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

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

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

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

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

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

Code Groups

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

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

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Key Takeaway from the Data:

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

MS-DRG Shift from Surgical to Medical

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

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

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

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

Resource:

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

In life, sometimes you win and sometimes you lose. The same goes for dealings with Medicare although most of us probably think we lose more than we win in this arena. But every now and then the providers come out to the good. At the beginning of last year, CPT code 96416 was the appropriate code to bill for prolonged chemotherapy infusions using a portable or implantable infusion pump. Last year, some Medicare Administrative Contractors (MACs) instructed to use an unlisted code for this service. Now there is a new code. Why have there been so many coding changes for this service and what is included in the current code?

The definition for CPT code 96416 is “Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump” and it was at one time the appropriate code to bill for these prolonged infusions. In April, 2016, CMS released MLN Matters Article SE1609. The main point of this article seemed to be to emphasize that the pump used for these prolonged infusions should not be billed separately as a DME item. The article stated, “Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit.”

The article went on to say that the MACs could direct use of a specific CPT or HCPCS code to be used to report the service, even a miscellaneous code “if there is no specified code that describes the drug administration service that also accounts for the cost of equipment that the patient takes home to complete the infusion that they later return to the physician or hospital.” Some MACs did instruct their providers to use the miscellaneous chemotherapy CPT code, CPT 96549. This caused great angst for providers because the Medicare OPPS unadjusted payment rate for 2016 for CPT 96549 was $30.87 as opposed to $280.27 for CPT 96416. The payment rate for the miscellaneous code failed to even cover the cost of providing the service.

Luckily for providers, this unfair payment situation was remedied with the creation of a new HCPCS code to describe the administration service and also account for the equipment cost. In the April 2017 OPPS Update, Medicare instructed the use of HCPCS code G0498 for these prolonged chemotherapy infusions “where the facility incurred a facility expense specific to the provision of the non-implantable, external infusion pump.” It is good to note that HCPCS code G0498 has the same OPPS status indicator (“S”) and payment rate ($279.45 for 2017) as CPT code 96416. And, CMS made the code retroactive to January 1, 2016.

The full description of HCPCS code G0498 is “Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living).” The code includes the chemotherapy administration service (the IV infusion of the drug), any supplies used, and the cost of using the pump. Providers should not report another code for the chemotherapy infusion – it is covered by this HCPCS code. The chemotherapy drug can be billed separately in addition to the administration code, G0498.

It feels good to win!

Q:

Sometimes patients are provided with orthoses they will carry home with them (such as a back brace) while they are an inpatient in the hospital. How do we determine if the hospital absorbs the cost of the orthosis or if the DME company can bill the patient’s Medicare?

A:

Medicare provides good information about this in the Fact Sheet Provider Compliance Tips for Spinal Orthoses. For orthoses provided to patients before or during an inpatient stay, the key is whether the patient will be using the orthosis for medically necessary treatment or rehabilitation during the inpatient stay. Payments for orthoses are included in payments to hospitals if the patient uses the orthosis during the admission. In these situations, the supplier should not submit claims to the DME MAC. The applicable situations are stated as follows in the Fact Sheet:

• The supplier provides the orthosis to the beneficiary prior to an inpatient admission or Part A covered SNF stay and the medical necessity begins during the stay (for example, after spinal surgery)
• The supplier provides the orthosis to the beneficiary during an inpatient stay prior to discharge and the beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.

However, if the orthosis is given to the patient for home use within two days prior to discharge and is not used during the hospitalization, then the DME may bill the patient’s Medicare. Per the Fact Sheet, “Payments for spinal orthoses are eligible for coverage by DME MACs if the orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay and the supplier provides the orthosis to the beneficiary within two days prior to discharge home, and the orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.” 

As of the writing of this article, there are 344 Medicare National Coverage Determinations (NCDs), 1,207 Local Coverage Determinations (LCDs) and 1,197 local Articles. From the Medicare Coverage Determination Process webpage, “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).” LCDs may also be developed when there is a need to further define an NCD. LCDs only contain reasonable and necessary language. Other information related to an item or service that does not deal with the medical necessity of the item/service is communicated through an article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.

When I first became aware of LCDs in my Compliance career, they were called LMRPs (Local Medical Review Policies). The main concept of LMRPs at the time was of a list of covered diagnoses (defined by, at that time, ICD-9 diagnosis codes). If an item, test, or service that had an LMRP was performed and one of the “covered” diagnosis codes was not on the claim, the line item for the item, test, or service was denied. LCDs still have lists of diagnosis codes (now ICD-10 codes) that support the medical necessity of the services. However, today’s policies go beyond the diagnosis codes and describe the indications and limitations for coverage. And although some LCDs are retired and others created, it seems that LCDs as a whole are addressing a wider range of services than ever before.

For example, National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdictions J6 and JK, retired their existing policy for Nerve Blocks for Peripheral Neuropathy (L35029) and added a new policy for Peripheral Nerve Blocks (L36850). The older policy only addressed the limitation that nerve blocks for multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases were not considered medically necessary and therefore not covered.

The new policy defines coverage for all possible uses of nerve blocks. This includes a list of seven indications that are reasonable and necessary for coverage and a long discussion of limitations (this includes the original limitation concerning neuropathies). Covered conditions for peripheral nerve blocks include the following. These are shortened descriptions, so please see the policy for complete descriptions.

• classic mononeuritis where neuro-diagnostic studies have failed to provide a structural explanation
• complex regional pain syndrome from peripheral nerve injuries/entrapment or other extremity trauma
• diagnostically for cases in which the clinical picture is unclear
• occipital neuralgia
• suspected entrapment of the suprascapular nerve
• blocked trigeminal nerve
• preemptive analgesia for post-surgical pain control

The limitations discuss frequency, total number of injections, and injections of multiple sites among other issues.

The caution to providers is to no longer rely simply on the presence or absence of a particular diagnosis code to determine coverage of a service. Yes, the diagnosis (and corresponding code) must be present, but coverage requirements go way beyond that. The patient’s condition must meet the indications for a particular service, there must be no limitations to coverage, and the documentation in the patient’s medical record must support the required indications. If not, the service is likely to be denied should a Medicare contractor perform a medical review.

Determining if services provided to Medicare patients meet all the indications of a coverage policy is a lot harder than simply looking for a diagnosis code, both for Medicare and for the provider. This requires a complex medical review by Medicare and internal evaluation of processes and documentation by the provider. It definitely goes beyond the diagnosis code list.

Back in September, 2016, an article was published concerning coding acute renal failure with ESRD. (Click here to see that article.) In answering the question I stated that a question had been submitted to the AHA Coding Advisor regarding patients diagnosed with both acute renal failure and ESRD. I finally received an answer on 4/12/17 and have added an update to the question.

Q:

Can acute renal failure be coded (ARF) with end stage renal disease (ESRD). Our PA has advised us not to code ARF with ESRD. He stated that once a patient has developed ESRD their kidneys are basically dead and no longer have the capability to function or produce any urine output so therefore would not be able to go into acute failure.

A:

This makes total sense but as coders we have to follow the Official Coding Guidelines and instructions given in the AHA Coding Clinic. MMP has re-submitted this question to the AHA Coding Clinic Advisor for further clarification. For the time being, until we receive a response back from them, you should follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both ARF and ESRD are both documented by the provider, code each condition separately.

Update – April 12, 2017
Confirmation was received from the AHA Coding Clinic Advisor. Continue to follow the instructions given in Coding Clinic 2nd Qtr. 2011 page 15. When both acute renal failure and ESRD are clearly documented in the record, both conditions are to be coded. 

Transmittals

FISS Implementation of the Restructured Clinical Lab Fee Schedule

• MLN Matters® Number: MM9837 Revised
• Related Change Request (CR) #: CR 9837
• Related CR Release Date: March 23, 2017
• Effective Date: January1, 2018
• Related CR Transmittal #: R3740CP
• Implementation Date: July3 , 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9837.pdf
• Affects clinical laboratory providers submitting claims to Medicare Administrative Contractors (MACs) for services paid under the Clinical Lab Fee Schedule (CLFS) and provided to Medicare beneficiaries.

Summary: Informs MACs about the changes to the Fiscal Intermediary Shared System (FISS) to incorporate the revised CLFS containing the National fee schedule rates.

Payment for Moderate Sedation Services

• MLN Matters® Number: MM10001
• Related Change Request (CR) #: CR 10001
• Related CR Release Date: April 14, 2017
• Effective Date: January 1, 2017
• Related CR Transmittal #: R3747CP
• Implementation Date: May 15, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10001.pdf
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for moderate sedation and anesthesia services provided to Medicare beneficiaries.

Summary: Revises existing Medicare Claims Processing Manual language to bring the manual in line with current payment policy for moderate sedation and anesthesia services.

Providers should refer to the revised Medicare Claims Processing Manual, Chapter12 (Physicians/Non-physician Practitioners), Sections 50 and 140 for information regarding the reporting of moderate sedation and anesthesia services.

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.2, Effective July 1, 2017

• MLN Matters Number: MM10082
• Related CR Release Date: April 14, 2017
• Related CR Transmittal Number: R3748CP
• Related Change Request (CR) Number: CR10082
• Effective Date: July1, 2017
• Implementation Date: July 3, 2017
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10082.pdf
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary: Informs about the quarterly update to the National Correct Coding Initiative (NCCI) procedure to procedure edits (PTP).

Other Medicare Announcements

Final Rule Correction – Medicare Physician Fee Schedule

• Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements; Corrections
• March 22, 2017
• https://www.gpo.gov/fdsys/pkg/FR-2017-03-22/pdf/2017-05675.pdf

Summary: Corrects technical errors in the addenda to the final rule published in the November 15, 2016, Federal Register.

CMS Voluntary Self-Referral Disclosure Protocol and Form

• Revision date March 27, 2017
• Use of the form is mandatory effective June 1, 2017. Parties submitting self-disclosures to the SRDP are encouraged, but not required, to use the SRDP Form now.
• https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Self_Referral_Disclosure_Protocol.html

Summary: New protocol and form to self-disclose actual or potential violations of the physician self-referral statute and/or noncompliant financial relationships with physician(s).

Renewal of Advance Beneficiary Notice of Non-coverage, Form CMS-R-131

• March 28, 2017
• Effective Date for use of this ABN form is June 21, 2017
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Summary: The ABN form and instructions have been approved by the Office of Management and Budget (OMB) for renewal. While there are no changes to the form itself, providers should take note of the newly incorporated expiration date on the form.  With the 2016 PRA submission, a non-substantive change has been made to the ABN. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.

Clinical Laboratory Data Reporting: Enforcement Discretion

• March 30, 2017
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/2017-March-Announcement.pdf

Summary: CMS will exercise enforcement discretion until May 30, 2017, regarding the data-reporting period for reporting applicable information under the Clinical Laboratory Fee Schedule and the application of the Secretary’s potential assessment of civil monetary penalties for failure to report applicable information. This discretion applies to entities that are subject to the data reporting requirements adopted in the Medicare Clinical Diagnostic Laboratory Tests Payment System final rule published on June 23, 2016 (81 FR 41036).

Decision Memo for Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Oxygen) (CAG-00060R)

• April 3, 2017
• https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=286&TimeFrame=7&DocType=All&bc=AgAAYAAACAAAAA%3d%3d&

Summary: Decision memo for HBO therapy that removes the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from NCD Manual 20.29, Section C. CMS has decided that no National Coverage Determination is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds and will amend NCD 20.29 by removing Section C, Topical Application of Oxygen. Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors.

New Mailbox for BNI Notices Questions

• Effective April 13, 2017

Questions regarding any of the Fee For Service Beneficiary Notice Initiative (BNI) notices may be sent to the new mailbox:  BNImailbox@cms.hhs.gov. 

The BNI notices are:

• FFS Advance Beneficiary Notice of Non-coverage (FFS ABN)
• FFS Home Health Change of Care Notice (FFS HHCCN)
• FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN) and SNF Denial Letters
• FFS Hospital-Issued Notices of Non-coverage (FFS HINNs)
• FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility  (FFS Expedited Determination Notices)
• Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) (Hospital Discharge Appeal Notices)
• FFS Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (FFS NEMB SNF) 

There is an exception for the Medicare Outpatient Observation Notice (MOON). Continue to send questions regarding the MOON to MOONMailbox@cms.hhs.gov.

Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule

• April 14, 2017
• Fact Sheet - https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-04-14.html

Summary: Updates 2018 Medicare payment and polices when patients are admitted into hospitals. The rule updates payment rates, quality initiatives, and code sets. In addition to the payment and policy proposals, CMS is soliciting ideas for regulatory, sub-regulatory, policy, practice and procedural changes to improve the health care delivery system, make it less bureaucratic and complex, and reduce burden for clinicians, providers and patients in a way that increases quality of care and decreases costs.

What was your strong subject in school – reading, writing, or math? To bill drugs correctly to Medicare, you need a little of all three.

Based on the physician’s order, 500 mg of Infliximab is administered to a patient. To bill for the Infliximab, a provider would report HCPCS code J1745 which has a description of “Injection, Infliximab, excludes biosimilar, 10 mg.” These means 50 units of J1745 would be reported on the claim to reflect the 500 mg given to the patient (500 mg dose divided by 10 mg description equals 50 units). If a patient requires a dose of 800 mg, then 80 units of J1745 would be billed for the amount of the drug administered and the provider may bill 20 additional units with a JW modifier if a 200 mg portion of a 250 mg single-use vial had to be wasted. The point here is that the units billed do not equal the dose amount; the units billed are based on the dose given and/or wasted and the HCPCS description of the drug. Units of service are reported in multiples of the units shown in the HCPCS narrative description. Furthermore, the physician’s order, the medication administration record, and applicable nursing or pharmacy notes must appropriately document the dosage ordered, the amount of drug administered, and any drug wastage.

Sounds straight-forward but evidently a lot of providers have problems getting this correct. The Medicare Supplemental Medical Review Contractor (SMRC) has issued notice of a new project to conduct post payment review of claims to identify incorrect units of service for outpatient drugs. According to the SMRC announcement, “Correct payments depend on providers’ accurate reporting of the HCPCS codes and units of service for each line item billed.”

The SMRC review project is at least partially in response to a July 2015 Office of Inspector General (OIG) report that identified $35.8 million in overpayments for selected outpatient drugs from July 2009 through June 2012. Eighty-eight percent of the overpayments identified in this OIG report were due to billing “either incorrect units of service or a combination of incorrect units of service and incorrect HCPCS codes.”

Medicare has established prepayment Medically Unlikely Edits (MUEs) to reduce payment errors. MUEs establish a limit for the units billed for a drug HCPCS code based on the maximum number of units a provider would reasonably administer to a patient for that code on that date of service. The OIG identified outpatient drugs that (1) had units of service that exceeded the MUE values or (2) did not have established MUE values but had units of service that exceeded the number of units a provider would reasonably administer to a beneficiary on a single date of service.

In addition to the SMRC review of outpatient drug units, the new Recovery Auditors for Regions 1, 2, and 3 have posted approved issues that address drug units. Those issues include:

• Automated review of drugs and biologicals whose units exceed the only FDA approved dose,
• Complex review of the drug Trastuzumab (Herceptin), J9355 - multi-dose vial wastage, dose vs. units billed. Documentation will be reviewed to determine if the billed amount of Trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines.
• Automated review of the drug Regadenoson (Lexiscan), J2785, billed with units greater than four (4).
• Automated review of the drug Zoledronic Acid billed with units greater than or equal to five (5) to identify excess units of J3489 as either excess units within a single line and/or as excess units across multiple lines/claims for the same beneficiary, the same HCPCS code and the same revenue center date.

A number of Medicare Administrative Contractors (MACs) are conducting medical reviews of drugs. These are generally complex reviews and drug units are only one of the issues considered. Search our knowlegde base for "drug review results" for more on this.

When billing for drugs, providers need to ensure they know the HCPCS code description, divide correctly, have the correct conversion factors in their charge description master (CDM), and have appropriate documentation in their records. A little reading, a little math and a little writing…

“The difference between the almost right word and the right word is really a large matter --- it’s the difference between the lightning bug and lightning.”- Mark Twain: Letter to George Bainton, October 15, 1888

In MMP’s article Case Mix Index: Beyond the Physician's Pen, our readers were introduced to the concepts of Medicare Severity Diagnosis-Related Groups (MS-DRGs), how an MS-DRG is assigned, Principal and Secondary diagnoses, Relative Weight (RW), and Case Mix Index (CMI). CMS defines CMI as a representation of the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. CMIs are calculated using both transfer-adjusted cases and unadjusted cases.

We also likened the way a CMI is calculated to calculating a student’s Grade Point Average (GPA).

Formula for CMI: Sum of RWs ÷ Total Number of MS-DRGs = CMI
Formula for GPA: Sum of Grade Points ÷ Sum of Credit Hours = GPA

A higher CMI reflects a more complex patient population that required higher resource utilization. A higher GPA reflects a higher level of academic achievement by the student which required a higher focus on academic studies resulting in the student having a more complex understanding of the subject matter.

CMI Pain Points for Hospitals

This article focuses on CMI pain points for hospitals including understanding that a successful MS-DRG Program is a collaborative process, there are several reasons that a CMI can fluctuate, and that slight shifts in CMI can have a significant impact on your hospital finances.

Pain Point: Understanding that a successful MS-DRG Program is a Collaborative Process

For a hospital to be successful in obtaining the CMI that truly reflects their patient population is a collaborative effort between the Physician, Clinical Documentation Improvement Specialists and Professional Coders. Here are the specific roles each team member must fill to truly tell the patient’s story.

• The Physician’s Role: Tell the Patient’s Story by providing complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.

• The Clinical Documentation Specialist’s Role: Interpret the documentation by performing concurrent medical record reviews and ask for clarity and/or accuracy of the clinical picture.  

• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also to ask queries when indicated. Ultimately, it is the Coding Professional’s role to translate documentation into codes for MS-DRG assignment.

Before moving on to the next Pain Point, it is important to note that CMS supports this collaborative process. In fact in the 2008 IPPS Final Rule CMS noted that they do “not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.”

AHIMA’s 2016 Practice Brief, Guidelines for Achieving a Compliant Query Practice, also supports the query process. Specifically, they note that a Physician Query is “a communication tool used to clarify documentation in the health record for accurate code assignment. The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical though processes, documented in a manner that supports accurate code assignment.”

Pain Point: Recognizing Factors Leading to CMI Fluctuations

As a Clinical Documentation Specialist in the hospital, I can remember monthly operational review meetings where inevitably the Chief Financial Officer (CFO) wanted an explanation for the shift (positive or negative) in CMI and placed this responsibility solely on the Clinical Documentation Improvement Team. Quite a few years have passed since then and I am hopeful that this is no longer the case at your hospital. However, if it is, share this article with your CFO to help him/her understand that shifts in CMI can happen that are beyond a Coder or Clinical Documentation Specialists control.

A decrease in CMI may be reflective of:

• Non-specific Physician documentation,
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical MS-DRGs in general are more resource intensive and will have a higher RW,
• Surgeons being on vacation;
• Inpatient admissions that could have been treated as an Outpatient, or
• Physicians being unresponsive to Coder and Clinical Documentation Specialists queries.
• Note, queries are asked to clarify documentation, not to question a physician’s clinical judgment.

An increase in CMI may be reflective of:

• Increase in surgical volume,
• Tracheostomy procedures that have an extremely high RW,
• Ventilator patients, or
• Improved physician response to queries resulting in improved documentation depicting the patient’s story.

Pain Point: Recognizing that Small Variances in CMI can Significantly Impact a Hospitals Finances

CMI shifts of even 0.1000 can have a significant impact on your hospital finances. To illustrate, the following table takes a look at the “We Care for You Hospital” which saw a decrease in their CMI of 0.1000 from FY 2015 to FY 2016.

The above example is just that, an example. In reality, surgeons go on vacation, surgical and medical volumes change, MS-DRGs are reassigned a new RW on an annual basis that may be higher or lower than the prior fiscal year, improved physician documentation can have a positive impact on your secondary diagnoses capture rate, and ICD-10 happened.

To validate there is more to CMI than meets the eye, I turned to our sister company RealTime Medicare Data (RTMD) to analyze Medicare Fee-for-service paid claims data. Specifically, I compared the Fiscal Year prior to ICD-10 implementation to the first full Fiscal Year after the October 1, 2015 ICD-10 implementation date. The following two tables contrasts the Top 10 MS-DRGs by RW, CMI, number of discharges and actual payment for the state of Alabama.

At the end of the day, accurate documentation captures the clinical severity of the patient that in turn can:

• Increase patient safety,
• Increase the accuracy of Quality measures,
• Decrease the risk of medical necessity denials,
• Result in more accurate Readmission and Mortality rates for your hospital,
• Impact physician and hospital profiles; and
• Support that your patients have received the right care, at the right time, at the right cost and in the right setting.

 

Resource:

Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations / page 47180 at https://www.gpo.gov/fdsys/pkg/FR-2007-08-22/pdf/07-3820.pdf

In our modern texting, emailing, and messaging world, numerous acronyms have become common in order to allow us to communicate faster. One example is “LOL” which in texting lingo means “laugh out loud.” But to a Medicare patient or provider, LOL can mean “limitation on liability.” Limitation on Liability is one of the Financial Liability Protection provisions of the Social Security Act which protects beneficiaries, health care providers and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay. Specifically, the LOL protections apply only when a provider believes that a Medicare covered item or service may be denied in a particular instance because it is not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. If a provider believes a service will not be covered by Medicare because it is not medically necessary, they must give advance notice to the patient in order to shift the financial costs to the patient.

The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is a form given to Fee-for-Service Medicare beneficiaries in situations where Medicare payment is expected to be denied. There are no substantive changes to the form for the latest approval but there is a new expiration date and the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.  The effective date for use of this ABN form is 6/21/2017.

As a reminder, hospitals may issue an ABN for services that are not medically necessary, for therapy services that exceed the therapy cap amount and do not qualify for an exception, for experimental/investigational services, and since 2011 for preventive services when frequency limitations are exceeded. An ABN is mandatory in order to shift liability to the patient for these types of services. ABNs may also be used voluntarily for services that are not a Medicare benefit or are excluded from coverage. The ABN form is also used in certain situations by suppliers, physicians, hospices, home health agencies, CORFs, and SNFs (Part B only).

An ABN may be issued at the initiation of a service such as the beginning of a new patient encounter, start of a plan of care, or beginning of treatment - for example, diagnostic tests that are not medically necessary such as laboratory tests. A notice can also be given when services are reduced or terminated. Examples of this would be when a patient’s progression in rehabilitative therapy supports fewer visits per week but the patient wants to continue at the same frequency or when therapy services are no longer medically necessary but the patient wishes to continue.

Medicare has a number of resources with information about the Advance Beneficiary Notice.

• Medicare Claims Processing Manual, Chapter 30, Section 40.3
• MLN Booklet – Medicare Advance Beneficiary Notices
• ABN Form Instructions
• Medicare FFS ABN webpage with links to the ABN form (English and Spanish)

So be prepared to use the new ABN form in June; you wouldn’t want anyone to laugh at you for using the wrong form – LOL! 

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

• In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
• Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
• High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

• Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
• Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
• Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

• Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
• Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
• Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
• Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
• Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following components:

• An assessment of changes in patient functional or medical status with revised plan of care;
• An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; and
• A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.