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The 2019 Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital Final Rule was released this past Thursday August 2nd. The display copy comes in at a mere 2,593 pages. So, if you are someone who likes to eat dessert before your meal or start a book by reading the ending, this article is for you. CMS finalized their “proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment.”  

Similar to there being so much more to a meal than dessert or a good story than the last page of a book, there is more you need to know and think about in relation to this finalized proposal. This article provides a look back at when this initially became a requirement, details an “almost apology” to hospitals from CMS, provides CMS’s expected outcomes from this rule change, a sampler, if you will, of some of the more notable comments to and responses from CMS and ends with an important list of items to keep in mind that did not change.

Background

In the 2014 IPPS Final Rule, CMS adopted the “2-Midnight” payment policy, codified “the longstanding policy that a beneficiary becomes a hospital inpatient if formally admitted pursuant to the order of a physician (or other qualified practitioner as provided in the regulations) in accordance with the hospital conditions of participation (CoPs), and made it a specific condition of Medicare Part A payment that a written inpatient admission order be present in the medical record.  

Commenters of the 2014 IPPS Proposed rule felt this requirement was “duplicative and burdensome on hospitals.” CMS’s response was that “The physician order reflects affirmation by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and the “order serves the unique purpose of initiating the inpatient admission and documenting the physicians (or other qualified practitioner as provided in the regulations) intent to admit the patient which impacts its required timing.”

They did “acknowledge that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”

Proposed Revision to the Policy, Why Now?

While the Final Rule does not include an apology to hospitals for making the status order a requirement of payment since October 1, 2013, CMS does note that, “it has come to our attention that some medically necessary inpatient admissions are being denied payment due to technical discrepancies with the documentation of inpatient admission orders.”

Common technical discrepancies cited by CMS include:

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

They further share they “have become aware that, particularly during the case review process, these discrepancies have occasionally been the primary reason for denying Medicare payment of an individual claim…we have concluded that if the hospital is operating in accordance with the hospital CoPs, medical reviews should primarily focus on whether the inpatient admission was medically reasonable and necessary rather than occasional inadvertent signature documentation issues unrelated to the medical necessity of the inpatient stay. It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for medically reasonable and necessary inpatient stays, even if such denials occur infrequently.”

Anticipated Outcome of Policy Revision

Two key outcomes CMS hopes to achieve through this Policy Revision are:

• First, to reduce this unnecessary administrative burden on physicians and providers, and
• Second, to “properly adjust the focus of the medical review process towards determining whether an inpatient stay was medically reasonable and necessary and intended by the admitting physician rather than towards occasional inadvertent signature or documentation issues unrelated to the medical necessity of the inpatient stay or the intent of the physician.”

Comments & CMS Responses

As mentioned earlier in this article, here are some key comments received and CMS responses related to the admission order policy change.

Comment: Concern the proposal may render the inpatient admission order completely insignificant and not required for any purpose.

CMS Response: “Our proposal does not change the requirement that, for purposes of Part A payment, an individual becomes an inpatient when formally admitted as an inpatient under an order for inpatient admission. The physician order remains a significant requirement because it reflects a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, and initiates the process for inpatient admission.”

Comment: Commenters referenced the January 2014 sub-regulatory guidance which explained that if a practitioner disagreed with the decision to admit a patient to inpatient status, the practitioner could simply refrain from authenticating the inpatient admission order and the patient would remain in outpatient status. There was a concern that if CMS no longer requires a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment, CMS would not be able to distinguish between orders that were simply defective and orders that were intentionally not signed.

CMS Response: “It should never have been the case that the only evidence in the medical record regarding this uncommon situation was the absence of the physician’s or other qualified practitioner’s signature. The medical record as a whole should reflect whether there was a decision by a physician or other qualified practitioner to admit the beneficiary as an inpatient or not.”

This fact is precisely why, under our current guidance, we acknowledged that in the extremely rare circumstance where the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors have discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record. We disagree with these commenters that reliance only on the absence of the signature in these uncommon situations reflected good medical documentation practice.”

Comment: Concerned the proposal would remove the requirement for an order altogether, affecting patient appeal rights, or increase financial liability.

CMS Response: “As stated earlier, the physician order remains a requirement for purposes of reflecting a determination by the ordering physician or other qualified practitioner that hospital inpatient services are medically necessary, initiating the inpatient admission. Additionally, regardless of this proposal and other physician order requirements described earlier, the hospital CoPs include the requirement that all Medicare inpatients must receive written information about their hospital discharge appeal rights.”

Commenters provided the example of a patient being in outpatient status receiving observation services but spent two medically necessary midnights and was discharged. The question being, can the stay be reviewed after discharge, a determination be made that the 2-midnight benchmark was met, and the hospital submit a claim for inpatient admission?

CMS responded by referring readers to the FY 2014 IPPS/LTCH PPS final Rule (78 FR 50942) where they stated that “The physician order cannot be effective retroactively. Inpatient status only applies prospectively, starting from the time the patient is formally admitted pursuant to a physician order for inpatient admission, in accordance with our current policy.”

Comment: Some commenters stated that the proposed policy change appears to suggest that the completion of admission orders would now be optional and other available documentation could be used to create retroactive orders.

CMS Response: “Regarding the comment about retroactive orders, it has been and continues to be longstanding Medicare policy to not permit retroactive orders. The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (for example, for a prescheduled surgery), but the inpatient admission does not occur until hospital services are provided to the beneficiary.”

Comment: Commenters inquired if the proposal would change the requirements regarding which practitioners are allowed to furnish inpatient admission orders.

Response: “The proposed revision relating to hospital inpatient admission order documentation requirements under Medicare Part A does not include revisions to the requirements regarding which practitioners are allowed to furnish inpatient admission orders.”

What was Not Proposed and Has Not Changed?

Hospitals have struggled with this requirement since it was finalized in the 2014 IPPS Final Rule. While I truly believe that this policy revision is a good thing for hospitals, it is vital to be mindful of what has not changed.

• Hospitals and physicians are still required to document relevant orders in the medical record to substantiate medical necessity requirements.
• The requirement remains that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.
• Nothing was proposed nor changed with respect to the “2 midnight” payment policy.
• Guidance from the Medicare benefits Policy Manual (MBPM), Chapter 1, Section 10.2 will not change. Specifically, “The order to admit may be missing or defective (that is, illegible, or incomplete, for example ‘inpatient’ is not specified), yet the intent, decision, and recommendation of the ordering practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record. In these situations, contractors have been provided with discretion to determine that this information provides acceptable evidence to support the hospital inpatient admission. However, there can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.”
• Physician certification of inpatient services continues to be a requirement for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities, and for cases of Critical Access Hospitals as per the CY 2015 OPPS/AC final rule (79 FR 66997), and 42 CFR part 312, subpart F, 42 CFR 424.13, and 42 CFR 424.15.

One final reminder, this policy change will become effective with hospital discharges on or after October 1, 2018. So for now stay vigilant with making sure there is a valid inpatient order in your records prior to the beneficiary being discharged.

Be on the lookout for more articles about the Final Rule over the next few weeks. Until then, you can access a copy of the Final Rule on the CMS IPPS Homepage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2019-IPPS-Final-Rule-Home-Page.html.

I did not realize the extent of peripheral nerve stimulation procedures until I started reading all of the related Medicare coverage policies – there was so much information, it almost got on my last nerve. All peripheral nerve stimulation is not the same. This is evidenced by several new coverage, or more accurately, non-coverage articles this month from the Medicare Administrative Contractors (MACs). Below is a listing of the MAC local coverage determinations (LCDs) and coverage articles that address peripheral nerve stimulation. Some of the policies listed may have a future effective date due to recent changes in coverage. You can easily view these policies by going to the Medicare Coverage Database and entering the Policy number in the Quick Search ‘Document ID’ field. 

There are different indications for different types of peripheral nerve stimulation.

Peripheral Nerve Stimulation (PNS) for Chronic Pain

Quoting from the Noridian JE Peripheral Nerve Stimulation article:

“Peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the underlying conditions and appropriate attempts at medication management, physical therapy, psychological therapy and other less invasive interventional treatments….PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the known anatomic location of a peripheral nerve.”

Coverage of PNS requires the patients have all of the following:

• Documented chronic and severe pain for at least 3 months,
• Documented failure of less invasive treatment modalities and medications,
• Lack of surgical contraindications including infections and medical risks,
• Appropriate proper patient education, discussion and disclosure of risks and benefits,
• No active substance abuse issues,
• Formal psychological screening by a mental health professional, and
• Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent implantation.

CPT codes for PNS addressed by the Noridian policy include: 61885, 64550, 64553, 64555, 64561, 64569, 64570, 64575, 64581, 64585, 64590, and 64595. Also see National Coverage Determination (NCD) 160.7 for other coverage information on Implanted Peripheral Nerve Stimulators.

Peripheral Nerve Stimulation for Urinary and/or Fecal Incontinence

Sacral nerve stimulation coverage for urinary and fecal incontinence is addressed by several MAC policies. Covered indications include:

• Urinary urge incontinence.
• Urgency-frequency syndrome.
• Urinary retention.
• Fecal incontinence.

There are limitations to coverage such as refractory or documented failure or intolerance to conventional therapy; only after a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms; and the exclusion of certain causes of the incontinence. Limitations vary slightly per policy so providers should read carefully the policy which applies to their MAC jurisdiction. CPT codes 64561, 64581, and sometimes 64585 or 64590 are addressed by the Sacral nerve stimulation policies.

Posterior tibial nerve stimulation (CPT code 64566) is generally covered in a physician office setting for urinary urgency, urinary frequency, and urge incontinence. Patients receive one 30-minute weekly treatment in the office for 12 weeks, but most MACs allow treatments for a longer time to patients who demonstrate significant improvement in overactive bladder (OAB) symptoms. Most MACs require documentation of failed standard anticholinergic drug therapy or intolerance to the anticholinergic drug therapy. Again, requirements vary from MAC to MAC, so providers need to be aware of their MAC’s requirements.

Non-Covered Peripheral Nerve Stimulation

As stated at the beginning of this article, new coverage articles this month detail the correct coding and non-coverage of certain types of peripheral nerve stimulation. Remember, coverage for services not addressed by a national coverage determination or Medicare manuals is determined by the individual MACs. Not all MACs make the same coverage determinations. If coverage of a particular service is not addressed by an LCD or coverage article for your MAC, you will need to contact your MAC to determine if they cover the service or not.

The WPS article for Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) explains that “PENS and PNT therapies combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS)…. PENS is performed with a few needle electrodes (not implanted) while PNT uses very fine needle-like electrode arrays (not implanted) that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue.”

Per the WPS article, therapeutic use of these services is non-covered and should be reported with CPT code 64999 and the respective procedure name. They should not be reported with:

• CPT codes 64553-64566 as these apply to percutaneous implantation of neurostimulator electrodes and not appropriate, as PENS and PNT use percutaneously inserted needles, OR
• CPT code 64590 as this applies to insertion or replacement of neurostimulator pulse generator or receiver and not appropriate, as PENS and PNT stimulation devices are not implanted, OR
• HCPCS code range L8680-L8689.
• It would also not be appropriate for providers to use any neurostimulator pulse generator or receiver implantation CPT codes such as CPT 63663, 63685, 63688, 64585, 64590.

Specifically, Biowave’s Deepwave percutaneous neuromodulation pain therapy system is one PENS system that is non-covered. (See NCD 160.7.1.B for discussion of coverage of PENS for diagnostic purposes.)

The two new Noridian coverage articles clarify that Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) is not covered for any condition. PNFS refers to use of a lead placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This service should also be billed with the unlisted CPT code 64999 for both the trial and permanent insertion of the electrode array.

One last peripheral nerve stimulation service for which Novitas JH and JL has a non-coverage policy is Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device).  As with the other non-covered peripheral nerve stimulation procedures, Novitas reports that auricular peripheral nerve stimulation has been inappropriately billed to Medicare using an incorrect CPT code (CPT 64555).  Per the Novitas policy, “The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system….The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.

The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.

While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.” The WPS policy that addresses PENS and PNT also states that any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.

With all the different types of peripheral nerve stimulation and the different coverage requirements, make sure your facility is assigning the correct code and that documentation supports the coverage indications. Denied claims can get on your last nerve.

On July 25, 2018, CMS finally released the 2019 Proposed Rule for Outpatient Prospective Payment System (OPPS) for hospitals and Ambulatory Surgical Centers (ASCs) (link to Proposed Rule). Toward the end of the OPPS portion of the rule, there is a section titled “Proposed Nonrecurring Policy Changes” that could also be appropriately named, “Bad News for Hospital Off-Campus Provider-Based Departments.”

Background

Before discussing the proposed rule changes, let’s define some terms and examine some history concerning provider-based departments (PBDs). Provider based entities are created or acquired by the main hospital to furnish healthcare services and are under the ownership, administrative, and financial control of the main provider, in accordance with Medicare’s provider-based rules (42 CFR 413.65). PBDs may be on-campus, that is immediately adjacent to the hospital’s main buildings or within 250 yards of the main buildings, or off-campus, which are PBDs located beyond 250 yards from the main hospital buildings.

The concern over the past several years with PBDs is that they furnish the same types of services provided in a physician office setting but receive higher Medicare payments due to Medicare’s payment rules for outpatient hospital services versus physician fee schedule payments. The Medicare patient (beneficiary) payment share is also more for hospital-based services. In 2015, Section 603 of the Bipartisan Budget Act of 2015, addressed some of these concerns. The Act required “new” off-campus PBDs to be paid under a payment system other than the OPPS that would provide payments more equitable with physician office payments. “New” off-campus PBDs were those PBDs that did not furnish and bill for services prior to the date of enactment of the Act, November 2, 2015.

CMS created other exceptions to the application of Section 603 so the below entities and services are known as “excepted” provider-based departments. Excepted PBDs and excepted services continue to be paid under OPPS.

• On-campus PBDs
• “Grandfathered” off-campus PBDs – those furnishing and billing for services before November 2, 2015
• Services furnished by a dedicated emergency department

This means “non-excepted” PBDs are those new off-campus PBDs that do not meet one of the above exceptions and that will no longer be paid under OPPS.

To implement the requirements of Section 603, beginning January 1, 2017, services provided by non-excepted off-campus PBDs are paid under the Medicare Physician Fee Schedule (PFS) at special rates established for this provision. Currently, and proposed for 2019, these non-excepted services, that would previously have been paid under OPPS, are paid under the PFS at 40% of the OPPS payment rate. Providers append modifier “PN” to these non-excepted services to trigger the reduced payment rate. In addition to the reduced payment rates, OPPS packaging rules and most adjustments continue to apply to these non-excepted services – a double whammy, so to speak. Excepted off-campus PBD services are reported with modifier “PO” to allow CMS to gather data on the volume of these services, but as stated above, payment for excepted services is currently still made under the OPPS rates.

Continuing Concerns

In the proposed rule, CMS states, “the majority of hospital off-campus departments continue to receive full OPPS payment (including off-campus emergency departments and excepted off-campus departments of a hospital), which is often higher than the payment that would have been made if a similar service had been furnished in the physician office setting.” Also, CMS is extremely concerned about the continuing growth of outpatient hospital services. Despite the implementation of a prospective payment system (OPPS) in 2000 and increased packaging in recent years, “the OPPS has been the fastest growing sector of Medicare payments out of all payment systems under Medicare Parts A and B” which CMS attributes in large part to the payment differential between hospital-based services and physician office services. Here are a few quotes from the proposed rule that highlight CMS’s concerns:

“Total spending has been growing at a rate of roughly 8 percent per year under the OPPS, and total spending under the OPPS is projected to further increase by more than $5 billion from approximately $70 billion in CY 2018 through CY 2019 to nearly $75 billion.”

“We (CMS) are concerned that the rate of growth suggests that payment incentives, rather than patient acuity or medical necessity, may be affecting site-of-service decision-making. This site-of-service selection has an impact on not only the Medicare program, but also on Medicare beneficiary out-of-pocket spending.”

“A large source of growth in spending on services furnished in hospital outpatient departments (HOPDs) appears to be the result of the unnecessary shift of services from (lower cost) physician offices to (higher cost) HOPDs. We would consider these shifts in the sites of service unnecessary if the beneficiary can safely receive the same services in a lower cost setting but instead receives care in a higher cost setting.”

“One-third of the growth in outpatient volume from 2014 to 2015 was due to an increase in the number of evaluation and management (E&M) visits billed as outpatient services. This growth in part reflects hospitals purchasing freestanding physician practices and converting the billing from the Physician Fee Schedule to higher paying hospital outpatient department (HOPD) visits… From 2012 to 2015, hospital-based E&M visits per beneficiary grew by 22 percent, compared with a 1-percent decline in physician office–based visits.”

The Proposed Solutions, i.e. the Bad News

CMS is proposing to take action on several fronts to decrease what they see as unnecessary and excessive spending on services provided in off-campus PBDs.

The most significant of these proposals is capping the OPPS payment for clinic evaluation and management (E&M) visits for excepted off-campus PBDs at the PFS-equivalent rate. This means clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs and currently billed with the PO modifier would be paid at the same reduced OPPS rate as those currently billed with the PN modifier by non-excepted PBDs. This would reduce the payment rate for clinic visits (G0463) in excepted off-campus PBDs from the proposed unadjusted Medicare OPPS payment rate of $116 to the reduced PFS (40% of OPPS) rate of $46. CMS also notes the beneficiary liability would correspondingly decrease from $23 to $9. This proposal is not budget-neutral and CMS estimates total savings of $760 million ($610 M Medicare saving and $150 M beneficiary savings).

A second cost-saving proposal is to expand the reduced payments for drugs purchased through the 340B Program to non-excepted off-campus PBDs. The implementation of reduced 340B drug payments last year did not affect the payments for drugs in non-excepted off-campus PBDs since they are not paid under OPPS. With this proposal, separately payable drugs (those with an OPPS status indicator of “K”) furnished and billed by non-excepted off-campus PBDs and purchased through the 340B program would be paid at ASP-22.5% for 2019 and subsequent years instead of the current payment of ASP+6%. In other words, the payment amount for SI “K” 340B drugs in non-excepted PBDs would decrease by 28.5%. Medicare would continue to pay ASP+6% for SI “K” drugs not purchased through the 340B program billed by non-expected off-campus PBDs.

In the last proposal to control increasing payments under OPPS for off-campus PBDs, CMS is proposing to limit the expansion of services in excepted off-campus PBDs. If an excepted off-campus PBD furnishes services from a clinical family of services that it did not furnish in a baseline period, those new services would be non-excepted and paid at the non-excepted reduced PFS payment rate effective January 1, 2019.

• CMS is proposing a one-year baseline period from November 1, 2014 through November 1, 2015, or one year from the first date the PBD furnished services under OPPS for those that began furnishing services after November 1, 2014.
• There are 19 clinical families of services defined by CMS and mapped to the applicable APCs in Table 32 in the Proposed Rule.

One last proposal related to PBDs that does not affect payment – YET – is the creation of a HCPCS modifier to be reported for outpatient hospital services furnished in an off-campus provider-based emergency department. Critical access hospitals (CAHs) would not be required to report this modifier.

It will be interesting to see which of these proposals for discouraging off-campus PBD services paid under OPPS will make it to the final rule. It is clear from reading the proposed rule that CMS is intent on limiting expansion and making payments more site-neutral. This is bad news for hospitals that have increased their bottom line through the expansion of off-campus services.

Q:

Is the “with” guideline used when there is documentation of Diabetes and Arthritis?

A:

No, the “with” guideline does not apply to “not elsewhere classified” (NEC) conditions. Arthritis, a form of Arthropathy, can be due to many other conditions besides Diabetes. Therefore, coders should not assume a cause and effect relationship between Diabetes and a “NEC” condition. The physician would have to document Arthritis as a diabetic complication in order for E11.618 to be assigned.

Diabetes, diabetic (mellitus) (sugar)

with

arthropathy NEC E11.618

References:

Coding Clinic: Second Quarter 2018, page 6

Fourth Quarter 2017, page 100-101

PATIENTS OVER PAPERWORK INITIATIVE

CMS launched the “Patients over Paperwork” initiative in October 2017. This initiative allowed CMS to establish “an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.” CMS is keeping stakeholders informed through information posted to the Patients Over Paperwork webpage as well as Newsletters highlighting ongoing efforts towards meeting their goal.  

July 2018 Newsletter

CMS posted the July 2018 Newsletter this past week making it the 6th Edition. This newsletter:

• Provides updates on how CMS is addressing Skilled Nursing Facility/Nursing Home burden.
• Describes how CMS is simplifying documentation requirements.
• Provides an update on where CMS is meeting with stakeholders to discuss burden.
• Reminds stakeholders about opportunities to provide feedback through requests for information from CMS.

Today, we delve into the specifics about reducing SNF/Nursing Home Burden and Opportunities for Providing Feedback to CMS

Addressing Skilled Nursing Facility/Nursing Home Burden

After what is described as spending hundreds of hours reviewing information, CMS indicates they listened, learned and acted.

• Listen: In response to Requests for Information (RFI) in 2017, CMS received 154 comments on burden related to the nursing home experience. In addition to soliciting comments and to capture customer perspectives CMS spoke with 93 people during visits to 3 nursing homes and hosted 22 listening sessions around the country.
• Learn: CMS found that Comments received from RFIs grouped into 9 themes. The themes were then grouped together and 15 actions that could be taken to address burden were identified. As a product of the site visits, CMS designed a Nursing Home Journey map depicting residents, families, and staff interaction in a nursing home.
• Action: One example provided in the newsletter are the changes being proposed in the Skilled Nursing Facility Prospective Payment System (SNF PPS) FY 2019 Proposed Rule. CMS highlights a proposed new case-mix model, Patient-Driven Payment Model (PDPM) “which would move Medicare towards a more unified post-acute payment system that better accounts for resident characteristics and unique care needs of the patients while also reducing significantly the administrative burden associated with SNF PPS.” They also highlight the proposal of a new factor to account for costs associated with a measure when evaluating measures for removal from the SNF Quality Reporting Program (QRP) measure set.

 

OPPORTUNITY TO PROVIDE FEEDBACK TO CMS

Medicare Physician Fee Schedule (MPFS) and Quality Payment Program

CMS touts in this newsletter the proposals being made are “historic” and if finalized,
“clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients.” In addition to clinicians there are several proposed revisions that could affect hospitals. A discussion of these proposals can be found in a related FAQ. Public comments must be received no later than 5 p.m. on September 10, 2018.

Stark Law

Through the RFI process CMS identified compliance with the Stark Law and its accompanying regulations as being a top area of burden. CMS is requesting input on several issues with the Law and “is particularly interested in the public’s input on the structure arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law.”

The comment period ends August 24, 2018. The RFI can be downloaded at https://www.federalregister.gov/documents/2018/06/25/2018-13529/medicare-program-request-for-information-regarding-the-physician-self-referral-law.

In addition to the MPFS Proposed Rule and Stark Law RFI, CMS lists several 2019 Proposed Rules aiming to reduce burden and provides links to the individual Proposed Rule and Fact Sheets. MMP strongly encourages you to review relevant proposed rules and provide comments.

Several years ago, our neighbor gave us a “stick” to plant. He said it was a fig tree. My husband and I were both doubtful this stick would ever become anything, let alone a fig tree. That fig tree is now about 12 feet around and 15 feet high, loaded with beautiful, sweet figs. It is so tall in fact that I have to have a ladder to gather the fruit growing up high. I often however, pick the low-hanging fruit as I pass by the tree. As well as the reality of my fig tree, “low-hanging fruit” is a saying for all easily obtained gains.

CMS quarterly publishes the Provider Compliance Newsletter about common billing errors and other erroneous activities related to Medicare Fee-for-Service (FFS) program. The newsletter provides examples of errors and offers tips on ways to avoid them. Articles identify the types of providers affected by the issues, such as physicians, non-physician practitioners, outpatient hospital, etc. as well as whether the errors were identified by the Comprehensive Error Rate Testing (CERT) program or by the Recovery Auditors (RACs). It is also not unusual for other types of Medicare reviewers, especially the Medicare Administrative Contractors (MACs), to select issues identified by the CERT or RACs for their medical review activities. High-risk issues can be easy “low-hanging fruit” for finding overpayments to recoup.

The July 2018 Medicare Quarterly Provider Compliance Newsletter includes an article related to outpatient hospital services concerning Medicare coverage of vagus nerve stimulation (VNS). This was at one time an issue being reviewed by the Recovery Auditors. Vagus Nerve Stimulation is a pulse generator,

surgically implanted under the skin of the left chest and connected to the left vagus nerve. Electrical signals sent from the battery-powered generator to the vagus nerve via the lead are in turn sent to the brain. VNS is used to treat certain types of epilepsy.

In July 1999, Medicare issued a National Coverage Determination (NCD) allowing coverage of VNS for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. The coverage is specifically limited to “partial onset” seizures and other types of seizures are not covered. In May 2007, CMS issued an additional non-coverage decision for the use of VNS for patients with resistant depression.

This means VNS is only covered for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. If you provide VNS for other types of seizures (not partial onset) or for resistant depression, Medicare will not cover the VNS. Specifically, one of the following diagnosis codes must be reported for Medicare to cover VNS:

• G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epileptic
• G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus
• G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
• G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
• G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
• G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus

Outpatient hospitals need to have systems in place to verify VNS is being performed for an appropriate, covered indication for their Medicare patients. If VNS is used for non-covered indications, inform the patient with an Advance Beneficiary Notice (ABN) so the patient understands they are financially liable for payment. This will allow your facility to avoid being “low-hanging fruit” for recoupments.

MEDICARE TRANSMITTALS

Revisions to the Telehealth Billing Requirements for Distant Site Services - REVISED

Revised criteria that allows the GT modifier to be present on Method II CAH claim lines.

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

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

The article is revised to show the Type of Service Code for CPT code 90739 remains as V.

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

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 24.3, Effective October 1, 2018

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10827.pdf

Medical Review of Evaluation and Management (E/M) Documentation

Provides direction to Medicare’s medical review contractors on how to review claims where a medical student documented the E/M service.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10627.pdf

Medicare Special Edition Articles

New Medicare Beneficiary Identifier (MBI) Get It, Use It – REVISED

This article was revised on July 11, 2018, to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNmattersArticles/downloads/SE18006.pdf

 

MEDICARE RULES

2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule

Addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

 

MEDICARE EDUCATIONAL RESOURCES

Medicare Billing for Cardiac Device Credits

Learn about billing Medicare inpatient and outpatient cardiac devices and reducing overpayments.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/cardiacdevicecredits-ICN909368.pdf

Beneficiary Notices Initiative (BNI) webpage – updated

New look for Medicare’s Notices webpage.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html

Medicare Fee for Service Recovery Audit Program webpage – updated

New look for Medicare’s RAC webpage

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Index.html

Transition to New Medicare Numbers and Cards Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Medicare Quarterly Provider Compliance Newsletter – July 2018

Addresses common billing errors and other erroneous activities and provides guidance to help health care professionals address and avoid the top issues of the particular quarter.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909378.pdf

 

MEDICARE FAST FACTS

Medicare Fast Facts resources this month include:

• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
• Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

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

 

OTHER MEDICARE UPDATES

Contract Award for A/B MAC Jurisdiction F

CMS awarded the Jurisdiction F contract to Noridian, the current incumbent contractor for JF.

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Whats-New-.html

Q:

Are there any proposed rule changes from the 2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule that may affect hospitals?

A:

Yes, there are several proposed revisions that could affect hospitals, although some of these will not be effective until 2020.  Here is a review of some of the issues:

Non-excepted Off-Campus Provider Based Departments

These are off-campus PBDs that did not begin billing Medicare until after November 2, 2015.  The Bipartisan Budget Act of 2015 required services in these PBDs be paid under a payment system other than the Outpatient Prospective Payment System (OPPS) in order to make payments more equitable with payments for similar services provided in a physician office setting. Medicare pays for these services under the Medicare Physician Fee Schedule at a percentage of the OPPS payment rates. For 2019, Medicare proposes to continue to pay 40% of the OPPS rate for these services. Hospitals will continue to bill these services on an institutional claim form using the PN modifier to identity non-excepted services. Packaging and other OPPS claims processing logic also apply to these services.

Clinical Laboratory Fee Schedule (CLFS)

The Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. Under the CLFS final rule, applicable laboratories must report to CMS for laboratory tests the private payor rates, the volume and the specific

HCPCS code associated with the test. Beginning in 2018, Medicare CLFS rates are based on this information specifically, equal to the weighted median of the private payor rates for each test.

The 2019 MPFS Proposed Rule seeks comments on a couple of suggestions that could affect whether a hospital outreach laboratory would meet the definition of an applicable reporting lab or not. One suggestion is using Form CMS-1450 bill type 14x to determine the majority of Medicare revenues and low expenditure thresholds in deciding if a lab must report data. The other suggestion is to use the CLIA certificate rather than the NPI to identify a laboratory that would be considered an applicable laboratory.

Therapy Services

CMS is proposing to discontinue functional limitation reporting beginning January 1, 2019. If finalized, they will also delete the HCPCS codes that were created for this reporting.

The Bipartisan Budget Act of 2018 (BBA of 2018) requires reduced payment for therapy services provided in whole or in part by a therapy assistant beginning in 2022. This includes payment to providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs) but, not to critical access hospitals (CAHs). CMS will create a new modifier that must be reported on claims for outpatient PT and OT services with dates of service on and after January 1, 2020, when the service is furnished in whole or in part by a therapy assistant. These two therapy modifiers would

be added to the existing three therapy modifiers – GP, GO, and GN − that are currently used to identify all therapy services delivered under a PT, OT or SLP plan of care, respectively. Modifiers GP and GO will be redefined to be reported when physical or occupational services are provided by a therapist.

Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Effective January 1, 2020, professionals must consult appropriate use criteria (AUC) before ordering applicable advanced diagnostic imaging services and furnishing professionals must report AUC consultation information on the Medicare claim. The first year (2020) is for education and operations testing and claims will not be denied for failure to include proper AUC consultation information.

Information in the proposed rule clarifies that hospital outpatient departments are required to report AUC information on claims. Specifically, the proposed MPFS rule clarifies that AUC consultation information must be reported on all claims for an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system. Applicable settings include a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and proposed this year, an independent diagnostic testing facility (IDTF). The AUC information to be reported on a claim includes which qualified clinical decision support mechanism (CDSM) was consulted; whether the service met, did not meet, or was not applicable for the AUC and the NPI of ordering physician. CMS also proposed to use established coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims.

Although emergency departments are listed specifically in the applicable settings, the exceptions for AUC consulting and reporting are 1) a service ordered for an individual with an emergency medical condition, 2) a service ordered for an inpatient, and 3) a service ordered by an ordering professional with a significant hardship.

To find out more about the above issues, you can find the 2019 MPFS Proposed Rule here. 

Can I be honest?

I have type 2 diabetes and take a pill for it every day, but I don’t like diabetes coding. Diagnosis code assignment for diabetes and diabetes-related conditions has always been confusing to me. When looking at a chart of a patient with diabetes, I frequently go back to the ICD-10 diagnosis coding guidelines and Coding Clinic articles to validate my understanding.

Based on some of the coding proficiency reviews we’ve done over the past couple of years, I think other coders may share some of my confusion.  One of the most common diagnosis coding discrepancies we come across with diabetes coding is the scenario of a patient with Type 2 diabetes who is also taking an oral antidiabetic drug. We usually see the appropriate diagnosis code for Type 2 diabetes, but ICD-10 diagnosis code Z79.84 is not reported for long-term use of an antidiabetic drug when it’s applicable.

Z79.84 was introduced October 2016, and in addition to all the other diabetes-related coding rules we already had, this new code came with, yet, another rule to remember:  When E11- is reported for type 2 diabetes, use an additional code to identify control using an oral antidiabetic / hypoglycemic drug.

In talking with coders and coding supervisors, one of the problems in picking up Z79.84 is that coders may not know which drugs are classified as an antidiabetic. The good news is – we don’t have to know if the drug is a biguanide versus an alpha-glucosidase inhibitor versus SGLT 2 inhibitor, etc., we just need to know which oral medications are considered antidiabetic or hypoglycemic.

Below is a list of the more common oral antidiabetic drugs we see. Did you realize the different preparations of Metformin had so many other names? Keep the list handy in case you see one of these drugs in your patient’s record, so you will have a better idea when Z79.84 should be reported in addition to the E11- diabetes code. Click here to see a more comprehensive list on the Healthline.com website.

Metformin / Kazano

Metformin / Invokamet

Metformin / Xigduo XR

Metformin / Synjardy

Metformin / Glucovance

Metformin / Jentadueto

Metformin / Actoplus

Metformin / PrandiMet

Metformin / Avandamet

Metformin / Kombiglyze XR

Metformin / Janumet

Sitagliptin / Januvia

Sitagliptin-Metformin / Janumet

Canagliflozin / Invokana

Canagliflozin-Metformin / Invokamet

Empagliflozin / Jardiance

Glimepiride / Amaryl

Glipizide / Glucotrol

Chlorpropamide / Diabinese

Tolazamide / Tolinase

Tobbutamide / Orinase

Q:

Services for Medicare patients referred to our hospital for outpatient treatments or testing are being denied by Medicare due to “clinical documentation not provided.”  Examples of the types of services being denied are therapeutic outpatient infusions and diagnostic tests such as CT scans. The only information the hospital has is the physician’s order and the nursing documentation or diagnostic report. How are we supposed to provide the clinical documentation to support the medical necessity of the service to the Medicare auditor?

A:

Information addressing this can be found in the Medicare Program Integrity Manual, Chapter 3. The bottom line is the billing provider is ultimately responsible for submitting all supporting documentation for services for which they billed, even if they have to obtain such information from another provider. 

Medicare auditors include the:

• Medicare Administrative Contractors - MACs,
• Recovery Auditors - RACs,
• Comprehensive Error Rate Testing reviewers - CERT and
• Zone or Unified Program Integrity Contractors - ZPICs/UPICs.

These auditors generally request documentation to support the services billed to Medicare from the billing provider. The CERT, and at their discretion, other Medicare auditors, may also request information from the referring provider when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentation necessary to support the service billed and supported by the Local and National Coverage Determinations.

However, because the provider selected for review or appealing a denial is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the requested documentation.  This means hospitals may have to obtain information supporting the medical necessity of services from the referring provider, such as physician office notes, and forward that documentation to the Medicare auditor. Failure to get this documentation to the Medicare auditor can result in payment denial for the billed service.