Knowledge Base - Full Library

Q:

Would you please clarify guidelines for when it is appropriate to code excisional vs non-excisional debridement?

A:

One thing to keep in mind, is the difference between an excisional debridement and a non-excisional debridement. 

An excisional debridement:

• Is a surgical procedure that involves an excisional method of removal, or cutting away tissue, necrosis and/or slough
• Groups to a surgical MS-DRG
• Results in a higher relative weight
• Translates into higher reimbursement
• Is classified to root operation “Excision”

A non-excisional debridement:

• Non-operative procedure involving brushing, scrubbing, irrigating or washing of devitalized tissue, necrosis, slough, and/or foreign material.
• May be classified to root operation “Extraction” (pulling or stripping out or off all or portion of a body part by use of force)
• Use “Extraction” of the specific body part instead of “Irrigation” when coding for debridement of areas other than skin
• May be classified to root operation “Irrigation” when procedure is performed by irrigating the devitalized tissue
• Does not group to a surgical MS-DRG

As stated in 3rd Qtr. Coding Clinic 2015: pages 3-5, "the provider is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the provider when the correlation between the documentation and the defined PCS term is clear.  It is the coder's responsibility to determine what the documentation equates to in the PCS definitions."   

When the physician’s intent of the procedure is to debride the wound, in most cases, he or she is not likely to use the PCS terms “Extraction, Irrigation or even Excisional”, as emphasized in the guideline above”   Documentation in the body of the procedure note should be descriptive enough for the coder to determine which procedure code to assign.

It should also be noted that this same Coding Clinic also emphasizes that a code is assigned for excisional debridement when the provider documents “excisional debridement” “AND / OR” the documentation meets the definition of the Excision root operation.  

Even when the physician states an excisional debridement was carried out; elements must also be documented in the body of the procedure note to support an excisional debridement.  You may find it easier to memorize “TINA D” in order to help with assignment of the more appropriate code for the procedure performed.

T - Technique used by the provider (cutting, scrubbing, trimming)

I - Instruments used (scissors, scalpel, pulse lavage, or curette)

N - Nature of the tissue removed (slough, necrosis, devitalized tissue, or non-viable tissue)

A - Appearance and size of the wound (fresh bleeding tissue or viable tissue)

D - Depth of the debridement (down to and including)

 

Additional things to remember:

1. Use of sharp instrument is not always indicative of excisional debridement.
2. Only one code, for the deepest layer documented is assigned when there are multiple layers involved of the same site
3. Both excisional and non-excisional debridement can be performed by:

• Physician
• Physician assistant
• Nurses
• Therapists

4. The location in which the procedure is performed is no indication of the type of debridement carried out.

Remember:  We cannot assume anything.  Documentation in the record needs to clearly support and reflect the procedure that was performed.   If not, then a query should be sent for clarification.

We often associate the term “it takes a village” with the raising of children. It is true that parents, grandparents, relatives, teachers, coaches, church members, healthcare providers, and/or others often play key roles in bringing up a physically and emotionally healthy, well-adjusted young person. But what brought the “it takes a village” phrase to my mind today was listening to a replay of Palmetto GBA’s webcast on Inpatient Psychiatric Facility (IPF) coverage and documentation requirements.

Palmetto likely offered this educational session in preparation for and in response to their Targeted Probe and Educate (TPE) medical review of DRG 885, Psychoses. This is a target review area for both Palmetto’s Jurisdictions -  J and M. First Coast, the Medicare Administrative Contractor (MAC) for Jurisdiction N, also has a planned TPE review for this DRG. The Palmetto webcast reminded providers that other Medicare review entities such as the CERT contractor, Recovery Auditors, and the Office of Inspector General (OIG) could review inpatient psych or any other Medicare services.

According to the webcast, the “villagers” involved and their concerns and responsibilities for IPF services are listed below. Many tasks will involve the input of multiple staff and are a shared responsibility – more evidence that “it takes a village.”

Physicians

• Patient must be under the care of a physician
• Write admission and other orders for patient’s care
• Perform a psychiatric evaluation of the patient at admission to include
• Medical history and mental status
• Onset of illness and admission circumstances
• Patient attitudes and behaviors
• An estimate of intellectual functioning, memory functioning & orientation; and
• A descriptive inventory of patient’s assets
• Certify/recertify the need (medical necessity) for inpatient care, which includes
• Patient psychiatric condition severe enough to warrant inpatient care
• Need for active treatment
• Intensive, comprehensive, multimodal treatments exceeding the level and intensity of those that may be rendered in an outpatient setting
• Generally, an expectation of improvement of the patient’s condition or for diagnostic purpose
• Establish a treatment plan that includes
• Substantiated diagnosis
• Short-term & long-range goals
• Specific treatment modalities utilized
• Each treatment team member’s responsibilities
• Adequate documentation to justify diagnosis & treatment/rehabilitation activities carried out
• Document H&P, evaluations, examinations, treatment plan, progress notes, and discharge summary

Clinicians (Nurses, Social Workers)

• Perform and document assessments and interviews
• Provide and document treatments including description of service, content and purpose, patient’s response and correlation to treatment plan goals

Utilization Review, Social Services, Discharge Planning

• Appropriate utilization of patient benefit days and lifetime reserve days in appropriate setting

Billing

• Submit correct type of bill (TOB) with appropriate revenue and occurrence codes
• Special considerations for
• Admission source “D” for patients transferred from acute care hospital to their psych distinct part unit (prevents overpayment due to ER adjustment)
• One day payment window
• Interrupted stays and occurrence span code 74
• Services provided by other facilities during IPF stay

Coders

• Assignment of correct primary and secondary diagnosis codes to the highest degree of specificity
• Discharge status code

These are just some of the coverage and documentation requirements to support Medicare inpatient psychiatric services. I recommend providers who offer inpatient psychiatric services listen to this webcast (located on Palmetto’s Past Events webpage) whether you are in Palmetto’s jurisdictions or not. The information applies universally to all Medicare inpatient psych services. Palmetto also shared some of their findings from TPE reviews so far as well as some of the CERT findings. Providers need to pay special attention to make sure their records include:

• Physician’s orders for admission and other services. Be sure all orders include a legible signature, a date, and the author’s credentials. If signatures are illegible, send an attestation log with the documentation upon review.
• Valid and timely certifications and recertifications.
• An initial psychiatric evaluation at the time of admission or no later than 60 hours after admission
• Documentation that services and treatments are related to improving the patient’s condition
• A valid, individualized treatment plan that supports psychotherapy with type, amount, frequency, duration, diagnosis & anticipated goals
• Documentation of active treatments during billing period
• Complete and sufficient documentation

You may want to hold a town hall meeting for all the villagers to communicate, coordinate and understand their individual and shared responsibilities. Sometime it takes a village meeting to guide a village.

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”

• Social Determinants of Health World Health Organization definition

The Office of Disease Prevention and Health Promotion’s Healthy People 2020 initiative includes a Social Determinants of Health (SDOH) topic area. They note that “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks…resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”

In general, since the Wednesday@One focuses on topics related to Medicare Rules and Regulations in the acute hospital setting, you may be asking, this is interesting but what does it have to do with the hospital? Well, I am glad you “asked.”

ICD-10-CM codes included in categories Z55-Z65 identify patients with potential health hazards to socioeconomic and psychosocial circumstances. Information represented in this code block is information that would typically be identified by a Social Worker, Case Manager, or admitting nurse as a hospital begins the discharge planning process as soon as the patient is admitted.

In Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, a question was asked to verify whether or not these codes could be assigned based on non-physician documentation. Advice given was that these codes represent social information and it would be acceptable to report them based on documentation from other clinicians following the patient.

To help you begin to understand what information is represented in these codes categories, the following table provides a high-level detail of the code categories and examples of codes within each category.

In MMP’s 2019 IPPS Proposed Rule series of articles, there was a related article discussing CMS’ efforts to account for social risk factors in several of the Hospital Quality Reporting Programs.

The Health People 2020 SDOH topic area has a goal to “create social and physical environments that promote good health for all.” A key to this is analyzing and acting upon data. As a hospital it is important that you begin to identify and utilize these codes.

If you are interested in learning more about SDOH’s, you can visit the Centers for Disease Control and Prevention (CDC) Social Determinants of Health web page at https://www.cdc.gov/socialdeterminants/.

The relationship between physicians and hospitals could be described as a symbiotic partnership, that is, a mutually beneficial relationship between different groups. Physicians need hospitals to provide the resources and personnel to care for their patients and hospitals need physicians to refer patients to the hospitals for such care when medically necessary. Physicians direct a patient’s care and decide when and what services are necessary. It also often falls on the physicians’ documentation to support that services and care provided and paid for by Medicare meet the requirements of being medically necessary. Unfortunately for hospitals, it is often their payment at risk if a physician provides a service in the hospital setting that is not medically necessary or fails to document sufficiently to support the medical necessity of the service. Because directing the patient’s care is the physician’s responsibility, many Medicare education resources about compliance are directed to the physicians. Likewise, hospitals must work with physicians to ensure services are appropriately provided and documented. Such is the case for ophthalmology services.

Though a number of ophthalmology services determined by the Office of Inspector General (OIG) to be at risk of “questionable billing” are more likely to be performed in a physician office setting, there are also services that could be performed in a hospital setting. Hospitals need to be aware of the concerns and requirements for these types of ophthalmology services.

A December 2014 OIG audit found that Medicare paid $22 million for ophthalmology claims in 2012 that were potentially inappropriate, according to national and local coverage requirements. The three eye conditions for which Medicare pays the most each year are cataracts, wet age-related macular degeneration (wet AMD), and glaucoma. The concerns for inappropriate payments related to these conditions are:

• Cataracts
• Medicare has a national requirement stating that it will not routinely cover more than one comprehensive eye examination and scan for beneficiaries whose only diagnosis was cataracts.
• It is medically impossible to perform more than one cataract surgery on the same eye because an eye’s natural lens will never grow back.
• Submitting disproportionately more claims for complex than standard cataract surgery.
• Wet AMD
• Some Medicare Administrative Contractors (MACs) have local coverage determinations (LCDs) limiting the number of wet AMD diagnostic or evaluation services for which a provider may bill annually.
• Medicare paid providers substantially more for treating wet AMD with the expensive biologic Lucentis instead of other biologic treatments that are similarly effective.
• Some MACs have LCDs specifying that Lucentis injections are not covered more frequently than once per month per eye. These guidelines are in keeping with the Food and Drug Administration (FDA)-approved dosing guidelines that Lucentis injections should be administered between once monthly and once every 3 months.
• Medicare has a national requirement that it covers each step of ocular photodynamic therapy only when both steps are performed on the same date. These steps are billed separately, but they must be performed within 30 minutes of one another.
• Glaucoma
• A national requirement states that Medicare covers either of two types of screening services once every 12 months for beneficiaries at high risk for glaucoma.

A September 2015 follow up OIG report found Medicare paid $171 million for services associated with the measures on which certain providers demonstrated questionable billing.

Prior to these OIG reports, the Recovery Auditors identified overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye for the same date of service. CMS published MLN Special Edition Article SE1319 in response to these findings. It reminded providers,

“According to the “National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services,” Chapter 8, Section D #3, cataract removal codes are mutually exclusive of each other and can only be billed once for the same eye. Because CPT codes describing cataract extraction (66830-66984) are mutually exclusive of one another, providers may not report multiple codes for the same eye even if more than one technique is used or more than one code could be applicable. Only one code from this CPT code range may be reported for an eye.”

The NCCI Policy Manual chapter and section noted above addresses 25 other correct coding guidelines for ophthalmology services of which providers should be aware.

For another ophthalmology service, CMS clarified in a 2005 ruling that a Medicare beneficiary may request insertion of a presbyopia-correcting intraocular lenses (IOLs) in place of a conventional IOL following cataract surgery. However, if the Medicare patient selects a presbyopia-correcting IOL, he/she is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery. The MLN Article describing this ruling included payment policies for facilities and physicians.  The policy relevant to hospital services states:

• For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital outpatient prospective payment system (OPPS) or the inpatient prospective payment system (IPPS), respectively;
• Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure. Medicare does not make separate payment to the hospital for an IOL inserted following removal of a cataract.
• For a presbyopia-correcting IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively;
• The facility will bill for removal of a cataract with insertion of a conventional IOL, regardless of
• whether a conventional or presbyopia-correcting IOL is inserted.
• When a beneficiary receives a presbyopia-correcting IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.
• There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.
• There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a presbyopia-correcting IOL following removal of a cataract that exceed the facility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.

The article also addresses coding requirements, beneficiary liability and notification requirements for these services.

Both hospitals and physicians must be aware of and follow the Medicare requirements for providing and billing ophthalmology services. Working together to “get it right” keeps the relationship between physicians and hospitals mutually beneficial for both parties and for Medicare.  

MEDICARE TRANSMITTALS

Revisions to the Telehealth Billing Requirements for Distant Site Services

Implements requirements for billing modifier GT for Telehealth Distant Site Services. As of January 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10583.pdf

Implementation of Changes to the Pre-Payment Additional Documentation Request (ADR) Letters for Medical Review

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2083OTN.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/MM10642.pdf

Updates to Publication 100-04, Chapters 1 and 27, to Replace Remittance Advice Remark Code (RARC) MA61 with N382

MACs will use N382 in place of MA61 to communicate reject/denials for patient identifiers (HICN or MBI) in all remittance advices and 835 transactions. However, MACs will continue to use RARC MA61 only when/if communicating rejections/denials related to a missing/incomplete/invalid social security number.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10619.pdf

Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Extensions per the Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act Included in the Bipartisan Budget Act of 2018

Information and implementation instructions for:

• Section 50204 – Extension of Increased Inpatient Hospital Payment Adjustment for Certain Low-Volume Hospitals
• Section 50205 – Extension of the Medicare-Dependent Hospital (MDH) Program
• Section 51005 – Adjustments to the LTCH Site Neutral Payment Rate

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10547.pdf

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) – REVISED

The article was revised on May 15, 2018, to clarify that one of the requirements of the SET program is it must be conducted in a hospital outpatient setting or in a physician’s office.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10295.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update – REVISED

A sentence is added to show that Part B payment for Q9995 includes the clotting factor furnishing fee.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10624.pdf

Intent to Reopen

Provides instructions for contractors to: provide notification of the reopening process and to notify the provider or supplier of their intent to reopen a specific claim when requested documentation is received after a denial of the claim has been made.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R796PI.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/MM10620.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2018 Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10644.pdf

 

MEDICARE COVERAGE UPDATES

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

CR10622 makes coding and clarifying adjustments to the following NCDs:

• NCD 110.18 Aprepitant
• NCD 150.3 Bone Mineral Density Studies
• NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR)
• NCD 220.6.16 Positron Emission Tomography (PET) for Infection/Inflammation
• NCD 220.6.17 PET for Solid Tumors
• NCD 220.13 Percutaneous Image-Guided Breast Biopsy

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/MM10622.pdf

 

MEDICARE PRESS RELEASES

CMS Announces Agency’s First Rural Health Strategy

The agency’s first Rural Health Strategy intended to provide a proactive approach on healthcare issues to ensure that the nearly one in five individuals who live in rural America have access to high quality, affordable healthcare.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-08.html

CMS Unveils Enhanced “Drug Dashboards” to Increase Transparency on Drug Prices

For the first time, the dashboards include year-over-year information on drug pricing and highlight which manufactures have been increasing their prices.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-05-15.html

 

MEDICARE EDUCATIONAL RESOURCES

Palmetto JM Provider Contact Center (PCC) Frequently Asked Questions (FAQs): January 2018 - April 30, 2018

https://www.palmettogba.com/palmetto/providers.nsf/ls/JM%20Part%20A"AYKQC62336?opendocument&utm_source=J11AL&utm_campaign=JMALs&utm_medium=email

MLN Fact Sheet Complying with Medicare Signature Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

Targeted Probe and Educate Video

https://my.happify.com/hd/why-gratitude-is-the-best-gift-we-can-give-our-children/?et=e2e969ce-70c2-474e-873b-a6e3fb839cf1

 

MEDICARE RULES

 Hospital IPPS and LTC 2019 FY Proposed Rule

The proposed rule proposes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). Also includes proposal concerning Quality Programs, EHR Incentive Programs, Cost-Reporting and Physician Claim Certifications.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08705.pdf

Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNF) Proposed Rule for FY 2019, SNF Value-Based Purchasing Program, and SNF Quality Reporting Program

This proposed rule would update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs) for fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09015.pdf

Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2019

This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2019.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-08961.pdf

FY 2019 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2018 (FY 2019)

This proposed rule would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs), which include psychiatric hospitals and excluded psychiatric units of an acute care hospital or critical access hospital.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-09069.pdf

 

OTHER MEDICARE UPDATES

Kepro Case Review Connections, Acute Care Edition, Spring 2018

A quarterly e-newsletter from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

https://www.keproqio.com/providers/spring-2018-acute-newsletter/

Trump Administration Releases Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs

https://www.hhs.gov/about/news/2018/05/11/trump-administration-releases-blueprint-lower-drug-prices-and-reduce-out-pocket-costs.html

“We rarely talk about cost. We talk about waste, quality, and safety, and we find our costs go down.”

• Patrick Hagan, former COO of Seattle Children’s Hospital

Risk Factor: Socio-economic Status

The Establishing Beneficiary Equity in the Hospital Readmission Reduction Program Act of 2015 (S. 688 and H.R. 1343) would have required the CMS to account for socio-economic status when calculating risk-adjusted readmission penalties. This bill garnered support from the Association of American Medical Colleges as well as the American Hospital Association. You can read more about this Act in a related MMP article.

A year later the House Ways and Means Committee released the Helping Hospitals Improve Patient Care Act of 2016 (H.R. 5273) that included a modified version of H.R. 1343. This latest version of the bill was passed in the House and was sent to the Senate where it was read twice and referred to the Committee on Finance. 

Fast Forward to the 2019 IPPS Proposed Rule which includes a discussion about “Accounting for Social Risk Factors” (including socioeconomic status) in the following Programs discussed in the Proposed Rule:

• Hospital Readmission Reduction Program (HRRP),
• Hospital Value Based Purchasing (VBP) Program,
• Hospital Acquired Condition (HAC) Reduction Program,
• Hospital Inpatient Quality Reporting (IQR) Program,
• IPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program, and
• Long Term Care Hospital Quality Reporting Program (LTCH QRP).

Accounting for Social Risk Factors

CMS notes their “commitment to ensuring that medically complex patients, as well as those with social risk factors, receive excellent care. We discussed how studies show that social risk factors, such as being near or below the poverty level as determined by HHS, belonging to a racial or ethnic minority group, or living with a disability, can be associated with poor health outcomes and how some of this disparity is related to the quality of health care.”

Specific CMS aims within their core objectives include:

• Improving health outcomes,
• Attaining health equity for all beneficiaries, and
• Ensuring that complex patients as well as those with social risk factors receive excellent care.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the National Academy of Medicine

The ASPE and National Academy of Medicine have examined the influence of social risk factors in the CMS value-based purchasing programs. To date, as required by the IMPACT Act of 2014, ASPE has provided a report to Congress where they found that “in the context of value-based purchasing programs, dual eligibility was the most powerful predictor of poor health care outcomes among those social risk factors they examined and tested.” ASPE is continuing to examine this issue in a second report required by the IMPACT Act that is due to Congress in the fall of 2019.

National Quality Forum (NQF)

CMS noted in the FY 2018 IPPS/LTCH PPS Final Rule, that the NQF “undertook a 2-year trial period in which certain new measures and measures undergoing maintenance review have been assessed to determine if risk adjustment for social risk factors is appropriate for those measures.” This period ended April 2017.

NQF Trial Conclusion:

The NQF notes in the July 2017 Social Risk Trial Final Report Abstract that “the trial period has illuminated the feasibility of adjusting measures for social risk, with 17 measures endorsed by NQF for factors such as a person’s level of education.” The NQF has extended the socioeconomic status (SES) Trial, allowing further examination of social risk factors in outcome measures.

The Centers for Medicare and Medicaid Services

CMS solicited feedback in the FY and CY 2018 Proposed Rules on which social risk factors provide the most valuable information to stakeholders for illuminating differences in outcome rates among patient groups. Commenters encouraged CMS to stratify measures by other social risk factors such as age, income, and educational attainment (82 FR 38404).

CMS Next Steps

As next steps, CMS is considering the following:

• Options to reduce health disparities among patient groups within and across hospitals by increasing the transparency of disparities as shown by quality measures,
• Implementing a hospital-specific disparity method that would promote quality improvement by calculating difference in outcome rates among patient groups within a hospital while accounting for their clinical risk factors,
• Implementing a method to assess hospitals’ outcome rates for subgroups of patients, such as dual eligible patients, across hospitals, allowing for a comparison among hospitals on their performance caring for patients with social risk factors.

Specific to the Hospital IQR Program, CMS acknowledges the complexity of interpreting stratified outcome measures and plans to stratify Pneumonia Readmission measure (NQF #0506) data by highlighting both hospital-specific disparities and readmission rates specific for dual-eligible beneficiaries across hospitals for dual-eligible patients in hospitals’ confidential feedback reports beginning Fall 2018. CMS is considering expanding confidential hospital feedback reports for other measures and eventually making this data publicly available on the Hospital Compare website.

CMS believes “the stratified results will provide hospitals with information that could illuminate disparities in care or outcome, which could subsequently be targeted through quality improvement efforts. We further believe that public display of this information could drive consumer choice and spark additional improvement efforts.” CMS plans to continue to work with the ASPE, the public and key stakeholders to “identify policy solutions that achieve the goals of attaining health equity for all beneficiaries and minimizing unintended consequences.”

“No payment may be made under (Medicare) part A or part B for any expenses incurred for items or services — which, …, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, …”Social Security Act 1862(a)(1)(A)

If your work involves knowledge of Medicare requirements, you are likely very familiar with the above statement that is the basis for the concept of “medical necessity” for covered healthcare services. But do you actually consider the implications of this statement when billing Medicare for services?

It appears a large number of providers did not assess their services against this statement before billing Medicare for specimen validity testing as a recent Office of Inspector General (OIG) report found $66.3 million in overpayments for this type of testing. Specimen validity testing is used to analyze urine specimens prior to drug testing to determine whether the specimens have been adulterated or tampered with. Although necessary to assure the legitimacy of the drug testing, these tests themselves are not used to provide a diagnosis or treatment to a patient.

As the OIG report explains, the requirements for laboratory testing are that tests meet the requirement for medical necessity as described above and more specifically, to be covered under Medicare Part B, clinical laboratory tests must:

• Be ordered by a physician who is treating a beneficiary for a specific medical problem;
• Be related to the patient’s illness, injury, symptom or complaint; and
• The results must be used in the management of the patient’s problem.

The overpayments occurred because the same tests used for specimen validity testing may be medically necessary if used to diagnose certain conditions. “For example, tests for urinary pH and specific gravity may be performed to diagnose diseases of the kidney and urinary system. If these tests are used for diagnosis, treatment, or management, they may be Medicare-covered services. However, when used for the purpose of determining whether a specimen is adulterated, the test results are not being used to manage a beneficiary’s specific medical problem. In these cases, specimen validity testing is not a separately billable Medicare-covered service.” 

Providers should have known this because, over the years, Medicare and their contractors have addressed this issue numerous times. Almost all the Medicare Administrative Contractors (MACs) have a Local Coverage Determination (LCD) for drug testing that includes direction that tests to validate urine specimens are not separately billable. The first such LCD instruction was in 2010 and in 2015 the Medicare National Correct Coding Initiative (NCCI) manual included the statement, “Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.” Beginning in 2016, new HCPCS codes for urine drug testing include specimen validity testing in their code descriptions and payments, regardless of whether specimen validity testing is performed or not. And in April 2016, NCCI edits were created to prevent payment for the type of lab tests performed for validity testing when billed on the same date of service as a urine drug test unless modified by the provider to indicate a “separate and distinct” service.

Although the number of overpayments dramatically decreased from 2014 to 2016, the OIG thinks further actions by CMS could reduce the risk of estimated overpayments of $12,146,760 over a 5-year period. The OIG recommends CMS “strengthen its system edits to prevent improper payments for specimen validity tests and instruct the Medicare contractors to educate providers on properly billing for specimen validity and urine drug tests.” Also, be warned that CMS may be recouping the overpayments identified in the OIG audit.

Now is a good time to investigate your billing practices for specimen validity testing with the understanding that if you have been separately billing these services, you owe the government some money back. Going forward, be sure to first apply the Social Security Act standard in determining whether to bill for services – i.e., to be paid under Medicare, a service must be reasonable and necessary for the diagnosis or treatment of illness or injury. After that, there are a lot more coverage rules that need to be considered, but it is a good place to start.

Q:

Have there been any recent updates to the hospital Post-acute Care Transfer (PACT) Policy?

A:

Yes. Transmittal 2055 added discharges to hospice care as a post-acute care setting that would invoke the payment adjustments of the Post-acute Care Transfer policy beginning FY 2019.

The transmittal summarizes the facts of Medicare’s transfer policies in the Background section:

“When a patient is transferred to another hospital and his or her length of stay is less than the geometric mean length of stay for the Medicare Severity Diagnosis-Related Group (MS–DRG), the transferring hospital would be paid based on a graduated per diem rate for each day of stay, not to exceed the full MS–DRG payment.  For discharges to certain post-acute care settings, this per diem-based payment adjustment is limited to discharges to certain MS-DRGs. Currently, the regulation limits post-acute care transfers to those where the patient is transferred to a distinct part hospital unit, a skilled nursing facility, or discharged with a written plan for home health services commencing within 3 days of discharge.”

The policy revision is based on the requirements of Section 53109 of the Bipartisan Budget Act of 2018. Beginning in FY 2019 (October 1, 2018), discharges to hospice care will also qualify as a post-acute care transfer and be subject to payment adjustments.

The post-acute care setting and discharge statuses to which the policy applies are:

• Inpatient rehab facilities and units (discharge status code 63)
• Long term care hospitals (code 62)
• Psychiatric hospitals and units (code 65)
• Children’s and Cancer hospitals (code 05)
• Skilled nursing facilities (code 03)
• Home with a home health plan of care that begins within 3 days (code 06)
• Hospice care (code 50 or 51) – NEW for claims with through date on or after October 1, 2018

Here are some other facts about the post-acute care transfer policy from a prior Wednesday@One article.

• PACT policy only applies to certain MS-DRGs. The list of MS-DRGs to which the policy applies is updated annually as Table 5 of the IPPS Final Rule.
• PACT policy only applies when the patient is transferred to certain post-acute care settings – see list above
• Medicare identifies transfers to the affected settings by the discharge status code on the claim. If Medicare receives a claim from a post-acute care provider for days immediately after discharge, they will ask the transferring hospital to adjust their discharge status code if needed.
• Payment is reduced to the transferring hospital. A per diem rate is calculated by dividing the MS-DRG rate by the GMLOS. The transferring hospital is paid 2x the per diem rate for the first day and the per diem rate for subsequent days up to the full MS-DRG payment.
• There are special pay MS-DRGs (also noted in Table 5) that are paid differently, with a higher payment percentage for the first day of hospitalization.
• Transfer cases are eligible for outlier payments.

Several years ago, there was a lot of excitement among laboratories and hospitals when CMS stated that a laboratory requisition did not have to be signed by the ordering practitioner. That excitement was short-lived however, when it became apparent that the lack of a signature requirement for lab requisitions did not mean a signed order for the laboratory testing was not required. Upon medical review by a Medicare contractor, the billing entity (such as the hospital) was required to submit a signed practitioner’s order, or other documentation, such as an office progress note, supporting the intent to order the specific laboratory tests. Many laboratories quickly realized it was easier and more efficient to continue to require the physician’s signature on the lab requisition.

Bearing this cautionary tale in mind, what does the proposed policy change to remove the requirement that written inpatient admission orders are a specific requirement for Medicare Part A payment actually mean for hospitals? I certainly do not think it means you no longer need an order for inpatient admission.

In fact, the 2019 Inpatient Prospective Payment System (IPPS) proposed rule states, “This proposal does not change the requirement that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.”

What it does mean is a shift in the focus of Medicare reviewers away from the admission order itself. The Proposed Rule affirms that Medicare reviewers will focus on the medical necessity of the inpatient services. The wording in the proposed rule also provides hints as to the types of “technical discrepancies” reviewers may overlook, such as:

• Missing practitioner admission signatures,
• Missing authentication signatures or co-signatures, or
• Signatures occurring after discharge.

Reviewers may also be more willing to allow payment for inpatient admissions when there is not an admission order but “the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record.” This should still be a rare occurrence because hospitals are expected to comply with the Medicare Conditions of Participation which require an admission order.

The rule change for admission orders does not change the “two-midnight” policy. This change, if finalized, will allow hospital personnel to concentrate on ensuring documentation is present in the record to support the medical necessary expectation of a two-midnight stay instead of chasing physicians to obtain signatures before the patient is discharged.

Q:

What is the “Approach” for a needle aspiration of Bone Marrow from a lumbar vertebra when performed during an open lumbar spinal fusion?

A:

The operative “Approach” for needle aspiration of Bone Marrow would be assigned to “Open”.  This would not be considered a “Percutaneous” approach because the aspiration did not cut through the skin.  The code assigned would be 07DS0ZZ, Extraction of Vertebral Bone Marrow, Open Approach

In addition, needle aspiration of bone marrow from the iliac crest is commonly performed during spinal fusions and would be assigned to 07DR0ZZ, Extraction of Iliac Bone Marrow, Open Approach.  This would be reported once even if performed bilaterally.  

Resources:

Coding Clinic, Third Quarter 2016, page 41

Coding Tip: Biopsy Coding in PCS When Fluid is Aspirated; Kim Carrier, Health Information Associates