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Q:

What information will a Review Contractor accept when reviewing a record for medical necessity of the services provided?

A:

The answer can be found in Chapter 3 of the Medicare Program Integrity Manual. Specifically, Section 3.3.2.1 – Documents on Which to Base a Determination indicates that “The MACs, CERT, Recovery Auditors, and ZPICs shall review any information necessary to make a prepayment and/or postpayment claim determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted with the claim and any other documentation subsequently requested from the provider or other entity when necessary. Reviewers also have the discretion to consider billing history or other information obtained from the Common Working File (in limited circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among others.

For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.”

This guidance applies to Medicare Administrative Contractors (MACs), the Comprehensive Error Rate Testing (CERT), Recovery Auditors, and Zone Program Integrity Contractors (ZPICs).

A Medicare patient presents to your hospital’s Emergency Department late one evening and immediately requires emergency surgery.  The procedure performed in the operating room is on Medicare’s inpatient-only list.  Due to the focus on the medical care and treatment of the patient, an order to admit the patient as an inpatient is not obtained until the next morning.  Can the inpatient-only procedure be reported on the inpatient claim according to the policy for the payment window for outpatient services treated as inpatient services?

This question was recently posed to Medical Management Plus by one of our clients.  I was sure I remembered that Medicare changed an older instruction and now allows the billing of an inpatient-only procedure on the inpatient claim under the 3-day payment window rule.  To confirm this, I read the relevant sections in Chapter 4 of the Medicare Claims Processing Manual, which are Section 10.2 about the payment window and Section 180.7 about inpatient-only services.  Neither section states that combining an inpatient-only procedure performed on an outpatient basis into the succeeding inpatient admission for payment is allowed.  But I am sure I remembered that - have I lost my mind?

I started back-tracking through old transmittals.  I noticed Section 180.7 was last updated January 1, 2016, but a review of that transmittal (Transmittal 3425, CR9486) shows the update was related to the comprehensive payment when a patient has an inpatient-only procedure performed and then expires or is transferred prior to an inpatient order being written. After further searching, I finally located Transmittal 3238, CR 9097.  This transmittal states:

“Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.” (emphasis added)

This is definitely what I was looking for, but the danger in relying on prior transmittals is they may no longer be effective.  That is why I always confirm any transmittal guidance against the actual manuals.  And remember, I did not find this verbiage in the manuals.  I noticed in the updated manual instructions accompanying this transmittal that there is no “red text” (updated instructions) for these two manual sections other than the ‘update’ dates.  As Alice in Wonderland would say, my investigation was getting “curiouser and curiouser.”  If nothing was added or changed for these manual sections, was something removed?  Exactly what was updated? My search continued.

I finally found (thanks to some old email correspondence) Transmittal 2234, CR 7443 from way back in 2011. It is the July 2011 OPPS Update transmittal and it includes the following revisions.  Added to both manual sections noted above is the statement – “inpatient only procedures that are provided to a patient in the outpatient setting on the date of the patient’s inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission are not paid for by CMS and must be submitted on a no-pay claim (Type of Bill (TOB) 110).”  Now the April 2015 update made sense!  Nothing was added or changed, but the above statement was removed from both manual sections.  And since it is still absent from the manual instructions, its removal stands.

So I wasn’t crazy after all – at least not about this issue.  It is acceptable to report an inpatient-only procedure performed on an outpatient basis on the ensuing inpatient admission (within the 3 day payment window) and Medicare will cover this related procedure.  In fact, I think the scenario I described above is the perfect example of when this bundling is appropriate.  I do not think CMS changed this policy simply to allow hospitals to obtain a late inpatient admission order when they failed to do so in a timely manner.  I think this rule change was intended to allow appropriate payment in the case of emergencies or when the outpatient surgical procedure intended must be changed to one that is on the inpatient-only list during the surgery.

I am glad CMS made this change, but I wish they had ‘included’ rather than ‘excluded’ instructions in the manual updates.  Then I would not have gone looking for something that was not there.

As we approach the 4th of July Holiday it is a time to reflect on the history of our great nation. It is also a time to say a prayer of thanks and gratitude for all those who have served and continue to serve to protect the personal freedoms and rights guaranteed to us by the Bill of Rights.

While there has been much debate as to whether healthcare is a right, Medicare beneficiaries, Medicare Advantage (MA) plan enrollees, Medicare as a Secondary Payor (MSP), and dual-eligible beneficiaries who are hospital inpatients have long had a statutory discharge appeal right.

Effective July 1, 2007, hospitals were required to begin delivering a revised version of the Important Message from Medicare (IM) form informing Medicare beneficiaries about their appeal rights. This second form was and still is to be given within two days of discharge. Additionally, beneficiaries who choose to appeal a discharge decision must also be provided the Detailed Notice of Discharge (DND) form from the hospital or his/her Medicare Advantage plan, if applicable.

Frequently Asked Questions

Over time, MMP has received questions regarding the process for delivering the IM form. On April 3, 2007 CMS released a Q&A document that in general has answered specific IM questions posed to us by our clients. Below are two of the most frequently asked questions and a link to the entire CMS document.

Question: Are we required to provide the IM and DND forms to all patients, regardless of payment source?

Answer: “This rule applies to all Medicare beneficiaries, including enrollees in Medicare Advantage (MA) plans and other Medicare health plans subject to MA regulations. Section 1154 of the Social Security Act applies to all patients who are under Medicare, regardless of where Medicare falls in the sequence of payment. Thus, all Medicare beneficiaries, no matter where in the sequence of payers Medicare falls, must receive these notices.”

Question: “Does the follow-up copy of the IM need to be signed again? If the follow-up copy is delivered and the patient ends up staying several more days, does another follow up copy need to be delivered?”

Answer: “The regulations do not require that the follow-up copy be signed. It serves as a reminder of the information that was given on the initial IM. However, while the beneficiary’s signature is not required, a hospital must be able to document that the notice has been delivered. One way to accomplish this would be to have the beneficiary initial the form to indicate that he or she has received it. We intend to provide an “Additional Information” area for an entry on the latest version of the IM. If the follow-up copy of the IM has been delivered and a beneficiary remains in the hospital for more than 2 additional calendar days, another follow-up copy should be issued according to the required timeframes.”

CMS Document Final Rule: Notification of Hospital Discharge Appeal Rights (CMS-4105-F) Qs And As (April 3, 2007) at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/CMS4105FINALRULEQsandAs2007.pdf

Appeal Notice Updates Timeline

As mentioned earlier, on July 1, 2007 hospitals were required to begin delivering a second copy of the IM letter within two days of the beneficiaries discharge. Since that time there have been updates to the IM Form CMS-R-193 and DND Form CMS 10066 as outlined below.

July 2010 IM Form Update

In 2010 the OMB released an updated form approved 07/10 that added a place to put the time the letter was signed in addition to the date.

August 2014 QIO Contact Information Change

With the 11th Scope of Work for the Quality Improvement Organizations (QIOs), responsibilities were split into two separate QIOs. The Quality Innovation Network (QIN) QIOs and the Beneficiary and Family Centered Care (BFCC) QIOs. Hospital Discharge Appeals are managed by the BFCC-QIOs. With this change, in August of 2014, CMS required hospitals to update their forms with the correct BFCC-QIO contact information no later than September 1, 2014.

June 2017 Form Update

A few weeks ago on June 6th CMS posted updated IM and DND forms to their Hospital Discharge Appeal Notices webpage. Comparing the new forms to the previous forms, MMP only noted the following form updates:  

• IM Form CMS-R-193:
• At the bottom left corner of the first page “Form CMS-R-193 (approved 07/10)” has been changed to “Form CMS-R-193 (Exp. 03/31/2020), and
• Above the “Additional Information” box on the bottom of page two the following verbiage has been added, “CMS does not discriminate in its programs and activities. To request this publication in an alternate format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.”
• DND Form CMS 10066:
• At the bottom of the form the following verbiage has been added, “CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov, and
• At the bottom left corner for the form “CMS 10066 (approved 07/10)” has been changed to “CMS 10066 (Exp. 10/31/2019).”

Additional information about Hospital Discharge Appeals can be found at the following resources.

BFCC-QIO Appeals webpages

• KEPRO at https://www.keproqio.com/providers/appeals.aspx
• Livanta at https://bfccqioarea5.com/casetypes.html

Medicare Claims Processing Manual, Chapter 30 – Financial Liability Protections, Section 200 – Expedited Review Process for Hospital Inpatients in Original Medicare at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, §482.13(a)(1) at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

TRANSMITTALS

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

• MLN Matters Number: MM10040
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R3780CP
• Related Change Request (CR) Number: 10040
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10040.pdf
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Updates the remittance advice remark code (RARC) and claims adjustment reason code (CARC) lists and also instruct ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print.

Claim Status Category and Claim Status Codes Update

• MLN Matters Number: MM10043
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R3782CP
• Related Change Request (CR) # 10043
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10043.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs MACs about system changes to update, as needed, the Claim Status and Claim Status Category Codes.

July 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• MLN Matters Number: MM10122
• Related CR Release Date: May 30, 2017
• Related CR Transmittal Number: R3783CP
• Related Change Request (CR) Number: 10122
• Effective Date: July 1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10122.pdf
• Affects providers and suppliers that submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS).

Summary: Describes changes to the OPPS to be implemented in the July 2017 update.

Guidance to Providers that Submit Outpatient Facility Claims and Those That Enter Claims Data via Direct Data Entry (DDE) Screens to Reduce Incidence of Claims Not Crossing Over

• MLN Matters Number: SE17015
• Article Release Date: June 6, 2017
• Related CR Transmittal Number: N/A
• Related Change Request (CR) Number: 10103
• Effective Date: August 7, 2017
• Implementation Date: August 7, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17015.pdf
• Affects institutional provider billers including those who submit HIPAA Accredited Standards Committee (ASC) 837 X12N institutional claims for outpatient hospital facility services to Medicare, and those who submit claims to Medicare via Direct Data Entry (DDE).

Summary: Instructs provider billing offices to correctly submit HIPAA ASC X12N 837 institutional claims to Medicare to reduce the incidence of receiving Return-to-Provider (RTP) edits on incoming 837 outpatient hospital facility claims as well as DDE claims due to edits that will be enforced as of August 7, 2017.

Screening for the Human Immunodeficiency Virus (HIV) Infection

• MLN Matters® Number: MM9980
• Related Change Request (CR) #: CR 9980
• Related CR Release Date: May 24, 2017
• Effective Date: April 13, 2015
• Related CR Transmittal #: R3778CP
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9980.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: MACs shall recognize the specified HCPCS codes for services related to the Screening for the Human Immunodeficiency Virus (HIV) Infection.

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

• MLN Matters Number: MM10086
• Related CR Release Date: May 26, 2017
• Related CR Transmittal Number: R1854OTN
• Related Change Request (CR) Number: 10086
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017, shared system edits, July 14, 2017, local edits
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10086.pdf
• Affects physicians, providers and suppliers billing Medicare Administrative Contractors
• (MACs) for services provided to Medicare beneficiaries.

Summary: A maintenance update of International Classification of Diseases, Tenth 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.

“Medicare Benefit Policy Manual” - Chapter 10, Ambulance Locality and Advanced Life Support (ALS) Assessment

• MLN Matters Number: MM10110
• Related CR Release Date: June 16, 2017
• Related CR Transmittal Number: R236BP
• Related Change Request (CR) Number: 10110
• Effective Date: September 18, 2017
• Implementation Date: September 18, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10110.pdf
• Affects ambulance providers and suppliers submitting Medicare Part B claims to the Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Clarifies the definitions for locality and ground ambulance services for ALS assessment. The term “locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. Your MACs have the discretion to define “locality” in their service areas.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017

• MLN Matters Number: MM10156
• Related CR Release Date: June 16, 2017
• Related CR Transmittal Number: R3797CP
• Related Change Request (CR) Number: CR 10156
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10156.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The October 2017 quarterly release of the edit module for clinical diagnostic laboratory services.

 

OTHER MEDICARE ANNOUNCEMENTS

5 Ways for Healthcare Providers to Get Ready for New Medicare Cards

• https://www.cms.gov/Medicare/SSNRI/5-Things-What-to-do-Now-Drop-In-English.pdf

Summary: Educates providers about steps for removing Social Security numbers from Medicare cards. 

New Medicare Forms

ABN Form

• Effective June 21, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Hospital Discharge Appeal Notices

• Important Message from Medicare and Detailed Notice of Discharge
• June 7, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html

Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-29.pdf

Summary: The Centers for Medicare & Medicaid Services (CMS) is releasing a new Appendix Z of the State Operations Manual (SOM) which contains the interpretive guidelines and survey procedures for the Emergency Preparedness Final Rule. Appendix Z applies to all 17 providers and suppliers included in the Final Rule.

OFFICE OF INSPECTOR GENERAL (OIG) NEWS

2017 Compendium of Unimplemented Recommendations

• https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2017.pdf

Summary: Identifies significant recommendations to Congress with respect to problems, abuses, or deficiencies for which corrective actions have not been completed. Focuses on the top 25 unimplemented recommendations that, in OIG’s view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and quality improvements and should, therefore, be prioritized for implementation.

OIG Spring 2017 Semiannual Report to Congress

• https://oig.hhs.gov/reports-and-publications/semiannual/index.asp#sar

Summary: Summarizing activities of the Office of Inspector General (OIG), Department of Health and Human Services (HHS or the Department), for the 6-month period that ended March 31, 2017.

Updates to the OIG Work Plan

• https://oig.hhs.gov/reports-and-publications/workplan/index.asp

Summary: OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Also, completed Work Plan items will be removed. Recently published reports can be found on OIG’s What’s New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.

I do not usually write articles about Medicare Coverage Decision Memorandums. This is because Coverage Decision Memos are not binding on contractors or Administrative Law Judges (ALJs) until they are implemented in a CMS-issued program instruction. Formal program instructions are supposed to occur within 180 days of the end of the calendar quarter in which the memo was posted on the Web site. If there are specific coding and billing instructions, they will also be published at the same time in a transmittal that updates the Medicare Claims Processing manual. The effective date of Medicare coverage of a particular service finalized in a National Coverage Determination (NCD) appears to always be made retroactive back to the date of the decision memo. So although the coverage of a service begins at the time of the Decision Memo, providers shouldn’t attempt to bill for the service until a final NCD and any associated billing/coding instructions are released.

This time I am going to make an exception because I think it is very interesting and an excellent Medicare benefit that CMS has decided to cover exercise therapy for patients with peripheral artery disease (PAD). PAD is the buildup of plaque in the arteries causing narrowing and affecting the lower extremities. Approximately 12% of Americans have PAD, but the prevalence increases with age. PAD causes pain and discomfort in the legs when walking or exercising but resolves with rest. This is known as intermittent claudication (IC). IC can dramatically affect patients’ functional independence and quality of life. As with all things Medicare, the minutiae are in the explanation of the coverage requirements.

Medicare will cover supervised exercise therapy (SET) when the following requirements are met:

• For beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD);
• Up to 36 sessions over a 12 week period;
• Sessions lasting 30-60 minutes comprising a therapeutic exercise-training program for PAD in patients with claudication;
• In a hospital outpatient setting, or a physician’s office;
• Delivered by qualified auxiliary personnel trained in exercise therapy for PAD to ensure benefits exceed harms; and
• Under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist trained in both basic and advanced life support techniques.

The patient must have a face-to-face visit with and obtain a referral for the SET from the physician treating their PAD. At this visit, the patient must receive information on cardiovascular disease and PAD risk factor reduction. This could include education, counseling, behavioral interventions, and outcome assessments. The Medicare Administrative Contractor may approve 36 additional sessions of SET for PAD based on a second referral. Medicare will not cover SET if a patient’s primary physician determines the patient has an absolute contraindication to exercise.

Exercise therapy is an effective way to alleviate the pain of PAD. SET may also prevent the progression of PAD and lower the risk of cardiovascular events that are prevalent in these patients. Greater access to SET programs could decrease the need for endovascular revascularization (ER) procedures so that ER can be reserved for cases where the patient is too functionally impaired for SET.

Providers should be on the lookout for the NCD and any associated claims processing instructions related to this decision memo.

How do you go from laboratory technologist to compliance professional? You see it often because the detail oriented mind of laboratorians fits well into the myriad details of compliance requirements. For me, I happened to be the manager of a hospital outpatient laboratory at the time the Office of Inspector General (OIG) released the Compliance Program Guidance for Clinical Laboratories. In short order, it fell upon my shoulders to “do something” about this Compliance Guidance. The OIG guidance was in part a response to recent concerns about laboratory billing practices. A prominent national laboratory had at the time been under scrutiny for adding one more laboratory test to a large, frequently ordered lab profile that consisted of a significant number of different lab tests. According to the government, this caused physicians to unknowingly (or at least without careful consideration of medical need) order “medically unnecessary” lab tests.

I often refer to this as “the original compliance sin” and the issue of medical necessity is still a major concern for compliance, and not only for laboratory tests. Medical necessity now involves various types of medical services – from ambulances, to cardiology procedures, to high-cost drugs, to joint replacements, to many other services and even back to laboratory tests. Two recent enforcement actions posted on the OIG’s website are related to medically unnecessary laboratory pathology services.

The first case involves Poplar Healthcare located in Memphis, Tennessee, which paid nearly $900,000 to resolve False Claims Act allegations. According to the Department of Justice (DOJ) Press Release, “The government alleges that Poplar, directly and through a subsidiary known as GI Pathology, promoted and billed the government for diagnostic tests that the government contends were not medically necessary.” Poplar conducted an extensive, multi-year promotional campaign promoting the use of a special pathology stain they claimed could definitively diagnose “mast cell enterocolitis.” The government contended Poplar’s claims about the stain were not supported by scientific evidence and were not consistent with FDA approval requirements.

A similar case against Piedmont Pathology in Hickory, N.C also involves the medically unnecessary use of pathology stains. In this case, the pathology laboratory was performing and billing for special stains on certain gastric biopsies. The special stains were performed before a pathologist reviewed routinely stained specimens to determine if there was a medical need for the additional special stains. Piedmont Pathology has agreed to pay the United States $601,000 to settle allegations that it violated the False Claims Act by submitting false claims to Medicare and Medicaid for medically unnecessary procedures. The DOJ press release provides further details.

Another similarity between these two cases is that both were “whistleblower” cases where a private citizen can bring suit on behalf of the government for false claims under provisions of the False Claim Act. The government can decide to take over the case and the whistleblower shares in any monetary recovery. In these cases, the relator’s share was $205,841 and approximately $120,200, respectively.

There are important take-aways for all providers from these settlements:

• The government is serious about the medical necessity of services (for all types of healthcare services);
• No service is too big or too small for government attention;
• Be careful what a vendor tries to sell you;
• Verify the medical need for the services you provide; and
• Watch out for the whistleblowers!

Q:

If a patient is diagnosed with encephalopathy secondary to gram negative pneumonia, which ICD-10-CM codes would be appropriate to report? J15.6 & G93.49 or J15.6 & G94?

A:

Per AHA Coding Advisor (question submitted by MMP) the “EAB (Editorial Advisory Board) recommends assigning codes G93.40, Encephalopathy, unspecified and a code for Gram-negative pneumonia” (J15.6).According to the AHA Coding Advisor, “the EAB of Coding Clinic recently resolved the issue of coding encephalopathy in diseases classified elsewhere”.

“Code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94 for certain etiologies”.

Look for information, in regards to encephalopathy and/or code G94, to be published in the upcoming Coding Clinic 2nd Qtr. 2017.

Another thing you want to keep in mind; encephalopathy is generally a manifestation from a source such as pneumonia, sepsis, UTI etc. Quite often this could reflect a metabolic type encephalopathy that temporarily may affect a patient’s electrolytes, vitamin or other chemical type balance that would adversely alter or affect brain function.   In order to give greater specificity, be sure to query the provider if there is lack of supporting documentation. 

TRANSMITTALS

Update FISS Editing to Include the Admitting Diagnosis Code Field

• MLN Matters® Number: MM9753
• Related Change Request (CR) #: CR 9753
• Related CR Release Date: April 28, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1832OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9753.pdf
• Affects providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Updates various system edits to look at the admitting diagnosis field. FISS editing is now being updated to ensure that all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx that are tied to the diagnosis code fields (other than the primary diagnosis field) include the admitting diagnosis field for Inpatient claims on Types of Bill (TOB) 011x, 012x, 018x, 021x, and 022x.

Screening for Hepatitis B Virus (HBV) Infection

• MLN Matters® Number: MM9859
• Related Change Request (CR) #: CR 9859
• Related CR Release Date: April 28, 2017
• Effective Date: September 28, 2016
• Related CR Transmittal #: R3761CP and R195NCD
• Implementation Date: January 1, 2018
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9859.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries

Summary: Medicare will cover screening for Hepatitis B Virus (HBV) infection for certain individuals when performed with an FDA approved/cleared laboratory tests

REVISED: Revision to clarify language on page 3, under the “Professional Billing Requirements.” It now reads, only when services are ordered by the following provider specialties found on the provider’s enrollment record…

Implementing the Remittance Advice Messaging for the 20 Hour Weekly Minimum for Partial Hospitalization Program Services

• MLN Matters® Number: MM9880
• Related Change Request (CR) #: CR 9880
• Related CR Release Date: April 28, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1833OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9880.pdf
• Affects Outpatient Prospective Payment System (OPPS) providers submitting Partial Hospitalization Program (PHP) claims to Medicare Administrative Contractors (MACs) for PHP services provided to Medicare beneficiaries.

Summary: Implements informational messaging, effective October 1, 2017, that conveys supplemental and educational information to the provider submitting claims for PHP services where the patient did not receive the minimum 20 hours per week of therapeutic services his plan of care indicates is required, on claims with line item date of service (LIDOS) on or after October 1, 2017.

New Physician Specialty Code for Advanced Heart Failure and Transplant Cardiology, Medical Toxicology, and Hematopoietic Cell Transplantation and Cellular Therapy

• MLN Matters® Number: MM9957
• Related CR Release Date: April 28, 2017
• Related CR Transmittal #: R283FM and R3762CP
• Related Change Request (CR) #: CR 9957
• Effective Date: October 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9957.pdf
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries

Summary: Establishes new physician specialty codes for Advanced Heart Failure and Transplant Cardiology (C7), Medical Toxicology (C8), and Hematopoietic Cell Transplantation and Cellular Therapy (C9).

Payment for Moderate Sedation Services Furnished with Colorectal Cancer Screening Tests

• MLN Matters Number: MM10075
• Related CR Release Date: April 28, 2017
• Related CR Transmittal Number: R3763CP
• Related Change Request (CR) Number: 10075
• Effective Date: January 1, 2017
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10075.pdf
• Affects physicians and other providers submitting claims to Part A and B Medicare Administrative Contractors (MACs) for sedation services furnished with colorectal cancer screening tests.

Summary: Ensures accurate program payment for moderate sedation services furnished in conjunction with screening colonoscopy services for which the beneficiary should not be charged the coinsurance or deductible.

Office of Inspector General Report: Stem Cell Transplantation

• MLN Matters® Number: SE1624 Revised
• Article Release Date: May 1, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1624.pdf

Summary: This article was revised on May 1, 2017, to make a number of clarifications and to delete the table that had been in the article.

Update FISS Editing to Include All Three Patient Reason for Visit Code Fields

• MLN Matters® Number: MM9672 - Revised
• Related Change Request (CR) #: CR 9672
• Related CR Release Date: May 17, 2017
• Effective Date: Claims received on or after October 1, 2017
• Related CR Transmittal #: R1852OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9672.pdf
• Affects providers submitting outpatient hospital claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: FISS edits to ensure all of the National Coverage Determination (NCD) edits within Reason Code ranges 3xxxx and 59xxx are tied to the diagnosis code fields including all three Patient Reason for Visit (PRV) fields for outpatient hospital claims on Types of Bills (TOB) 013x and 085x. CR9672 makes no policy changes.

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare SetAside Arrangements (NFMSAs)

• MLN Matters® Number: MM9893
• Revised Related Change Request (CR) #: CR 9893
• Related CR Release Date: May 10, 2017
• Effective Date: October 1, 2017
• Related CR Transmittal #: R1845OTN
• Implementation Date: October 2, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9893.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

Summary: Establishes two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA).

Clarifying Medical Review of Hospital Claims for Part A Payment

• MLN Matters Number: MM10080
• Related CR Release Date: May 12, 2017
• Related CR Transmittal Number: R716PI
• Related Change Request (CR) # 10080
• Effective Date: June 13, 2017
• Implementation Date: June 13, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10080.pdf
• Affects providers that submit institutional claims to Medicare Administrative Contractors (MACs) for inpatient hospital services provided to Medicare beneficiaries.

Summary: Clarifies the medical review requirements for Part A payment of short stay hospital claims (more commonly referred to as the "Two-Midnight" Rule) for MACs, Supplemental Medical Review Contractors (SMRC), Recovery Audit Contractors and the Comprehensive Error Rate Testing (CERT) contractors.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2017 Update

• MLN Matters Number: MM10107
• Related CR Release Date: May 18, 2017
• Related CR Transmittal Number: R3776CP
• Related Change Request (CR) Number: CR 10107
• Effective Date: July 1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10107.pdf
• Affects physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries

Summary: The HCPCS code set is updated on a quarterly basis. Change Request (CR) 10107 informs MACs of updating specific drug/biological HCPCS codes.

July 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.2

MLN Matters Number: MM10115

• Related CR Release Date: May 18, 2017
• Related CR Transmittal Number: R3777CP
• Related Change Request (CR) Number: 10115
• Effective Date: July1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10115.pdf
• Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary: The I/OCE is being updated July 1, 2017. The I/OCE routes all institutional outpatient claims (which includes non-Outpatient Prospective Payment System (OPPS) hospital claims) through a single integrated OCE.

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR); Delay of Effective Date

• Published in Federal Register May 19, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-05-19/pdf/2017-10340.pdf

Summary: This final rule finalizes May 20, 2017 as the effective date of the rule. It also finalizes a delay of the applicability date of the regulations from July 1, 2017 to January 1, 2018.

Q:

Several of our physicians sometimes have scribes do their documentation for them.  Do both the scribe and the physician have to sign this documentation?

A:

No; only the physician’s signature is required.  CMS recently released Transmittal 2017 updating the Medicare Program Integrity Manual to provide instructions to providers regarding signature requirements when scribe services are used by a physician/non-physician practitioner (NPP).

According to the Transmittal, “Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.” 

In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.

Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.

With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.

CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.

Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”

For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.

Code Groups

First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group. 

Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.  

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Key Takeaway from the Data:

• For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
• MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
• MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
• Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.

MS-DRG Shift from Surgical to Medical

Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely. 

In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:

• Patient A
• Dates of Service: 3/29/2016 – 4/19/2016
• Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
• Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
• MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
• Relative Weight: 17.657
• CMS FY 2016 National Average Reimbursement $95,944.77.
• Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
• MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
• Relative Weight: 1.0427
• CMS FY 2016 National Average Reimbursement $5,665.86
• Patient B
• Dates of Service: 5/3/2016 – 5/13/2016
• Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
• Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
• MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
• Relative Weight: 6.1746
• CMS FY 2016 National Average Reimbursement: $33,551.79 
• Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
• MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
• Relative Weight: 1.1925
• CMS FY 2016 National Average Reimbursement: $6,479.85
• Patient C
• Dates of Service: 7/18/2016 – 7/23/2017
• Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
• Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
• MS-DRG Assigned: 572 Skin Debridement without CC/MCC
• Relative Weight 1.0391
• CM FY 2016 National Average Reimbursement: $5,646.30
• Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
• MS-DRG 603: Cellulitis without MCC
• Relative Weight: 0.8429
• CMS FY 2016 National Average Reimbursement: $4,580.18

MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.

Resource:

2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html