignment of a skin substitute. Notice the change of 0541T and 0542T from E1 (non-payable) due to FDA approval in March of the device associated with these codes – the codes are now S and M respectively, to reflect the technical payment to the hospital and the professional payment for the physician report.

Although payment for skin substitutes are packaged with an SI of N, a lower and higher payment for the application of the product is made due to the assignment of the skin substitute to the Low Cost Group or High Cost Group based on product cost. The reporting of different application HCPCS codes for the low and high cost groups drives the appropriate payment.

There were numerous new codes, including several for biosimilars, and some code replacements for drugs and biologicals as shown in Table B.

The American Medical Association (AMA) releases new Category III codes twice a year – in January and July to be effective the following July and January respectively. For the July 2019 update, CMS is implementing 20 CPT Category III codes that the AMA released in January 2019 for implementation on July 1, 2019.

Proprietary Laboratory Analyses (PLA) codes are CPT codes for labs or manufacturers to more specifically identify their test. Tests with PLA codes must be performed on human specimens and must be requested by the clinical laboratory or the manufacturer that offers the test. For July 1, 2019, one PLA code was deleted and 21 new codes were added.

School is never out in the real world, so study the Medicare OPPS status indicator alphabet to know if and how your hospital will be paid for outpatient services.

Q:

What is the code assignment for a patient with a history of emphysema presenting to the hospital with COPD exacerbation? 

A:

Emphysema, unspecified (J43.9) should be assigned for a patient that has COPD exacerbation with emphysema, as long as the patient does not have chronic bronchitis.  There is an Excludes1 note, found in the alphabetic index under category J44, that excludes coding J44.1 with code J43.9.

J44  Other chronic obstructive pulmonary disease

        Excludes1:  emphysema without chronic bronchitis (J43.-)

There was some confusion of how to capture the acuity for COPD after Coding Clinic, Fourth Quarter, 2017 published the above information; however, advice in Coding Clinic, First Quarter 2019, further clarifies coding emphysema (J43.9) only when a present also has acute exacerbation of COPD.

The Centers for Disease Control and Prevention (CDC)/7National Center for Health Statistics (NCHS), the organization responsible for revisions to ICD-10-CM, is aware of this issue and has agreed to consider a Coordination and Maintenance proposal for possible revisions to the instructional note..

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Fourth Quarter, 2017

Coding Clinic, First Quarter 2019

Q:

Our facility plans to start giving the new drug, Evenity (romosozumab-aqqg), but we are unable to find a HCPCS code for this newly FDA-approved drug. How should we bill Medicare for it and what can we expect to be paid?

A:

For Medicare, it would be appropriate to report HCPCS code C9399 (unclassified drug or biological). Medicare says this code can be reported for new drugs & biologicals that are approved by the FDA for which there is no HCPCS code that describes the drug.

From the FDA announcement on April 9, 2019, “The U.S. Food and Drug Administration today approved Evenity (romosozumab-aqqg) to treat osteoporosis in postmenopausal women at high risk of breaking a bone (fracture). These are women with a history of osteoporotic fracture or multiple risk factors for fracture, or those who have failed or are intolerant to other osteoporosis therapies.”

Instructions for billing and payment of newly approved drugs that have not yet been assigned a HCPCS code can be found in Chapter 17 of the Medicare Claims Processing Manual, Section 90.3. Beginning January 1, 2004, hospitals can bill for new drugs and biologicals that are approved by the FDA for which a product-specific HCPCS code has not been assigned with HCPCS code C9399 (Unclassified drug or biological).

In addition to reporting C9399, the hospital should enter the National Drug Code (NDC), the quantity of the drug administered, and the date furnished in the Remarks section of the claim. The Medicare Administrative Contractor (MAC) will manually price the drug or biological at 95 percent of Average Wholesale Price (AWP). Medicare pays 80% of this amount and the Medicare beneficiary is liable for the remaining 20%, after their deductible is met.

You know that old saying, time flies by when you are having fun? Well, the older I get, it is more apt to say that time flies by regardless of the fun factor. I will leave it up to you, the reader, to decide if the 2014 QIO Program Transition was fun. Fun or not, here we are five years later and the 11th Scope of Work (SOW) is coming to an end.

On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th SOW that will run from 2019-2023. This article highlights fun activities related to this transition for you the provider and provides information about a temporary pause of Short Stay and Higher Weighted DRG (HWDRG) Reviews.

BFCC-QIO 12th Scope of Work, What You Need to Know and Do

Know Your Region

With the 11th SOW, KEPRO and LIVANTA provided services in 5 distinct Regions with each Region having a specific phone number and contact information.  CMS has restructured the coverage areas for the 12th SOW based on the Medicare Regional Offices. Effective June 8, 2019 there will be ten Regions as outlined in the following table:

‍Update Your Appeals Notices

Acute care providers will need to update the Important Message from Medicare (IM) with the correct BFCC-QIO name and phone number for your region. Both LIVANTA and KEPRO have indicated that it is acceptable to use labels to cover the existing information on your current appeals notices.

Memorandum of Agreement 

A new Memorandum of Agreement (MOA) is required for ALL Medicare health care providers (even if your BFCC-QIO is not changing). KEPRO has a page dedicated to MOA updates, and includes FAQs and a link to sign up for an email distribution list to receive updates from KEPRO.

Phone Numbers for BFCC QIO Services

Again, effective June 8th, all calls should be directed to phone numbers provided on the BFCC-QIO websites. As this time, KEPRO and LIVANTA will continue to handle all discharge appeals, quality complaints and immediate advocacy for Medicare patients and families.

All transition updates, including phone numbers, are available on KEPRO and LIVANTA’s websites at:

• KEPRO Transition webpage: https://www.keproqio.com/providers/transition
• LIVANTA Transition webpage: https://livantaqio.com/en/provider/transition.

Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews

In the 11th SOW the BFCC-QIOs were responsible for HWDRG and Short Stay Reviews. As of May 8, 2019, a temporary pause was placed on both types of reviews. Per CMS, this action was taken to procure a new BFCC-QIO contractor and going forward HWDRG and Short Stay reviews will resume with a single organization performing these reviews on a national basis.

CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019. MMP will continue to follow this story and report as soon as a contract is awarded. In the meantime, have fun identifying your BFCC-QIO, updating your Appeals Notices, and completing a new MOA. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

Notice of New Interest Rate for Medicare Overpayments and Underpayments -3rd Qtr Notification for FY 2019

The Medicare contractors shall implement an interest rate of 10.375 percent effective April 17, 2019 for Medicare overpayments and underpayments.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R313FM.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11280.pdf

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)

A maintenance update of International Classification of Diseases, 10th Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11229.pdf

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11252.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11292.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update

Updates the HCPCS code set for codes related to drugs and biologicals.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf

 

OTHER MEDICARE TRANSMITTALS

Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

Introduces the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11003.pdf

Re-implementation of the AMCC Lab Panel Claims Payment System Logic

Because CMS no longer has payment logic to roll up panel pricing for organ or disease-oriented panels (also known as Automated Multi-Channel Chemistry or AMCC tests), laboratories must report the HCPCS code for the AMCC panel test where appropriate and not report separately the tests that make up that panel.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11248.pdf

Documentation of Evaluation and Management Services of Teaching Physicians

A change in policy of documentation for teaching physicians providing evaluation and management (E/M) services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11171.pdf

Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)

Effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11152.pdf

Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes

Provides educational information regarding reporting of the HCPCS Level II code modifiers for the Patient Relationship Categories and Codes (PRC).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11259.pdf

Additional Processing Instructions to Update the Standard Paper Remit (SPR)

Effective October 1, 2019, MACs will mask the Patient Control Number field (also named the Patient CNTRL Number) or the Patient Account Number (ACNT) field on any print file used to create an SPR for mailing if it contains a HICN or SSN in accordance with the Social Security Number (SSN) Fraud Prevention Act of 2017.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11289.pdf

 

MEDICARE SPECIAL EDITION ARTICLES

Proper Use of Modifier 59

Clarifies existing policy on the proper use of Modifier 59. Revised article to correct updated CPT code.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1418.pdf

 

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD90.2): Next Generation Sequencing (NGS)

CMS covers diagnostic laboratory tests using next generation sequencing when performed in a CLIA-certified laboratory when ordered by a treating physician and when specific requirements are met.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10878.pdf

Delay in Final Chimeric Antigen Receptor (CAR) T-cell therapy National Coverage Determination

CMS will not be issuing a final National Coverage Determination on CAR T-cell therapy for cancer today (5-17-19), but a decision is forthcoming.

https://www.cms.gov/newsroom/press-releases/cms-statement-delay-final-chimeric-antigen-receptor-car-t-cell-therapy-national-coverage

 

MEDICARE PRESS RELEASES

CMS outlines comprehensive strategy to foster innovation for transformative medical technologies

https://www.cms.gov/newsroom/press-releases/cms-outlines-comprehensive-strategy-foster-innovation-transformative-medical-technologies

 

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities

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

 

OTHER MEDICARE UPDATES

2020 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf

Fact Sheet for Proposed Rule - https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

BFCC-QIO Contract Awarded for 12th Scope of Work to Start July 2019

The 11th Scope of Work is coming to an end. On April 30th KEPRO and LIVANTA were again awarded the BFCC-QIO contracts for the 12th Scope of Work (SOW) that will run from 2019 – 2023

https://www.fbo.gov/index.php?s=opportunity&mode=form&tab=core&id=71c33a58f785d1b2d57426641f2e9ef0&_cview=0

Temporary Pause of BFCC-QIO Short Stay and HWDRG Reviews

CMS has temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). CMS took this action to procure a new BFCC-QIO contractor. Going forward, Short Stay reviews and HWDRG reviews will resume with a single organization performing reviews on a national basis. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.

https://qioprogram.org/qionews/articles/temporary-pause-bfcc-qio-short-stay-and-hwdrg-reviews

Local Coverage Determination (LCD) Process Modernization Qs & As

Describes recent changes to the LCD process.

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/LCD_QsAs.pdf

System Edits Will Be Activated for OPPS Providers with Multiple Service Locations

On July 1, 2019, CMS will begin enforcing edit requirements for Outpatient Prospective Payment System (OPPS) providers with multiple service locations submitting claims to Medicare.

www.shorturl.at/eBFW6

Q:

Our facility has recently started performing digital mammography, but Medicare is denying all of the charges for HCPCS codes 77063 (screening digital tomosynthesis for mammography) and G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral). Do you know what could be causing these denials?

A:

There are a couple of reasons why you could be receiving these denials. You should be able to determine the reason from the Claim Adjustment Reason Code (CARC) on your remittance.

Lack of Primary Code

One possibility is that you are reporting these add-on codes without the primary code.

• CPT code 77063 must be reported with CPT 77067 (screening mammography).
• HCPCS code G0279 is to be listed separately in addition to CPT codes 77065 (diagnostic mammogram, unilateral) or 77066 (diagnostic mammogram, bilateral).

The manual wording from the Medicare Claims Processing Manual, chapter 18 , section 20.2.1 indicates CPT code 77063 will be returned to the provider for institutional claims if billed without 77067, but HCPCS code G0279 will be denied if not reported with the appropriate code.

 “Effective for claims with dates of service January 1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also contain HCPCS code 77065 or 77066. A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code 77065 or 77066 with an explanation that payment for code G0279 cannot be made when billed alone.”

Lack of Appropriate FDA Certification Status

We have seen denials of the two codes (77063 and G0279) on claims with a CARC of 171- “Payment is denied when performed/billed by this type of provider in this type of facility.” We believe this is related to lack of appropriate FDA certification. See CMS Transmittal R1387CP or section 20.1 of the Medicare Claims Processing Manual, chapter 18.

All facilities providing screening and diagnostic mammography services (except VA facilities) must be certified by the Food and Drug Administration (FDA). The FDA maintains this data in the Mammography Quality Standard Act (MQSA) file and shares the file with CMS and their contractors weekly. The MQSA indicates whether a facility if certified to perform film or digital mammography.

CMS contractors rely on the FDA certification data contained in the MQSA file to know whether the mammography facility is certified to perform digital mammography. Contractors will deny a claim for a mammography service if the nature of the billed HCPCS code (i.e., film or digital) does not correspond to the FDA certification status listed on the MQSA file for the billing mammography facility.  This means if the FDA MQSA file does not indicate a facility is certified to perform digital mammography, the Medicare contractor will deny the HCPCS codes for these digital mammography services, i.e. HCPCS codes 77063 and G0279.

There is a new trend going around FaceBook of describing your age by memories and events instead of a number. For example, I am “Walt Disney's Wonderful World of Color on Sunday nights” old. In fact, I am so old that I actually had the measles as a child. Unfortunately, this is becoming a new “event” of present day and a very scary one at that. I had a very light case of the measles as a child, but my little brother was extremely ill, only avoiding hospitalization because our family doctor made frequent house calls to check on him (another phenomenon of the past). The key to preventing a new epidemic of this life-threatening disease is to get the measles vaccine. There are other vaccines that are recommended for children and adults. I am traveling out of the country soon and got two vaccines this week based on the CDC recommendations for travelers. Pediatricians usually keep up with the recommended vaccines for children, but it is harder for adults. Here is an excellent article from NPR about adult vaccines.

Medicare covers vaccines for influenza, pneumococcal pneumonia, and hepatitis B (for higher risk individuals). As always for providers of Medicare services, where there are services provided, there are billing rules. Recently NGS, the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, featured influenza vaccines as the topic of their Medicare BLAST. Medicare BLAST is a quick, ten-question game from NGS that challenges the Medicare knowledge of providers and one of the most creative and fun educational tools I’ve encountered.

Here is some information about Influenza Vaccines from the Medicare BLAST and other Medicare resources.

• Influenza vaccines are payable once per flu season. For Medicare pricing purposes the season runs from August to July of the following year, such as from August 2018-July 2019. Frequency limits are based on the flu season, not the calendar year, so a Medicare patient could receive two flu vaccines in the same calendar year. For example, if a Medicare beneficiary gets a shot in January 2019 for the 2018/2019 flu season, they could get another shot in October 2019 for the 2019/2020 flu season.
• Medicare patients can receive an influenza vaccine and a pneumococcal pneumonia vaccine during the same visit. The administration codes (G0008 and G0009 respectively) may be billed together on the same claim for the same date of service. A modifier is not needed when billing the two administration codes for the influenza and pneumococcal vaccine.
• The Part B deductible, coinsurance, or copayment do not apply to the seasonal influenza virus vaccine or its administration. Medicare covers the vaccine as long as the patient is eligible for and enrolled in Traditional Medicare.
• Medicare does not require that a doctor order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision. A physician is not required to be present during the administration of the influenza vaccine.
• Vaccines provided to inpatients of a hospital are covered under the vaccine benefit. The hospital bills on type of bill 012x using the discharge date of the hospital stay or the date benefits are exhausted.
• Hospital providers should bill for the vaccines and their administration on the same bill. Hospitals are paid at reasonable cost for the vaccine and under the OPPS payment rate for the vaccine administration.
• Simplified (roster) billing procedures are available to mass immunizers, including hospitals. See section 10.3.2 of the Chapter 18 of the Medicare Claims Processing Manual for more information on roster billing.

In addition to Section 10 of the Medicare Claims Processing Manual, Chapter 18 (at the link above), another good resource on Medicare vaccines is the MLN Educational Tool on Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B.

People have differing opinions about vaccines, but I am solidly for them. I went to elementary school with a little girl who wore braces from polio, my brother could have died from the measles, my grandfather was one of the few survivors at his Army base of the flu pandemic of 1918, and years ago I thought I was going to die from the flu. I have taken the flu vaccine every year since. Not all vaccines are 100% effective and there may be some side effects, but overall, they help protect you and those around you from serious illnesses.

Q:

In our Cancer Center, we are giving the drug Rasburicase (Elitek) by infusion. Should we charge this as a chemotherapy infusion or as a therapeutic infusion?

A:

Rasburicase is classified as an antihyperuricemic drug, so you should report the infusion as a therapeutic infusion – not as a chemotherapy infusion.

At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the third article in our series about the 2020 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications.

 

Pre-MDC

Extracorporeal Membrane Oxygenation (ECMO)

In FY 2019, three new procedure codes were finalized describing different types of ECMO treatments being used (central and peripheral). However, the codes were not finalized prior to the release of the FY 2019 IPPS Proposed Rule meaning there was no proposed Major Diagnostic Category (MDC), MS-DRG or O.R. vs. Non-O.R. designation made for the new codes.  

Given this unique situation, CMS Clinical Advisors reviewed the predecessor central ECMO code (5A15223) and determined the new peripheral codes should not sequence to Pre-MDC MS-DRG 3 where the central ECMO code is assigned.

Instead the new Peripheral ECMO codes were designated as Non-O.R. Procedures impacting MS-DRG assignment for specific medical MS-DRGs. The following table reflects the differences in ECMO Procedures DRG assignment:

In the FY 2020 IPPS Proposed Rule, stakeholders expressed the following concerns:

• MS-DRG assignment for ECMO should not be based on how the patient is cannulated as most of the cost can be attributed to a patien’ts severity of illness,
• There was a lack of opportunity for public comment on the final MS-DRG assignments,
• Patient access to ECMO treatment and programs is now at risk because of inadequate payment, and
• CMS did not appear to have access to enough patient data to evaluate for appropriate MS-DRG assignment.

On review, Clinical Advisors support the assignment of the new ICD-10-PCS procedure codes for peripheral ECMO procedures to the same MS-DRG as the open central ECMO. Therefore, CMS is proposing the following:

• Reassign peripheral ECMO codes from MS-DRGs 207, 291, 296 and 870 to Pre-MDC MS-DRG 003,
• Remove ECMO from the description of these MS-DRGs, and
• Maintaining the assignment of peripheral ECMO codes of Non-O.R. affecting MS-DRG assignment.

Allogenic Bone Marrow Transplant

A request was made to create new MS-DRGs for cases that would identify patients undergoing an allogeneic hematopoietic cell transplant (HCT) procedure according to the donor source (related or unrelated donor source). The requester indicated this would more appropriately recognize the clinical characteristics and cost differences in allogeneic HCT cases.

CMS data analysis of MS-DRG 014 cases reporting HCT related donor source, HCT unrelated donor source and unspecified donor source had comparable average length of stay and average costs. Thus, no proposal was made to create new MS-DRGs. However, as a result of CMS’ review of procedure codes they are proposing to:

• Reassign 4 ICD-10-PCS codes for HCT procedures specifying autologous cord blood stem cell as the donor source from MS-DRG 014 to MS-DRGs 016 and 017, and
• Delete 128 clinically invalid codes from the transfusion table describing arterial access as transfusion procedures always use venous access rather than arterial access.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

• XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
• XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures impacting MS–DRG assignment.

For FY 2019, CMS finalized their proposals to:

• Assign ICD-10-PCS procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
• Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
• CAR T-cell therapy was approved for new technology add-on payments in FY 2019.
  

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. The requestor noted this would improve payment in the inpatient setting. CMS does not believe enough data is available to make a change at this time. However, CMS is seeking comments on payment alternatives for CAR-T cell therapies and have proposed to continue the new technology and add-on payments for FY 2020.

 

MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures

Current logic for case assignment to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively) “is comprised of two lists of logic that include procedure codes for operating room (O.R.) procedures involving dilation of a carotid artery (common, internal or external) with intraluminal device(s).”

CMS identified 46 ICD-10-PCS procedures codes in the second list that do not describe dilation of a carotid artery with intraluminal device. CMS is proposing to remove these 46 codes from MS-DRGs 034, 035 and 036. (The 46 codes are available in a table on pages 19182 – 19183 of the Proposed Rule in the Federal Register.)

These 46 ICD-10-PCS codes are also assigned to MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC, respectively.) Therefore, CMS also examined claims data for this MS-DRG group and are proposing to:

• Remove 96 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from the logic for MS-DRG group 037-038 and 039,
• Reassign 6 ICD-10-PCS procedure codes describing dilation of a carotid artery with an intraluminal device from MS-DRG group 037, 038 and 039 to MS-DRG group 034, 035, and 036.

 

MDC 4: Diseases and Disorders of the Respiratory System

Pulmonary Embolism

A request was made to reassign the following three ICD-10-CM diagnosis codes for Pulmonary Embolism (PE) with acute core pulmonale from MS-DRG 176 (PE without MCC) to MS-DRG 175 (PE with MCC):

• I26.01 – Septic pulmonary embolism with acute cor pulmonale,
• I26.02 – Saddle embolus of pulmonary artery with acute cor pulmonale, and
• I26.09 – Other pulmonary embolism with acute cor pulmonale.

The requestor noted with the FY 2019 IPPS Final Rule special logic change where a Principal Diagnosis could no longer be its own CC or MCC this resulted in these three codes being assigned to MS-DRG 176 when no other MCC is present. The requestor stated MS-DRG 176 does not appropriately account for cost and resource utilization associated with these cases.

CMS claims analysis supported the requestor’s statement about cost and resource utilization. Therefore, CMS is proposing to:

• Reassign cases reporting diagnosis codes I16.01, I26.02 and I26.09 to MS-DRG 175, and
• Revise the MS-DRG 175 title to “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”

The difference in RW, GMLOS and National Payment Rate are reflected in the following table.

‍MDC 5: Diseases and Disorders of the Circulatory System

Transcatheter Mitral Valve Repair (TMVR) with Implant

CMS received a request to modify the current MS-DRG assignment for TMVR with implant procedures (MS-DRG 228 and 229: Other Cardiothoracic Procedures with MCC and without MCC, respectively). CMS provides a detailed discussion of the MitraClip® System (MitraClip®) for transcatheter mitral valve repair in previous rulemakings:

• FY 2014 IPPS Final Rule: CMS was unable to consider the application for a new technology add-on payment for MitraClip® because it did not receive FDA approval by the July 1, 2013 deadline.
• FY 2015 IPPS Final Rule:
• Proposal was finalized to not create a new MS-DRG or to reassign cases reporting ICD-9 procedure code 35.97 describing MitraClip® to another MS-DRG, and
• Under a new application, the request for new technology add-on payments for the MitraClip® System was approved.
• FY 2016 IPPS Final Rule: For ICD-10 based MS-DRGs to fully replicate for ICD-9-CM based MS-DRGs, ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) which identified MitraClip® technology in ICD-10-PCS code translation was assigned to new MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with MCC and without MCC, respectively) and continued to be assigned to MS-DRGs 231 and 232 (Coronary Bypass with PTCA with MCC and without MCC, respectively).
• FY 2017 IPPS Final Rule:
• The new technology add-on payment was discontinued.
• ICD-10-PCS code 02UG3JZ (Supplement mitral valve with synthetic substitute percutaneous approach) was reassigned from MS-DRGs 273 and 274 to the new “collapsed” MS-DRG pair MS-DRG 228 and 229 (Other Cardiothoracic Procedures with MCC and without MCC, respectively).
  

The requestor in the FY 2020 IPPS Proposed Rule believes that TMVR is more similar to the replacement procedures in MS-DRGs 266 and 267 compared to other procedures currently assigned to MS-DRGs 228 and 229 and “noted that both TMVR procedures and endovascular cardiac valve replacements use a percutaneous approach, treat cardiac valves, and use an implanted device for purposes of improving the function of the specified valve.”

In the Proposed Rule CMS indicates “Our clinical advisors continue to believe that transcatheter cardiac valve repair procedures are not the same as a transcatheter (endovascular) cardiac valve replacement.

However, they agree with the requestor and, based on our data analysis, that these procedures are more clinically coherent in that they also describe endovascular cardiac valve interventions with implants and are similar in terms of average length of stay and average costs to cases in MS-DRGs 266 and 267 when compared to other procedures in their current MS-DRG assignment. For these reasons, our clinical advisors agree that we should propose to reassign the endovascular cardiac valve repair procedures (supplement procedures)…to the endovascular cardiac valve replacement MS-DRGs.”

After additional data analysis, CMS is making the following proposals:

• Modify the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing transcatheter cardiac valve repair (supplement) procedure,
• Revise the title of MS-DRG 266 from “Endovascular Cardiac Valve Replacement with MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC,”
• Revise the title of MS-DRG 267 from “Endovascular Cardiac Valve Replacement without MCC” to “Endovascular Cardiac Valve Replacement and Supplement Procedure without MCC,”
• Create two new MS-DRGs with a two-way severity split for the remaining (non-supplement) transcatheter cardiac valves.
• Proposed New MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC), and
• Proposed New MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC).

Pacemaker Leads

CMS noted that ICD-10-PCS procedure code 02H60JZ (Insertion of pacemaker lead into right atrium, open approach) was inadvertently omitted from the GROUPER logic for MS-DRGs 260, 261, and 262. They are proposing to add this procedure code to the list of Non-O.R. procedures that would impact MS-DRGs 260, 261, and 262 when reported as a stand-alone procedure code.

 

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Knee Procedures with Principal Diagnosis of Infection

CMS received a request to add ICD-10-CM diagnosis codes M00.9 (Pyogenic arthritis, unspecified) and A54.42 (Gonococcal arthritis) to the list of principal diagnoses for MS-DRGs 485, 486, 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively) in MDC 8.

Currently, when reported as the principal diagnosis, these two ICD-10-CM diagnosis codes group to MS-DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection with and without CC/MCC, respectively) when a knee procedure is also reported on the claim. CMS notes that neither of these codes is specific to the knee.

After analysis, CMS is proposing the following:

• Add ICD-10-CM diagnosis code M00.9 to the list of principal diagnosis codes for MS-DRGs 485, 486 and 487. Note, clinical advisors did not recommend the same for ICD-10-CM diagnosis code A54.42 as this code is not specifically indexed to include the knee or any infection in the knee.
• Add 10 additional ICD-10-CM diagnosis codes specific to the knee and describing an infection, and
• Remove 8 ICD-10-CM diagnosis codes from the list of principal diagnosis for MS-DRG 485, 486 and 487 as they do not describe an infection of the knee.

Scoliosis: Neuromuscular and Secondary Scoliosis and Kyphosis

Requests were made to add ICD-10-CM diagnosis codes describing neuromuscular scoliosis and ICD-10-CM diagnosis codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458 (Spinal Fusion except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, without CC/MCC, respectively).

After analysis, CMS is proposing to add 5 codes describing neuromuscular scoliosis and 8 codes describing secondary scoliosis and secondary kyphosis to the list of principal diagnosis codes for MS-DRGs 456, 457, and 458. CMS also identified 34 ICD-10-CM diagnosis codes describing conditions involving the cervical region that are not clinically appropriate for assignment to MS-DRGs 456, 457, and 458. CMS has proposed to remove these 34 codes from this MS-DRG group.

 

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Extracorporeal Shock Wave Lithotripsy (ESWL)

Data analysis revealed a steady decline in inpatient cases reporting urinary stones and an ESWL procedure over the past five years. CMS indicates that due to an ESWL procedure being a Non-O.R. procedure and the decreased usage of this procedure in the inpatient setting, clinical advisors believe there is no longer a reason to subdivide the MS-DRGs for urinary stones (MS-DRGs 691 &692, and 693 & 694) based on ESWL procedures.

CMS is proposing to:

• Delete MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC respectively) and
• Revise the MS-DRG title for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC.”

 

MDC 12: Diseases and Disorders of the Male Reproductive System

Currently, four ICD-10-CM diagnosis codes describing body parts with male anatomy are assigned to MDC 5 (Diseases and Disorders of the Circulatory System) in MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively).

There was a request to review these codes and consider reassignment to MDC 12. Based on this request and claims data analysis, CMS is proposing to reassign these four codes from MDC 5 in MS-DRGs 302 and 303 to MDC 12 in MS-DRGs 729 and 730 (Other Male Reproductive System Diagnosis with CC/MCC and without CC/MCC, respectively).

 

MDC 14: Pregnancy, Childbirth and the Puerperium

Proposed Reassignment of Diagnosis Code 099.89 (Other specified Diseases and Conditions complicating pregnancy, childbirth and the puerperium)

CMS is proposing to reclassify ICD-10-CM diagnosis code 099.89 (Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) from a postpartum condition to an antepartum condition.

If finalized, coding logic would assign a case with an O.R. procedure and this code to MS-DRGs 817, 818, or 819 (Other Antepartum Diagnoses with O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

When no O.R. procedure is reported on the claim, the logic would assign the case to MS-DRGs 831, 832, and 833 (Other Antepartum Diagnoses without O.R. Procedure with MCC, with CC, and without CC/MCC, respectively).

 

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Proposed Assignment of Diagnosis Code R93.89 (Abnormal finding on diagnostic imaging of other specified body structures)

There was a request to reassign ICD-10-CM diagnosis code R93.89 from MS-DRGs 302 and 303 (Atherosclerosis with MCC and without MCC, respectively) in the Circulatory MDC 5 to MDC 23. The requestor did not suggest a specific MS-DRG assignment in MDC 23.

After analysis, CMS is proposing to reassign ICD-10-CM diagnosis code R93.89 to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

There are several proposals being made to move diagnosis and procedures codes back into a specific MDC for FY 2020. For those interested, you can find these proposals on pages 19216 – 19229 of the Proposed Rule in the Federal Register.

MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 24, 2019.