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March Medicare Transmittals and Other Updates
Published on 

3/27/2017

20170327
 | Recovery Auditor 
 | Billing 
 | Medicare Coverage 
 | Outpatient Services 
 | Patient Status 

TRANSMITTALS

Gender Dysphoria and Gender Reassignment Surgery

Summary: Coverage determinations for gender reassignment surgery will continue to be made by the local MACs on a case-by-case basis.

April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1

Summary: Instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims.

Clarification of Admission Order and Medical Review Requirements

Summary: Clarifies the rulemaking language of the Centers for Medicare & Medicaid Services (CMS) as it relates to “Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.”

Billing for Advance Care Planning (ACP) Claims

Summary: Provides billing instructions for ACP when furnished as an optional element of an AWV. CMS has made the CPT code 99497 (Advance care planning) separately payable for Medicare OPPS claims when the service meets the criteria for separate payment under OPPS.

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

  • MLN Matters® Number: MM 10005
  • Related Change Request (CR) #: CR 10005
  • Related CR Release Date: March 3, 2017
  • Effective Date: April 1, 2017
  • Related CR Transmittal #: R3728CP
  • Implementation Date: April 3, 2017
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10005.pdf
  • Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).

Summary: Describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update.

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

Summary: Announces the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services. This is a Recurring Update Notification that applies to Chapter 16, Section 120.2, of the ʺMedicare Claims Processing Manual.”

 

Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

Summary: This article was rescinded on March 15, 2017. Information on the inpatient transfer policy is located in the "Medicare Claims Processing Manual" (100-04), Chapter 3. For questions concerning clarification on the proper usage of patient discharge status codes, providers should be utilizing the "UB-04 Manual" which is maintained by the National Uniform Billing Committee.  

 

OTHER MEDICARE ANNOUNCEMENTS

 

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

Summary: This interim final rule with comment period (IFC) further delays the effective date of the final rule entitled ‘‘Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model’’ from March 21, 2017 until May 20, 2017. This IFC also delays the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to October 1, 2017 and effective date of the specific CJR regulations itemized in the DATES section from July 1, 2017 to October 1, 2017. We seek comment on the appropriateness of this delay, as well as a further applicability date delay until January 1, 2018.

Proposed Decision Memo for Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (CAG-00449N)

Summary: CMS) proposes that the evidence is sufficient to cover supervised exercise therapy (SET) for beneficiaries with intermittent claudication (IC) for the treatment of symptomatic peripheral artery disease (PAD). 

OIG Report on Outpatient Dental Services
Published on 

3/20/2017

20170320
 | FAQ 
 | OIG 
 | Outpatient Services 

A recent television commercial shows an older gentleman with whom all the older ladies want to dance. He attributes his popularity with the ladies to his beautiful smile and perfect dentition. Unfortunately, older Americans will not be getting that perfect smile paid for by Medicare. Medicare does not cover dental services except in rare circumstances. That is a shame, because good dental health affects much more than just a person’s popularity. Poor dental hygiene also contributes to an increased risk for heart disease, stroke, dementia, respiratory problems, and diabetic complications.

Per the Social Security Act, Medicare does not cover items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. Medicare only covers dental services if they are incident to and an integral part of a procedure or service that is covered by Medicare. For example, tooth extractions performed in preparation for radiation treatment for jaw cancer would be covered, but tooth extractions because of tooth decay are not.

The Office of Inspector General (OIG) has identified improper payments for non-covered dental services as a topic in their annual Work Plan since 2012. This March, the OIG released their report summarizing the results of audits of dental services’ payments for six Medicare Administrative Contractors (MACs). Those MACs are CGS, First Coast, NGS, Noridian, Novitas, and WPS. The audit report also includes recommendations CMS could implement to help ensure that future claims for hospital outpatient dental services meet Medicare coverage requirements.

The OIG selected a sample of 600 claims from a total of 15,690 hospital outpatient dental services for the six contractors, totaling $10,874,814 paid to providers during the period January 1, 2011, through December 31, 2014.  They did not include dental services associated with a diagnosis related to cancer or physical trauma because those services are generally eligible for Medicare payment. On the basis of their results, the OIG estimated that the six contractors improperly paid providers an estimated $9,783,023 for hospital outpatient dental services that did not comply with Medicare requirements. This is approximately 90% of the total dental service payments considered. The types of dental services performed and paid that are not covered by Medicare included:

  • tooth socket repairs, generally performed in preparation for dentures,
  • routine oral evaluations, x rays, and tooth extractions,
  • excisions and gum repair (performed when removing inflamed gums and when reshaping healthy gums for a cosmetic or functional purpose), and
  • periodontal osseous surgery (performed when treating gum disease).

The OIG recommended the implementation of national edits for hospital outpatient dental claims, but CMS did not concur with this recommendation since dental coverage is based on the specific clinical needs of the beneficiary. CMS does agree to work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.

It pays to take care of your teeth when you are young, because once you reach Medicare age, you are on your own.

Debbie Rubio

Cardiac Rehab Requirements
Published on 

3/10/2017

20170310
No items found.

“Learn from the mistakes of others. You can never live long enough to make them all yourself.”― Groucho Marx

Last month, CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15, published results of their ongoing service-specific complex medical review of cardiac rehabilitation services. One J15 state improved their charge denial rate but the other state’s denial rate increased. And overall neither of the charge denial rates are that great, ranging this quarter from 46.8% to 55.7% which means about half of the cardiac rehab charges submitted are being denied. The good news here is that the rest of us can learn from the mistakes of others and proactively address the documentation deficiencies identified in the CGS medical review.

In addition to “requested records not submitted,” the main denial reasons in the CGS review were that the cardiac rehab sessions did not include all the required services and the physician supervision requirements were not met. Specifically for the required cardiac rehab service components, the review findings noted “the following components of the cardiac rehabilitation program were not submitted in the medical record:

  • Physician-prescribed exercise
  • Cardiac risk factor modification
  • Psychosocial assessment
  • Outcomes assessment
  • An individualized treatment plan”

Years ago, CGS published an article that describes the requirements for cardiac rehab (originally published September 24, 2012, but updated August 24, 2016). Here is information from the article that addresses the components identified as missing in the medical review. Please refer to the entire article at the link above for more complete information.

  1. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.
  2. There should be documentation in the chart that the physician prescribed a specific exercise for each day (a note or order from the physician, signed and dated) and a record showing the patient did the exercise.
  3. The physician's prescription for exercise should include the mode of exercise (typically aerobic), the target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs), the duration of each session (e.g., "20 minutes") and the frequency (number of sessions per week).
  4. The cardiac rehab professional supervising the patient’s exercise should document the patient's name, date, a description of the exercise showing the doctor's prescription was followed, and their signature and credentials.
  5. They should also monitor and record the patient's objective and subjective responses to the exercise therapy.
  6. Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patient's individual needs.
  7. The plan of care prescribed and signed by the physician should include a comment that cardiac risk factor modification will be addressed, which risk factors are important to this particular patient (cholesterol lowering for example, or sedentary life-style, or tobacco use) and directing education, counseling and behavioral intervention.
  8. The record must contain documentation demonstrating how such risk factors were addressed with concurrent notes, signed and dated by the appropriate individual at the time these services are delivered.
  9. A form signed and dated stating, "tobacco cessation education done” is not adequate documentation. There should also be a progress note discussing what intervention is made and its outcome by the person who does the intervention.
  10. Psychosocial assessment documentation should be present.
  11. Although a psychologist or psychiatrist may conduct this assessment, recognized tools for depression screening, accompanied by the physician's plan of action based on the results is also acceptable.
  12. A note stating a standardized test was done and its score is not sufficient documentation of a psychosocial assessment.
  13. Documentation should include the dated signature of the health care professional who conducted the assessment; an interpretation of the results; and the dated signature of the physician who utilized the results of the recognized screening tool to prepare the plan of care.
  14. Outcomes assessment
  15. The outcomes assessment shows whether services did or did not result in benefit to the patient (such as weight loss, walking distance, etc.).
  16. If a goal was not met, it is prudent to include what modifications were made to the care plan to address the failure.
  17. The assessment must be signed and dated by the person doing the assessment, with his or her credentials, on the day the assessment is done.
  18. An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days
  19. A progress note from the treating physician, done at the time of admission to the cardiac rehabilitation program that explains
  20. the patient's clinical history,
  21. the reason for the prescription of cardiac rehabilitation (covered diagnosis/condition),
  22. a discussion of the individual patient's needs and how they would be met by an exercise program, and
  23. incorporates components #1-3 above, i.e. description of the exercise program, risk factor modification program, and goals for the psychosocial assessment.
  24. Documentation from the treating physician no later than 30 days into treatment that utilizes the outcomes assessment (#4 above) to specify any modifications needed in the plan of care previously prescribed, or reason(s) to continue the present plan.

Direct physician supervision in a hospital department means a physician is immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. Non-physician practitioners may not serve the supervising role for cardiac rehabilitation services.

CGS’s article makes it clear that the required components of cardiac rehab cannot simply be check-boxes that are marked off. Each component serves a purpose in ensuring the patient’s needs are identified, addressed, and met by the cardiac rehab program. By studying the findings of the CGS review and the related education article, providers can learn from the mistakes of others and be better prepared to weather a review themselves.

Debbie Rubio

Medicare Signature Requirements
Published on 

3/6/2017

20170306
 | Documentation 

Medicare requires that practitioners ordering or providing services authenticate their orders and other documentation notes. A simple enough concept, but sometimes it is the simple things that seem to trip us up. Medicare reviews often cite lack of physicians’ signatures on orders, procedure notes, diagnostic reports or progress notes as a documentation deficiency that could result in a denial of payment. A review of Medicare signature requirements is an excellent reminder of the basics of good documentation.

What forms of signatures are acceptable?

Signatures may be handwritten or electronic. Stamped signatures generally are not acceptable, but are permitted in the case of an author with a physical disability who can provide proof to a CMS contractor of inability to sign due to the disability.

Can signatures be added to documentation that is not signed?

No. Providers may not add late signatures to medical records beyond the short delay that occurs during the transcription process.

Medicare does not accept retroactive orders. If an order is unsigned and there are no signed progress notes that specify the tests/services being ordered, a Medicare reviewer will disregard the order. This will result in a documentation error, which may involve recoupment of an overpayment.

For other types of medical record documentation that lack a signature besides orders, an attestation statement from the author of the medical record may be submitted. An attestation may read as follows, though no specific format is required:

            “I, John R. Doe (printed name), hereby attest that the medical record entry for March 9, 2016 accurately reflects signatures/notations that I made in my capacity as M.D. when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Must orders for clinical diagnostic tests be signed?

No - but yes. The order for a clinical diagnostic test does not have to be signed. However, if the order itself is not signed, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the clinical diagnostic test be performed. The documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature. It also must specify the tests ordered; simply saying “labs ordered” is not sufficient. And, a copy of this signed documentation must be submitted to the Medicare contractor in the case of a Medicare review.

What if a signature is illegible?

If there is a printed signature below the illegible signature, this is acceptable. Providers can also submit a signature log to address illegible signatures. A signature log should list the typed or printed name of the author associated with the author’s handwritten initials or signature. Note that providers may create and submit a signature log at any time. It is a good practice to maintain a signature log of all practitioners.

Another way to address illegible signatures is an attestation statement. The attestation must be signed and dated by the author of the medical record entry in order to be valid for Medicare medical review purposes. It also must contain sufficient information to identify the Medicare patient/beneficiary.

Must signatures be dated?

It depends. If Medicare regulations specify that a date is required for the particular type of documentation then it must be dated. For example, for rehabilitative therapy services, the Medicare Benefit Policy manual states, “Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.” Therefore, for therapy certifications, a dated signature is required.

If the Medicare regulations do not specify that a date is required, undated documentation may be acceptable. Documentation that is not dated is acceptable for medical review purposes if the reviewer is able to determine the date the service was performed and/or ordered based on other documentation in the record.

Since the issue of missing and illegible signatures continues to be a common error, Medicare provides a variety of resources addressing the requirements. Providers must get back to the basics of documentation by ensuring appropriate signatures are present.

Debbie Rubio

Pleural Effusion Coding
Published on 

2/28/2017

20170228
 | RAC Information 
 | FAQ 

Q:

What is the appropriate diagnosis code for Pleural Effusion when there is documentation of Pleural Effusion with CHF and the Pleural Effusion requires a Thoracentesis?


A:

Assign J91.8, Pleural Effusion in Other Conditions Classified Elsewhere, when the Pleural Effusion with CHF requires treatment, such as a Thoracentesis or diagnostic testing. Typically, Pleural Effusion with CHF would not be reported because it is minimal and does not require specific treatment. Previously, in ICD-9-CM, we used 511.9, Unspecified Pleural Effusion. Resource: Coding Clinic, Second Quarter 2015, page 15

MOON Countdown: Definitions, FAQs and Resources
Published on 

2/28/2017

20170228
 | Recovery Auditor 
 | Documentation 
 | Patient Status 

Hospitals are at T-7 days for the March 8, 2017 compliance date with the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act). In the spirit of last minute preparations, this article is meant to reinforce key definitions, provide CMS responses to comments found in the 2017 IPPS Final Rule in the form of questions and answers and links to MOON resources.

 

Definitions

The MOON is intended to inform beneficiaries who receive observation services for more than 24 hours that they are outpatients receiving observation services and not inpatients, and the reasons for such status.

  • Outpatient Defined
    The Medicare Claims Processing Manual (Pub. 100-04), Chapter 1, Section 50.3.1, defines an Outpatient as “a person who has not been admitted as an inpatient but who is registered on the hospital or critical access hospital (CAH) records as an outpatient and receives services (rather than supplies alone) directly from the hospital or CAH.”
  • Observation Services
    Observation services are “services that are reasonable and necessary, specifically ordered by a physician or other nonphysician practitioner authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services, and meet other published Medicare criteria for payment.”

    “Individuals receiving observation services will always be registered as outpatients; however, not all outpatients receive observation services.”
  • Decision to order Observation Services
    “By definition… the reason for ordering observation services will always be the result of a physician’s decision that the individual does not currently require inpatient services and observation services are needed for the physician to make a decision regarding whether the individual needs further treatment as a hospital inpatient or if the individual is able to be discharged from the hospital.” (Source: 2017 IPPS Final Rule referencing the Medicare Benefits Policy Manual (Pub. 100-02), Chapter 6, Section 20.6.)

Questions and Answers

Again, CMS’ responses to comments from the 2017 IPPS Final Rule have been formatted as Questions and Answers.

Question: Several commenters requested clarification as to whether the timeframe starts:

  1. After services begin following the written order for observation services;
  2. When related services commence if such services commence before the written order was executed and the patient occupies an outpatient bed count; or
  3. Based on the documentation of when nursing care began.

Answer: CMS indicated “there may be times when an individual is subject to an order for observation services, but is not actually receiving observation services. For example, following an order for observation services in an emergency department, a hospital may need to wait to begin furnishing observation services until a bed is available for the patient. In this situation, services are considered initiated when observation services commence.”

They went on to clarify “that the start of observation services, for the purposes of determining when more than 24 hours of observation services have been received, is the clock time as documented in the patient’s medical record at which observation services are initiated (furnished to the patient) in accordance with a physician’s order.”

Question: Will time be counted as Billable or Elapsed Time?

Answer: CMS believes using elapsed time is most consistent with language in the NOTICE Act. “Therefore, for purposes of identifying the 24-hour timeframe for which an individual has received observation services, and thus is required by the NOTICE Act to receive notice by the hospital or CAH, observation time will be measured as the elapsed time in hours beginning at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.”

Question: What if the Inpatient Admission occurs prior to delivery of the MOON?

Answer: As recommended by a commenter, CMS agrees that when “an inpatient admission occurs prior to delivery of the MOON, the MOON should be annotated with date and time of the inpatient admission. Therefore, we are requiring that, in the event that a patient is subsequently admitted as a hospital inpatient directly after receiving observation services for more than 24 hours, and the inpatient admission occurs prior to delivery of the MOON, the MOON be annotated with the date and time of the inpatient admission. Additional guidance regarding elements for the free text field of the MOON will be provided in the CMS Internet Only Manual.”

Question: How will the MOON work with the 2-Midnight Policy?

Answer: “The NOTICE Act requires hospitals to inform patients who have remained outpatients of the hospital and received observation services for more than 24 hours that they are not hospital inpatients and are subject to potentially different cost-sharing requirements and postacute care benefits than someone who has been admitted as an inpatient. We note that a scenario could arise whereby a patient is admitted to the hospital immediately after being a hospital outpatient receiving observation services for greater than 24 hours. In such a scenario, the inpatient admission may be payable under Medicare Part A under the 2-midnight policy and, as stated earlier, the hospital or CAH would still be required to furnish the MOON to the patient within 36 hours after the time the individual begins receiving observation services.”

Question: Can a Hospital or CAH deliver the MOON before an individual has received more than 24 hours of observation services as an inpatient?

Answer: Yes.

  • This affords hospitals flexibility to deliver the MOON consistent with any applicable state law requiring notice within 24hrs.

    Note: “Hospitals and CAHs subject to State law notice requirements may also attach an additional page to the MOON to supplement the “Additional Information” section in order to communicate additional content required under State law, or may attach the notice required under State law to the MOON.”
  • This allows hospitals and CAHs to spread out the delivery of the MOON and other hospital paperwork in an effort to avoid overwhelming and confusing beneficiaries.

    Note: CMS does not encourage delivery of the MOON at the initiation of outpatient observation services.

Question: Can the MOON form be altered?

Answer: No, because the MOON is a standard form approved by the Office of Management and Budget (OMB), Hospitals and CAHs are not permitted to alter the included language, only the information to be included in the free text fields.

The MOON must remain two pages, except as needed for the additional information field. The pages of the notice can be two sides of one page or one side of separate pages, but must not be condensed to one page.

Hospitals may include their business log and contact information on the top of the MOON. Text may not be shifted from page 1 to page 2 to accommodate large logos, address headers, or any other information.

Question: Can you use “drop down” boxes in the free text field for telling the patient why they are not an inpatient?

Answer: CMS indicates in the 2017 IPPS Final Rule, “We may consider, in the future, the other suggestions commenters made to improve the MOON, such as checkboxes with common reasons for the patient’s outpatient status or suggested narratives for insertion in this section.”

Question: If more space is needed for “Additional Information”, may a Hospital attach additional pages to the MOON?

Answer: Yes

Question: Can you (CMS) clarify the effect of a resident’s order for services on the counting of hours of observation care?

Answer: “To the extent that a resident is authorized by State licensure law and hospital staff bylaws to order outpatient services, once observation services are initiated in accordance with the resident’s order, the 24 hour time period will commence.”

Question: What do you do if the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation?

Answer: As discussed in the proposed rule (81 FR 25134), an English language version of the proposed MOON was submitted to OMB for approval. We stated in the proposed rule that once we receive OMB approval, a Spanish language version of the MOON will be made available. If the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, we expect hospitals and CAHs to employ their usual procedures to ensure notice comprehension. (We refer readers, for example, to the Medicare Claims Processing Manual (Pub. 100–4), Chapter 30, Section 40.3.4.3., for similar existing procedures related to notice comprehension for the Advance Beneficiary Notice of Noncoverage (ABN).) Usual procedures may include, but are not limited to, the use of translators, interpreters, and assistive technologies. Hospitals and CAHs are reminded that recipients of Federal financial assistance have an independent obligation to provide language assistance services to individuals with limited English proficiency (LEP) consistent with section 1557 of the Affordable Care Act and Title VI of the Civil Rights Act of 1964. In addition, recipients of Federal financial assistance have an independent obligation to provide auxiliary aids and services to individuals with disabilities free of charge, consistent with section 1557 of the Affordable Care Act and section 504 of the Rehabilitation Act of 1973.”

Question: Does the beneficiary have appeal rights under the NOTICE Act?

Answer: No, “The MOON is a required informational/educational notice regarding patient status provided by a hospital or CAH when the beneficiary is still in the hospital or CAH and receives observation services as an outpatient for more than 24 hours. The MOON explains the current status of the patient as an outpatient and not an inpatient, in addition to the implications of being an outpatient receiving observation services. As we explained in the proposed rule, delivery of the MOON does not constitute an initial determination issued in response to a claim for benefits, and the MOON itself is not a notice of an initial determination (81 FR 25134). Furthermore, delivery of the MOON by a hospital or CAH does not constitute a denial of coverage of any services, and does not constitute a noncoverage decision with respect to post-hospital SNF care as asserted by the commenter. In fact, generally beneficiaries will still be receiving care when the MOON is delivered and will sometimes be formally admitted as inpatients after delivery of the MOON.

The NOTICE Act does not provide for appeal rights regarding the notice itself, which makes sense given the nature of the document, as explained above. The NOTICE Act also does not afford any new appeal rights beyond those already available (under section 1869 of the Social Security Act), nor does the NOTICE Act limit or restrict currently available appeal rights. Consistent with the legislation, the proposed rule did not propose to expand or limit appeal rights. For the reasons discussed above, we are not adopting the various recommendations with respect to amending the MOON to include appeal rights or an explanation of the lack of appeal rights.”

 

MOON and Condition Code 44

“In rare circumstances where a physician initially orders inpatient services, but following internal utilization review (UR) performed while the patient is hospitalized, the hospital determines that the services do not meet its inpatient criteria and the physician concurs with UR and orders the discontinuation of inpatient services and initiation of outpatient observation services (that is, a Condition Code 44 situation), we stated in the proposed rule that the MOON would be delivered as required by the NOTICE Act (when outpatient observation services have been ordered and furnished for more than 24 hours). If observation services are ordered when Condition Code 44 applies, the 24-hour time period for observation notification commences at the same time that observation services are initiated under a physician’s order, consistent with existing policy for observation services furnished to outpatients. (We refer readers to the Medicare Claims Processing Manual (Pub. 100–04), Chapter 1, Section 50.3.)

As discussed in the proposed rule and as stated in the notice announcing CMS Ruling CMS–1455–R (78 FR 16614), the Part B Inpatient Billing Ruling, in cases where reviewers find that an inpatient admission was not medically reasonable and necessary after the beneficiary is discharged, and thus, not appropriate for payment under Medicare Part A, the beneficiary’s patient status remains ‘‘inpatient’’ as of the time of the inpatient admission. The patient’s status is not changed to outpatient because the beneficiary was formally admitted as an inpatient, and there is no provision to change a beneficiary’s status after he or she is discharged from the hospital. Where CMS denies a claim after the beneficiary has been discharged because the inpatient admission was not medically reasonable and necessary, there would be no need to issue the MOON because the individual’s status remains inpatient, despite the fact that the inpatient admission was improper. Similarly, where a hospital determines through UR after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary and the hospital bills the services that were provided on a Medicare Part B claim, the NOTICE Act notification requirements would not apply for these individuals because their status would also remain inpatient.” (Excerpt from page 281-282 2017 IPPS Final Rule pdf document)

 

MOON Resources

Beth Cobb

February Medicare Transmittals and Other Updates
Published on 

2/28/2017

20170228
 | Recovery Auditor 
 | Coding 
 | Outpatient Services 

TRANSMITTALS

Medicare Outpatient Observation Notice (MOON) Instructions

Summary: Updates Chapter 30 of the “Medicare Claims Processing Manual” to include the Medicare Outpatient Observation Notice (MOON), CMS-10611, and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). The instructions included in Chapter 30 provide guidance for proper issuance of the MOON.

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

  • MLN Matters® Number:MM9861
  • Related Change Request (CR) #: CR 9861
  • Related CR Release Date: February 3, 2017
  • Effective Date: October 1, 2016 - Unless otherwise noted in individual requirements
  • Related CR Transmittal #: R1792OTN
  • Implementation Date: March 3, 2017 - MAC local systems; April 3, 2017 - FISS, MCS, CWF Shared systems
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9861.pdf
  • Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 10th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Revisions to State Operations Manual (SOM), Appendix C-Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services

Implementation of New Influenza Virus Vaccine Code

Summary: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90682 (Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use) for claims with dates of service on or after July 1, 2017.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.1, Effective April 1, 2017

Summary: The latest package of Correct Coding Initiative (CCI) Procedure to Procedure (PTP) edits, Version 23.1, effective April 1, 2017. The National Correct Coding Initiative (NCCI) developed by the Centers for Medicare & Medicaid (CMS) helps promote national correct coding methodologies and controls improper coding.

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

  • MLN Matters® Number: MM9911
  • Related Change Request (CR) #: CR 9911
  • Effective Date: for claims processed on or after October 2, 2017
  • Related CR Release Date: February 3, 2017
  • Related CR Transmittal #: R3715CP
  • Implementation Date: October 2, 2017
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf
  • Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Summary: Modifies the Medicare claims processing systems to help providers more readily identify the Qualified Medicare Beneficiary (QMB) status of each patient and to support providers’ ability to follow QMB billing requirements.

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

Summary: CMS will establish two (2) new set-aside processes: a Liability Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA). An LMSA or an NFMSA is an allocation of funds from a liability or an auto/no-fault related settlement, judgment, award, or other payment that is used to pay for an individual’s future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by Medicare.

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

Summary: Revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat-rate basis using HCPCS code P9604 for Calendar Year (CY) 2017.

Advance Care Planning (ACP) Implementation for Outpatient Prospective Payment System (OPPS) Claims

Summary: Implements system changes necessary to process Advance Care Planning (ACP) services for OPPS claims.

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

  • MLN Matters® Number: MM9982
  • Related Change Request (CR) #: CR 9982
  • Effective Date: July 1, 2017 (Unless otherwise noted in individual NCDs)
  • Related CR Release Date: February 17, 2017
  • Related CR Transmittal #: R1798OTN
  • Implementation Date: March 20, 2017, for MAC edits and July 3, 2017, for Shared Systems
  • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9982.pdf
  • Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: The 11th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

Episode Payment Model Operations

Summary: Prepares Medicare’s claims processing systems and provides information for implementation of Episode Payment Models (EPMs)

 

OTHER MEDICARE ANNOUNCEMENTS

Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures

Summary: This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, this final rule revises procedures that the Department of Health and Human Services follows at the Centers for Medicare & Medicaid Services (CMS) and the Medicare Appeals Council (Council) levels of appeal for certain matters affecting the ALJ level.

Recommendations to Providers Regarding Cyber Security

Summary: The Centers for Medicare & Medicaid Services (CMS) is reminding providers and suppliers to keep current with best practices regarding mitigation of cyber security attacks. We have outlined resources to assist facilities in their reviews of their cyber security and IT programs.

U.S. Department of Justice: Evaluation of Corporate Compliance Programs

Summary: The DOJ must evaluate corporate compliance programs in the specific context of a criminal investigation. In conducting an investigation of a corporate entity, determining whether to bring charges, and negotiating plea or other agreements, prosecutors should consider specific factors such as “the existence and effectiveness of the corporation’s pre-existing compliance program” and the corporation’s remedial efforts “to implement an effective corporate compliance program or to improve an existing one.” This document provides some important topics and sample questions that the Fraud Section (of the DOJ) has frequently found relevant in evaluating a corporate compliance program.

Payment Reduction for Film X-Rays and Computed Radiography
Published on 

2/21/2017

20170221
No items found.

Q:

I understand that beginning January 1, 2017, Medicare requires a FX modifier be reported on x-rays taken using film so they can reduce the payment amount. We actually do not use film for our x-rays. For our imaging equipment that is not digital we convert the images to a digital format that is uploaded to our PACS. If we are converting our images to digital, does the FX modifier reporting requirement and payment reduction apply to us?


A:

The short answer is no. The process you describe is computed radiography. Computed radiography (CR) uses very similar equipment to conventional radiography except that in place of a film to create the image, an imaging plate (IP) made of photostimulable phosphor is used. The imaging plate is run through a special laser scanner, or CR reader, that reads and digitizes the image. The digital image can then be viewed and enhanced using software that has functions very similar to other conventional digital image-processing software, such as contrast, brightness, filtration and zoom. (Wikipedia definition)However, beginning in 2018 Medicare will make payment reductions for computed radiography (CR) services also. Payment reductions for both film x-rays and computed radiography are from a provision in the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. The purpose of this provision of the Act is to encourage U.S. healthcare providers to adopt digital radiography (DR) which improves workflow and efficiency as well as delivering lower radiation doses. From a financial standpoint, DR lowers the cost per procedure by allowing for higher throughput.

Effective January 1, 2017, the required reporting of the FX modifier for film x-rays will cause Medicare to reduce the payment amount for the x-ray by 20%. Starting in 2018, payments for imaging studies performed on CR equipment will be reduced by 7% for the next five years (2018-2022), and 10% after that. Medicare will announce the reporting requirements for x-rays using CR equipment, such as reporting a modifier, prior to the 2018 effective date.

Comments from the industry indicate the impact for film x-rays will be minimal because there are very few hospitals that still use film-based systems. Many more CR systems are in use so this payment reduction is likely to affect a lot more hospitals. Before next year, hospitals that use CR equipment will have to decide whether it is more financially beneficial to update their CR systems to digital or accept the reduced payments. 

Arthroscopic Shoulder Debridement
Published on 

2/7/2017

20170207
 | RAC Information 
 | FAQ 

Q:

Can debridement be reported separately in addition to shoulder arthroscopy procedures?


A:

The answer is it depends. Although the shoulder has three “areas” or “regions”: the glenohumeral joint, the acromioclavicular joint and the subacromial bursal space, CMS generally considers the shoulder to be a single anatomic structure. Arthroscopic treatment of a shoulder injury in adjoining areas of the same (ipsilateral) shoulder constitutes treatment of a single anatomic site. National Correct Coding Initiative (NCCI) procedure-to-procedure edits should not be bypassed with the addition of a modifier for arthroscopic shoulder procedures unless performed on the opposite (contralateral) shoulder.Limited debridement (e.g. CPT code 29822) and usually extensive debridement (e.g. CPT code 29823) are included in shoulder arthroscopy procedures even if the limited debridement is performed in a different area of the same shoulder than the other procedure. According to the American Association of Orthopaedic Surgeons Coding, Coverage and Reimbursement Committee, “Code 29822 covers limited debridement of soft or hard tissue and should be used for limited labral debridement, cuff debridement or the removal of degenerative cartilage and osteophytes. Code 29823 should be used only for extensive debridement of soft or hard tissue. It includes a chondroplasty of the humeral head or glenoid and associated osteophytes or multiple soft tissue structures that are debrided such as labrum, subscapularis and supraspinatus.” (see April 2006 AAOS Bulletin)

However, CMS does make three exceptions related to separate reporting of extensive debridement in Section E, Chapter 4 of the NCCI policy manual. If extensive debridement (CPT 29823) is performed in a different area of the same shoulder with one of the following arthroscopic shoulder procedures, it may be reported separately:

  • CPT 29824 – Arthroscopic claviculectomy including distal articular surface
  • CPT 29827 – Arthroscopic rotator cuff repair
  • CPT 29828 – Biceps tenodesis

Remember, the separate reporting of extensive debridement only applies to the three CPT codes listed above. Extensive debridement is included in other shoulder arthroscopy procedures, for example CPT codes 29806, 29807, and 29821. Section I. of Chapter 4 of the NCCI policy manual states, “With limited exceptions open or arthroscopic procedures performed on a joint include debridement (open or arthroscopic) if performed. A debridement code may be reported with a joint procedure code only if the debridement is performed on a different joint or at a site unrelated to the joint. See Section E (Arthroscopy) for discussion of exceptions.”

Reference: National Correct Coding Initiative (NCCI) Policy Manual, 2017, Chapter 4. 

Coding Guidelines for Respiratory Failure
Published on 

2/7/2017

20170207
No items found.

It seems that in the world of coding, “respiratory failure” (whether acute, chronic or acute on chronic) continues to be a daily challenge. Very seldom is it a simple cut and dry diagnosis. There always seems to be just enough gray to give coders on any given day some doubt. It’s not only important for a coder to be familiar with the guidelines associated with respiratory failure but they should also be aware of the basic clinical indicators as well.

OFFICIAL CODING GUIDELINE Acute or acute on chronic respiratory failure may be reported as principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Refer to Section II of the ICD-10-CM Official Guidelines for Coding and Reporting on “Selection of Principal Diagnosis”.

 

Please note: Coding must be based on provider documentation. Establishing a patient’s diagnosis is the sole responsibility of the provider. Coders should not disregard physician documentation and/or their clinical judgement of a diagnosis, based on clinical criteria published by Coding Clinic or any other source. Sources such as Coding Clinic should be used to become familiar with clinical criteria for a condition to guide coders in reporting the most accurate and specified diagnosis/procedure possible.   If for any reason there is doubt due to lack of clinical indicators/criteria, then that physician should be queried for clarification. Refer to Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinic 4th Qtr. 2016 page 147 for further clarity on this guideline.

Respiratory Failure

  1. Life-threatening condition that may be caused by a respiratory condition as well as a non-respiratory condition.
  2. Look for documented signs / symptoms of:
  3. SOB (shortness of breath)
  4. Delirium and/or anxiety
  5. Syncope
  6. Use of accessory muscles / poor air movement
  7. Distended neck veins / peripheral edema
  8. Tachycardia
  9. Tachypnea
  10. Confusion
  11. Sleepiness
  12. Altered consciousness
  13. Cyanosis (bluish color to skin, lips and/or fingernails)
  14. Pursed lips
  15. Difficulty / inability speaking due to respiratory difficulty
  16. Profuse sweating
  17. Restlessness
  18. Acute Respiratory Failure is supported as principal diagnosis when at least 2 of the following critical values (ABG’s) are met.
  19. pH < 7.35
  20. PO2 < 55
  21. PCO2 > 50
    Keep in mind, this is a guideline and not solely to be the determining factor for   diagnosing Acute Respiratory Failure. A patient with a chronic lung disease such as COPD may have an abnormal ABG level that could actually be considered that particular patient’s baseline. What is normal for one patient could be abnormal for another. In a patient with a chronic lung condition, the physician would consider the degree of change from a patient’s baseline before diagnosing Acute Respiratory Failure.
  22. Acute Respiratory Failure
  23. Common causes:
  24. Pneumonia
  25. Cardiac arrest
  26. Chest trauma
  27. Overdose
  28. Heart failure
  29. Pulmonary embolism
  30. COPD exacerbation
  31. Asthma exacerbation
  32. Inhalation of toxic chemicals, smoke or fumes
  33. Stroke
  34. Obstruction
  35. Develops quickly
  36. Short-term condition
  37. Usually admitted to ICU
  38. Requires aggressive and/or emergency treatment via oxygen through nasal cannula, face mask, ventilation and/or tracheostomy
  39. Patient receiving 40% or more supplement O2 strong indication
  40. Absence of vent does not preclude diagnosis
  41. Requires close monitoring and evaluation
  42. Respiratory Acidosis (CC)
  43. Is the same as Acute Hypercapnic Respiratory Failure
  44. Respiratory Acidosis is a “CC” whereas Acute Hypercapnic Respiratory Failure is a “MCC”
  45. Query for clarification when Respiratory Acidosis is documented
  46. Chronic Respiratory Failure
  47. Common Causes:
  48. COPD
  49. Pulmonary fibrosis
  50. Cystic fibrosis
  51. Interstitial lung disease
  52. Spinal cord injury
  53. Muscular dystrophy
  54. Chest injury
  55. Develops gradually overtime
  56. Ongoing condition that requires long-term treatment
  57. Home O2 and/or trach status are indications of CRF
  58. Post-procedural Respiratory Failure
  59. Code J95.821 is reported when respiratory failure follows surgery
  60. Code J95.822 is reported when respiratory failure follows surgery and the patient has known/documented chronic respiratory failure

 Four classification types for ARF

  • Hypoxic – most common
  • Common acute symptoms:
  • Tachycardia
  • SOB
  • Rapid breathing
  • Confusion
  • Inability to communicate
  • Hypotension
  • Hypercapnia – often accompanied by hypoxemia
  • Common acute symptoms
  • Dizziness
  • Muscle weakness / twitching
  • Elevated blood pressure
  • Tachycardia
  • Lethargy
  • Headache
  • Confusion
  • Flushed skin
  • Post-operative
  • Shock – Septic, Cardiogenic or Hypovolemic

Treatment

  • Humidified oxygen therapy
  • Mechanical ventilation, BiPAP, CPAP
  • Bronchodilation
  • Establish electrolyte and pH balance
  • Treatment of the underlying source/cause

 

Acute Respiratory Failure as Principal Diagnosis

OFFICIAL CODING GUIDELINE
ICD-10-CM codes from subcategory J96.0 or subcategory J96.2

Official Guidelines for Coding and Reporting:

ICD-10-CM – Section I.C.10.b.1

Acute or Acute on Chronic Respiratory Failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

‍OFFICIAL CODING GUIDELINE

ICD-10-CM codes from subcategory J96.0 or subcategory J96.2

Official Guidelines for Coding and Reporting:

ICD-10-CM – Section I.C.10.b.3

When a patient is admitted with Respiratory Failure and another acute condition (e.g., Myocardial Infarction, Cerebrovascular Accident, Aspiration Pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the Respiratory Failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II.C) may be applied in these situations.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

 

When coding Respiratory Failure (or any condition) and trying to determine whether it should be assigned as principal diagnosis or not, look for:

  1. All signs and symptoms at the time of admission
  2. Clinical indicators
  3. Supporting physician documentation
  4. Treatment plans

With any record, keep in mind that because a condition may be present on admission does not necessarily mean it qualifies for principal diagnosis. You have to ask yourself these questions:

  • After study, is this the condition that was chiefly responsible for admission?
  • How aggressive was the work-up and treatment?
  • Is there another condition that equally meets the criteria for principal diagnosis?
  • Are there any chapter specific guidelines to consider?
  • Could this condition have been treated as an outpatient?

I wish I could say that assigning the appropriate principal diagnosis and coding in general was as easy as ABC, but it’s not. Some are a little easier than others but there seems to always be a little gray area to muddle through. Clear and precise documentation goes a long way in helping to determine the principal diagnosis.

As you take on a record to code, forget about the one you just finished. Each record and the circumstances surrounding the admission will be different.   Always be aware of the coding guidelines and follow through the steps listed above. You’ll find that assigning the principal diagnosis will be a little easier.

References:

ICD-10-CM/PCS Official Coding Guidelines for 2017

2017 CDI Pocket Guide

2016 CDI Pocket Guide

2017 AHA Coding Handbook

Marsha Winslett

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