Knowledge Base - Full Library

TRANSMITTALS

Implementation of New Influenza Virus Vaccine Code

• Transmittal R3617CP, Change Request 9793, MLN Matters Article MM9793
• Issued September 30, 2016, Effective August 1, 2016, Implementation January 3, 2017
• Affects physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
• Summary of Changes: Provides instructions for payment and edits for the common working file (CWF) to include influenza virus vaccine code 90674.

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

• Transmittal R3614CP, Change Request 9806, MLN Matters Article MM9806
• Issued September 23, 2016, Effective October 1, 2016, Implementation January 3, 2017
• Affects physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• Summary of Changes: Quarterly updates to the national coverage determinations (NCDs) for clinical diagnostic laboratory services.

Update to Hepatitis B Deductible and Coinsurance and Screening Pap Smears Claims Processing Information

• Transmittal R3615CP, Change Request 9778, MLN Matters Article MM9778
• Issued September 23, 2016, Effective December 27, 2016, Implementation December 27, 2016
• Affects physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
• Summary of Changes: Updates erroneous information regarding coinsurance and deductible for hepatitis B virus vaccine and screening Pap smears.

Notice of New Interest Rate for Medicare Overpayments and Underpayments -1st Qtr Notification for FY 2017

• Transmittal R273FM, Change Request 9863
• Issued October 12, 2016, Effective October 18, 2016, Implementation October 18, 2016
• Summary of Changes: Quarterly update of the interest on overpayments and underpayments to Medicare providers

OTHER UPDATES

BFCC-QIOs Resuming Short-Stay Reviews

• Inpatient Hospital Reviews
• Effective September 12, 2016
• Summary of Changes: BFCC-QIOs will resume initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay hospital claims.

Hospital Appeals Settlement

• Inpatient Hospital Reviews
• Issued September 28, 2016
• Summary of Changes: CMS has decided to once again allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Specific details of the settlement will be released in the near future. Please continue to monitor CMS’ website for additional information.

KEPRO, BFCC-QIO Releases Short Stay Reviews FAQ #1

KEPRO, the BFCC-QIO for Area’s 2, 3 and 4, provided a Short Stay Review webinar for key stakeholders on September 19 and 20, 2016. In October they released a pdf document titled FAQ #1: Short Stay Reviews which includes a first round portion of questions submitted during the webinars. An updated documented will be posted to their website once all remaining questions are answered.

Adjustment to the amount in controversy threshold amounts for calendar year (CY) 2017 for Medicare appeals

• Federal Register notice
• September 23, 2016
• Summary of Changes: Announcement of the annual adjustment in the adjustment to the amount in controversy (AIC) threshold amounts for ALJ hearings and judicial review under the Medicare appeals process for 2017. The CY 2017 AIC threshold amounts are $160 for ALJ hearings and $1,560 for judicial review.

 Notice of interim final rule adjusting Civil Monetary Penalties (CMP)

• Survey and certification letter
• September 8, 2016
• Summary of Changes: Announces adjustments for inflation of the CMP amounts authorized under the Social Security Act.

Partnership for Patients and the Hospital Improvement Innovation Networks: Continuing Forward Momentum on Reducing Patient Harm

• CMS Fact Sheet
• September 29, 2016
• Summary of Changes: CMS) awarded $347 million to 16 national, regional, or state hospital associations and health system organizations to serve as Hospital Improvement Innovation Networks (HIINs).

October 2016 Medicare Quarterly Provider Compliance Newsletter Released

• October 2016 Quarterly Compliance Newsletter
• Summary of Changes: Addresses Comprehensive Error Rate Testing (CERT) review of Transluminal Balloon Angioplasty, Venous; Endovenous Ablation Therapy of Incompetent Vein; Blepharoplasty; and Transurethral Resection of the Prostate and Recovery Auditor findings regarding Post-Acute Care Transfer and Skilled Nursing Facility (SNF) Coding Validation.

The October 2016 release of the Medicare Quarterly Provider Compliance Newsletter included two issues specific to hospitals. This article focuses on the Recovery Auditors automated review performed to identify discharge status codes that had been improperly submitted under the IPPS Post-Acute Care Transfer (PACT) Policy.

Recovery Auditor Finding

“Analysis of discharge status codes and secondary claim data identified improper payments. Where a hospital used discharge status code 01, but should have shown a transfer to another care setting with a different discharge status code, the hospital may be overpaid for the inpatient services. It is crucial that hospitals place the correct discharge status code on claims to avoid subsequent overpayment identification and recovery.”

Transfer Policy Background

MLN® Acute Care Hospital Inpatient Prospective Payment System Fact Sheet (ICN 006815) indicates that under the Transfer Policy DRG payments are reduced when:

• The patient’s LOS is at least 1 day less than the geometric mean LOS for the DRG;
• The patient is transferred to another hospital covered by the Acute Care Hospital IPPS or, for certain MS-DRGs, discharged to a post-acute setting (PACT Policy);
• The patient is transferred to a hospital that does not have an agreement to participate in the Medicare Program (effective October 1, 2010); and
• The patient is transferred to a CAH (effective October 1, 2010)

PACT Policy and Discharge Status Codes

Cases with a length of stay less than the Geometric Mean Length of Stay (GMLOS) for a PACT DRG will not reimburse the full Diagnosis Related Group (DRG) payment if the patient was transferred to a post-acute care (PAC) setting. This policy involves the following patient discharge status codes:

When a patient is discharged with the status code of 01, Medicare’s overpayment edit will look for:

• “The presence of a transfer claim to a Skilled Nursing Facility, Cancer Hospital, Psychiatric Hospital, Children’s Hospital, Inpatient Rehab Facility, or Long Term Care Facility that commences or continues within one day of the acute care discharge, or
• A transfer claim to Home Health Care that commences or continues within three days of the acute care discharge.”

How to Avoid this Problem

Medicare advises that “hospitals should take steps to assure claims coders understand that the patient discharge status code is a crucial data element in determining payment for inpatient stays.” They go on to provide links to resources providing more information on how to avoid these errors.

MMP, Inc. advises that key stakeholders in your facility read and share the October 2016 issue of the Medicare Quarterly Compliance Newsletter.

It is still quite warm here in the deep South so it seems crazy to think that Christmas is only a little over two months away. It is a joyous time of year, but also an extremely busy and stressful time. I should be making my list now of all I have to do in order to be ready. I wonder if Santa Claus, in keeping with the words of a famous Christmas song, is “making a list and checking it twice” so he can determine who is naughty and who is nice? It appears the Medicare Comprehensive Error Rate Testing (CERT) program contractor also has some naughty and nice lists.

The CERT auditors are somewhat different from most other Medicare reviewers. They do not target at-risk issues or use data analytics to select specific topics. Instead they perform random audits of all claims to determine if the Medicare Administrative Contractors (MACs) are paying claims correctly. Their reviews produce overall error rates for the various MACs. These random reviews result in the CERT having lower error rates than those of targeted reviews, but also allow a broader brush of the pen. Using this random approach allows the CERT to identify new and unexpected issues that often then become an “at-risk” issue for the MACs to review further in their targeted reviews.

Medicare publishes a Quarterly Provider Compliance Newsletter that provides education on how to address common billing errors and other claim review findings. The October 2016 edition provides feedback from some CERT findings related to several different types of procedures. One other good thing about CERT reviewers is that they make multiple attempts to obtain the appropriate documentation unlike other reviewers who just go with what is submitted the first time. But once documentation requests attempts are exhausted, it seems apparent that the CERT reviewer checks off a list of what documentation elements must be included to justify payment for the services.

The procedures reviewed by CERT and addressed in the newsletter that are most likely to affect hospitals are venous transluminal balloon angioplasty procedures (HCPCS code 35476) and endovenous ablation therapy (EVAT) of incompetent veins (HCPCS code 36475). Denials for both of these procedures were mainly due to:

• No documentation to support the medical need for the procedure
• No procedure or operative note
• No documentation of diagnostic studies required for coverage, and
• No physician’s signature on a procedure note, diagnostic report or progress note

Specific examples given in the newsletter provide further insight.

• A letter was sent to the CERT program, but the documentation in the medical record was still incomplete documentation.

“Note that physician attestations by themselves do NOT provide sufficient documentation of medical necessity, even if signed by the ordering physician. For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.”

• There must be a signed order or signed documentation of intent to order the service.

There is nothing more to say - you have to have an order or documented intent and it must be signed.

• Documentation in the medical record (progress notes, operative notes, diagnostic studies, etc.) must be signed by the performing physician.

Signatures cannot be added at a later time (especially after a copy of the unsigned documentation has been submitted to CERT). In some cases, it is appropriate to provide an attestation verifying the authorship of unsigned or illegibly signed documentation. For more information on Medicare signature requirements, see Complying with Medicare Signature Requirements Fact Sheet and MLN Matters Article SE1419 - Medicare Signature Requirements Educational Resources

• There must be documentation of the reason/need to perform the procedure.

Hopefully procedures would not be performed without a reason to do so – make sure the H&P includes the medical justification for the need for the procedure. If Medicare has specific criteria for the procedure (such as a National or Local Coverage Determination), there must be documentation fulfilling those requirements – for example, documentation supporting failed conservative treatment before the procedure if required.

• There must be a procedure or operative note supporting that the service was performed.

This one seems obvious, but a physician’s progress note post-procedure documenting completion of a successful procedure does not fulfill this requirement.

I recommend reading through this quarter’s Compliance Newsletter. The examples are entertaining (though likely not to those whose claims were denied) and you will definitely learn about the requirements for these procedures and procedures in general. This may allow you to proactively review the documentation in your own records and you can use the examples in the newsletter to educate staff and physicians if a need is identified.

You may even decide to make a list and check it twice…

News related to the Zika virus has slipped from the headlines as the United States deals with a major hurricane and the upcoming presidential election, but the Zika virus hasn’t gone away. According to the Center for Disease Control and Prevention (CDC), as of October 5, 2016, there were 3,818 cases of Zika Virus disease cases in the United States with most of these cases being travel-associated. However, 105 cases in South Florida (Miami and Miami Beach area) are locally acquired mosquito-borne cases. Zika infection during pregnancy can cause serious birth defects and other pregnancy problems, and a small proportion of people with recent Zika virus infection may develop Guillain-Barre syndrome. You can learn more about the Zika virus on the CDC Zika Virus website.

In order to properly treat Zika virus infection, a diagnosis must first be established. According to Medicare MLN Matters Article SE1615, “Currently there are a few diagnostic tests that can determine the presence of the virus. These tests are available through the CDC and CDC-approved state health laboratories. A small number of tests have been issued an Emergency Use Authorization by the Food and Drug Administration (FDA) and may be available through commercial laboratories.”

Medicare Part B will pay for testing for the Zika virus that is reasonable and necessary for diagnosis or treatment. Since there are currently no specific HCPCS codes for Zika virus testing, Article SE1615 directs laboratories to obtain guidance on appropriate billing codes from their local Medicare Administrative Contractors (MACs). The MACs may require resource and costs information from the testing labs in order to establish appropriate payment rates.

In reviewing the websites of the different MACs and the Medicare Coverage Database, I was able to locate the following MAC specific instructions for billing for Zika virus testing.

NGS - http://tinyurl.com/hpp7zhe

“Testing for the Zika virus may be considered medically necessary when a beneficiary’s clinical history and symptoms indicate the possibility of infection with the virus. Coverage for this testing is not available on a screening basis, but only for situations in which there is valid medical reason to suspect Zika infection.

Providers billing for Zika viral testing may submit claims using the following codes:

• CPT Code 87798 (infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism)
• ICD-10 Code A92.9 (through 9/30/2016)
• ICD-10 Code A92.5 (10/1/2016 and thereafter)”

Noridian - http://tinyurl.com/zc4kxu7

Noridian has issued Coverage Articles (see the one for Noridian JE at the link above) for Zika Virus Testing by PCR and ELISA Methods (A55326 and A55327). These articles list several billing codes that may be appropriate based on the type of test performed.

Novitas – http://tinyurl.com/zuxqf3v

“Presently, there are no specific HCPCS (Healthcare Common Procedure Coding System) codes for testing of the Zika virus; however, Novitas recommends that laboratories refer to coding resources such as the HCPCS and Current Procedural Terminology manuals to select the most appropriate unlisted code. Please keep in mind that medical documentation must support the services billed. To establish appropriate payment amounts for the tests, laboratories should provide resources and cost information upon request.”

Palmetto - http://tinyurl.com/hslt92h

“To bill for Zika virus testing, submit the claims with CPT 87999. Please keep in mind that medical documentation must support the services billed. Clinical laboratories may be asked by Medicare administrative contractors to provide resources and cost information to establish appropriate payment amounts for the tests.”

If your MAC is not listed above, you should contact them for billing information.

Do you ever wonder what your ancestors would think of the modern day advances in technology and medicine? Even in my lifetime, the flip communicator of Star Trek science fiction fame has become a reality. In fact, flip-phones are already out of style and current cell-phones do much more than simply allow communication. Laboratory medicine is no exception to technology advances and scientists are now able to study gene sequences, gene mutations, and other biological markers. This opens a whole new world of laboratory testing and brings about a new subject for Medicare coverage policies.

There are numerous local coverage determinations (LCDs) related to this type of advanced laboratory testing. These policies may reference molecular pathology or molecular diagnostic studies, biomarkers, phenotyping, genomic assays or genetic testing. Palmetto GBA has developed the Molecular Diagnostic Program (MoIDX®) to identify and establish coverage and reimbursement for molecular diagnostic tests. The following Medicare Administrative Contractor (MAC) jurisdictions participate in this program, so these MACs may have more LCDs for biomarkers than non-participating MACs.

• Noridian JE and JF
• Palmetto GBA JM
• WPS J5 and J8
• CGS J15

The Novitas Local Coverage Determination for Biomarkers for Oncology discusses the consideration of medical necessity for biomarkers. “The emergence of personalized laboratory medicine has been characterized by a multitude of testing options which can more precisely pinpoint management needs of individual patients. As a result, the growing compendium of products described as biomarkers requires careful evaluation by both clinicians and laboratorians as to what testing configurations are reasonable and necessary under the Medicare Act. There are a plethora of burgeoning tools, including both gene-based (genomic) and protein-based (proteomic) assay formats, in tandem with more conventional (longstanding) flow cytometric, cytogenetic, etc. biomarkers.” In order to be medically necessary, these tests must have proven clinical validity/utility, be clinically actionable, and be used to assist in the management and/or treatment of the patient. Biomarkers may be used for diagnosis, classification, monitoring, surveillance, prognosis, or prediction of response to a particular therapy.

Below are some of the indications for which biomarkers are utilized. These tests may be performed by specialty laboratories but providers need to be familiar with the LCDs relevant to their MAC jurisdiction if they are performing or billing for this type of testing.

Oncologic Indications

• Molecular Pathology, Molecular Diagnostic Testing, and Biomarkers policies that list numerous genetic/biomarker tests and/or conditions that are covered. (J5, J8, JH, JL, J15, JN, J6, JK, and JN)
• Breast and Ovarian Cancer
• BRCA1 and BRCA2 genetic testing for susceptibility to breast or ovarian cancer is covered when there is a personal history of breast cancer or certain other types of cancer (JN, JE, JF, J15, JM, and JJ)
• OVA-1 is an ovarian cancer blood test that is reported to detect ovarian cancer in a pelvic mass (J6 and JK)
• Several LCDs address tests used to decide breast cancer treatment options, such as Oncotype DX TM, Prosigna test, and Breast Cancer Index℠ (JN, J15, JE, JF, and JM)
• Colorectal Cancer
• Testing for KRAS mutations before using Epidermal Growth Factor Receptor (EGFR) antibodies in the treatment of colorectal cancer (JJ)
• A stepped approach genetic testing for Lynch Syndrome, the most common hereditary cause of colorectal cancer (JN, J15, JE, JF, and JJ)
• NRAS testing for metastatic colorectal cancer (J15, JE, and JF)
• Prostate Cancer
• ConfirmMDx epigenetic assay for prostate cancer (MDxHealth, Irvine, CA) to reduce unnecessary repeat prostate biopsies under certain conditions (J15, JE, and JF)
• To assist in determining treatment options for prostate cancer such as Decipher®, Genomic HealthTMOncotype DX®, or PolarisTM PC Genomic Assay (JE, JF, J15 and JM)
• Non-Small Cell Lung Cancer
• Tests for genomic alterations in tumor specimens for NSCLC to determine if a patient is a candidate for targeted therapy (J6, JK, JE, JF, J15, JM, and JJ)
• Gliomas
• The presence of chromosome 1p/19q deletions in gliomas can assist in tumor differentiation, prognosis and treatment plan. (J15, JM, JE, and JF)
• MGMT promoter methylation status is a strong and independent prognostic factor in patients with newly diagnosed glioblastoma multiforme and can aid in treatment decisions for older patients. (J15, JE, JF, and JM)
• Myeloproliferative Disease
• Provides coverage of a sequential genetic testing approach for the diagnostic workup for myeloproliferative disease (MPD) including polycythemia vera (PV), essential thrombocytopenia (ET), and primary myelofibrosis (PMF). (J15, JE, JF, and JM)

Non-Oncologic Indications

• Pharmcogenomics
• Genetic testing (CYP2C19, CYP2D6, CYP2C9 and VKORC1) for drug response limited to certain drugs such as Plavix, amitriptyline or nortriptyline for treatment of depressive disorders and tetrabenazine doses greater than 50 mg/day, and warfarin. (J15, JN, J5, J8, JE, JF, and JJ)
• Lipid Biomarkers for Cardiovascular Risk Assessment
• The policies indicate the medical indication(s) for individual lipid biomarkers that may be covered to characterize a given lipid abnormality or disease, to determine a treatment plan or to assist with intensification of therapy. Each individual lipid biomarkers must be specifically ordered and the reason for the test order documented in the patient’s medical record. (J15, JM, JE, JF, J5, and J8)
• Hypercoagulability/Thrombophilia
• Testing for Factor V Leiden (FVL) variants in the F5 gene and F2 G20210A mutations is indicated for pregnant patients who have a history of personal VTE associated with a non-recurrent (transient) risk factor who are not otherwise receiving anticoagulant prophylaxis. (J5, J8, J15, JM, JE, and JF)
• RBC Phenotyping
• Medicare will cover pretransfusion molecular testing using the HEA BeadChip™ assay to prevent the development of alloantibodies or when identification of antibodies is difficult for specific reasons. (J15, JE, JF, JM and JJ)
• HLA-B*15:02 Genotype Testing
• Patients of Asian and Oceanian ancestry with the HLA-B*1502 had an increased risk to develop severe, sometimes lethal diseases of the skin and mucous membrane when exposed to carbamazepine, phenytoin or fosphenytoin. (J15, JE, JF, and JM)
• Refractory Depression
• Limited coverage for the GeneSight® Psychotropic gene panel ordered by licensed psychiatrists and neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe depression after at least one prior neuropsychiatric medication failure.

(J15, JE, and JF)

As you can see, the uses of genetic testing are many and varied and will only expand over time as clinical studies demonstrate the efficacy of new tests. This means you will see more and more LCDs related to these types of tests – watch for these in our monthly updates of coverage policies.

“Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Under the two-midnight rule, hospitals may approach the decision for observation services a little differently. When a patient presents to the hospital, the first decision for the physician is, “does the patient require care in a hospital setting?” If the answer to this question is yes, then for patients with an expectation of a two-midnight stay an inpatient admission is appropriate. If the physician does not think the patient will require two midnights of care in the hospital or is unsure, then observation services are generally appropriate. When a patient who is receiving observation services approaches a second midnight in the hospital, a change to inpatient status is appropriate if the patient still requires care in a hospital setting. Considering this, it should be rare that a patient receives observation services beyond a second midnight.

Observation services are not appropriate for preparation time for outpatient testing, or for routing pre-op or post-operative services. Even with the two-midnight rule, observation services still remain a period of treatment or monitoring in order to make a decision concerning the patient’s admission or discharge.

When to Start

“Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time that observation care is initiated in accordance with a physician’s order.”

What does this mean exactly? First, there must be a physician’s order for observation before observation services can begin. Observation orders cannot be back-dated. For example, when condition code 44 is used to change a patient’s status from inpatient to outpatient, observation services do not begin until there is an order for observation (which would be after the change to outpatient status). Observation services would begin at the time that order was written.

If the patient is already actively receiving care, such as in the example above, then observation begins at the time the observation order is written. For patients being transferred to a room after an observation order is written, observation care may not begin until the patient begins to receive evaluation and/or care in the hospital room.

Rounding

Observation hours are rounded to the nearest hour. This means everything from 9:01 through 9:29 is rounded to 9:00 and from 9:31 to 9:59 is rounded to 10:00. 9:30 is ambiguous and could be rounded either way. The example in the Medicare manual is a patient receiving observation services from 3:03 p.m. until 9:45 p.m. – this equals 7 hours of obs.

Concurrent Active Monitoring

“Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy).”

Medicare does not provide a list or any examples beyond the two noted in the statement above for what constitutes a procedure with “active monitoring.” This is something the hospital will have to determine, but generally includes near-constant monitoring by a nurse or other health care professional. If such a procedure occurs during a period of observation, the hospital must subtract or “carve out” that time from the total observation hours. This could be accomplished by using the beginning and ending time of the procedure, or Medicare allows hospitals to use an “average length of time” for interrupting procedures and deduct that amount of time from the observation hours.

When to End

“Observation time ends when all medically necessary services related to observation care are completed.”

Observation ending time may not coincide with the time of the physician’s discharge order. Sometimes necessary medical care may end prior to the discharge order or care may extend beyond the time of the discharge order. If after care has ended, the patient is waiting for transportation home, the waiting time should not be included in observation time.

Observation hours end when an order is written to admit the patient as an inpatient. The observation services will be bundled into the inpatient claim, but for accurate records this is when observation counting stops.

Why Bother?

Isn’t observation packaged, so why does the counting of observation hours matter? Well, yes, but no. The outpatient claim line item for observation services, billed with HCPCS code G0378, is a packaged service and receives no separate payment. However, if certain criteria are met, an observation comprehensive APC is paid for the associated visit code, such as any level ED visit, an outpatient clinic visit, or a direct referral for observation services. If 8 or more hours of observation are billed with a visit code and without a primary procedure (status indicator J1) on the claim or surgical procedure (status indicator T) on the day of or before obs, then the claim qualifies for an observation comprehensive APC payment. For 2016, the unadjusted national Medicare payment for the obs C-APC is $2174.14. Definitely worth following the rules.

Hospitals have been dealing with observation services for a long time and most providers probably have their systems down on how to accurately count and report observation services. But a reminder of the rules never hurts. 

Influenza Vaccine Payment Allowances - Annual Update for 2016-2017 Season

• Transmittal 3611, Change Request 9758, MLN Matters Article MM9758
• Issued 9/9/2016, Effective 8/1/2016, Implementation by 11/1/2016
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for influenza vaccines provided to Medicare beneficiaries.

Summary of Changes: Provides the availability of payment allowances for the following seasonal influenza virus vaccines.

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, MLN Matters Article MM9751
• Issued 8/19/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: The 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

October 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3602, Change Request 9768, MLN Matters Article MM9768
• Issued 8/26/2016, Effective 10/1/2016, Implementation 10/3/2016
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient Prospective Payment System (OPPS)..

Summary of Changes: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update.

Claim Status Category and Claim Status Codes Update

• Transmittal 3599, Change Request 9680, MLN Matters Article MM9680
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, and Home Health & Hospice (HH&H) MACs for services provided to Medicare beneficiaries.

Summary of Changes: Updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.

Annual Clotting Factor Furnishing Fee Update 2017

• Transmittal 3607, Change Request 9759, MLN Matters Article MM9759
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers billing Medicare Administrative Contractors (MACs) for services related to the administration of clotting factors provided to Medicare beneficiaries.

Summary of Changes: This annually recurring CR announces the update to the Clotting Factor Furnishing Fee.

JW Modifier: Drug /Biological Amount Discarded/Not Administered To Any Patient - Frequently Asked Question

• Issued 8/26/2016, Effective 1/1/2017,FAQs
• Affects Providers and suppliers submitting claims for Part B drugs.

Summary of Changes: An FAQ document concerning use of the JW modifier

End of Temporary Suspension of the BFCC-QIO Short Stay Reviews

• Inpatient Hospital Reviews
• Effective 9/12/2016
• Affects acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities.

Summary of Changes: BFCC-QIOs will resume initial patient status reviews of short stays to determine the appropriateness of Part A payment for short stay hospital claims.

Medicare Fee for Service National Recovery Audit Program   (April 1, 2016 – June 30, 2016) Quarterly Newsletter              

• Recovery Auditor 3rd Qtr 2016 Newsletter

Summary of Changes: Overpayment and underpayment correction amounts for each RA region and the top issue per region.

Notification of Final Rule Published- Emergency Preparedness

• Survey-and-Cert-Letter-16-38
• Issued 9/8/2016, Effective 11/16/2017
• Affects Medicare and Medicaid Participating Providers and Suppliers.

Summary of Changes: The Emergency Preparedness Rule outlines the requirements for all providers and suppliers in regards to planning, preparing and training for emergency situations.

Q:

Have there been any recent notifications where Medicare Administrative Contractors (MACs) are reviewing professional claims related to denied hospital claims?

 

A:

Yes. In July, Noridian JE posted notification of “initiation of CMS approved cross recovery of professional claims related to denied institutional facet injection services, CPT codes 64493 – 64495; 64635 – 64636.” As a reminder, CMS published Transmittal 534 in August 2014 stating MACs have the discretion of also reviewing “related” Part B claims for services denied by Part A. The MACs are required to post notification of such related reviews. Although this is not good news for physicians, it may help hospitals by improving communication and coordination between hospitals and physicians since both parties now have something at stake.

Do you sometimes feel that your life is a circus? Does this especially apply at times to your role in healthcare? The circus often includes people and animals jumping through hoops – lions, small dogs, clowns - through big hoops, small hoops, or flaming hoops. In Medicare’s clarification concerning reporting “therapy-like” services that appeared in the October 2016 OPPS Update, providers have a choice of hoops.

Before we choose a hoop, let’s consider what exactly Medicare means when they refer to “non-therapy outpatient department services that are similar to therapy services.” Rehabilitative therapy services, that is physical therapy, occupational therapy, and speech language pathology services, are provided by therapists under a plan of care in accordance with Section 1835(a)(2)(C) and Section 1835(a)(2)(D) of the Act and are paid for under Section 1834(k) of the Act. These services require functional limitation reporting and are subject to the therapy cap. Sometimes, hospital outpatients will be provided therapy-like services during the perioperative period of a Comprehensive APC (C-APC) procedure without a certified therapy plan of care. When non-therapy outpatient department services are included on the same claim as a C-APC procedure (status indicator (SI) = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure and their payment is included as a packaged part of the payment for the C-APC procedure.

Hoop One

In the July 2016 OPPS Update, CMS put forth a requirement to be effective July 1, 2016, for these non-therapy outpatient department services adjunctive to a C-APC to be reported without HCPCS codes and with revenue code 0940. In comments on the June 8, 2016 Hospital Open Door Forum, CMS stated this change in reporting requirements was due to provider concerns about having to report functional limitation G codes and modifiers with these packaged “therapy-like” services. Provider response to CMS’s explanation was that this solution simply created different problems from the one it solved. Shortly after, CMS delayed the implementation of the reporting change for therapy-like services until October 1, 2016. The October OPPS update gives provider two options for claims received on and after October 1, 2016 for dates of services on and after January 1, 2015. One option continues to be reporting these “non-therapy” therapy services with revenue code 0940 and no HCPCS codes. Hopefully CMS has made modifications to claim processing systems to allow the reporting of revenue code 0940 without HCPCS codes, since this revenue code historically has required the presence of HCPCS codes.

Hoop Two

The second option in the October update for reporting “therapy-like” services adjunctive to C-APCs is that providers can continue to report these with the therapy revenue codes (042x, 043x, and 044x) and with therapy HCPCS/CPT codes. However, if a provider chooses this option, they must follow all the requirements of rehabilitative therapy code reporting, including occurrence codes, therapy modifiers, and the reporting of functional limitation G codes and modifiers. The therapy cap will not be affected since payment for these services is packaged into the comprehensive APC payment.

So do you want to jump through the hoop into the lion’s mouth or the flaming hoop? Your choice, but neither one is without its complications.

Fall is my favorite time of year. How could it not be when kids are going back to school, college football returns, and although the summer heat lingers longer than I would like, we have some spectacular fall foliage. Everything I love about fall at the most basic is consistent from year to year but in truth brings about tremendous change. Maybe it’s my oldest nephew entering high school this year, or the first weekend of regular season football shattering the predictions in the football standings - at the end of the day one constant of fall is change.

The one constant I have seen in health care for more years than I care to think about now is change. Exhibit A: the ICD-10-CM Official Guidelines for Coding and Reporting updates go into effect every fall on October 1st with the start of a new CMS Fiscal Year. In the update, narrative changes appear in bold text. However, with the FY 2017 Guidelines there are some significant changes, of which one in particular has sparked a lot of debate in the Coding and Clinical Documentation Community.

Key NARRATIVE Changes

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

Code assignment and Clinical Criteria

The New addition to the guidelines, “Code assignment and Clinical Criteria,” is the “hot button” that has sparked much debate as to what this really means.  

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This guidance poses a real dilemma for Professional Coders and Clinical Documentation Improvement (CDI) Specialists as we include clinical indicators when constructing a query for the physician and government contractors have become notorious for denying a claim for lack of clinical indicators in the documentation supporting the coded diagnosis. Unfortunately, I have yet to see, read or hear about a good solution for this guidance.

Zika virus infections

1. “Code only confirmed cases
   Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guidelines Section II, H.
   
   In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.
   
   If the provider documents “suspected”, “possible” or “probable” Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and *suspected) exposure to other viral communicable diseases.”

Hypertension

With the transition to ICD-10 last October there was one code for Hypertension (I-10). There was no longer a way to differentiate when it was actually a “hypertensive crisis” or “hypertensive emergency.”

As of October 1, 2016, they are back.

“Hypertensive Crisis
Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.”

 

Documented Pressure Ulcer Stage

There are two new changes for 2017. First being for patients admitted with pressure ulcers documented as healing. “For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.”

The second change is for the patient admitted with pressure ulcer evolving into another stage during the admission. “If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.”

 

While I have highlighted a few of the key narrative changes, it is worth noting that there are over 40 narrative changes in the guidelines. Looking for specific changes also made me realize how many times the guidelines advise “when documentation is unclear the provider should be queried” (26 times).

From the CDI Specialist perspective the guidelines provide a good foundation for understanding and appreciating the coding conventions to which Coding Professionals must adhere. They are also an essential read for anyone preparing for the Certified Clinical Documentation Specialist (CCDS) exam.

I encourage Coding Professionals and CDI Specialists to read the entire document and be on the lookout for how to register for our fall Inpatient Coding Updates Webinar that is held annually in October.