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“Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs.”- Pub. 100-07, State Operations Manual, Appendix A- Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 149, 10-09-15)

Whether true or not it seems the longer I work in health care the more it becomes apparent that when CMS makes “suggestions for process changes” sooner or later suggestions become requirements. Flash back to May 17, 2013 when CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning Conditions of Participation (CoPs) at 42 CFR 482.43. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”

Fast forward to October 29,2015 when CMS announced proposed revisions to the discharge planning requirements that hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies must meet in order to participate in the Medicare and Medicaid program. Several of the “blue boxes” are now being proposed as requirements.

While there are other proposals being made, this article focuses on the proposed changes specific to Discharge Planning in the Acute Care Hospital setting.

PROPOSED RULE BACKGROUND

Legislative History

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the standardization of Post-Acute Care (PAC) assessment data that can be evaluated and compared across PAC provider settings, and used by hospitals, CAHs, and PAC providers, to facilitate coordinated care and improved Medicare beneficiary outcomes.

CMS notes that they are currently developing additional public guidance and that many of the PAC provisions are being addressed in separate rulemakings. More information can be found on the CMS website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html .

This Proposal would implement the discharge planning requirements mandated in section 1899B(i) of the IMPACT Act by modifying the discharge planning or discharge summary Conditions of Participation (CoPs) for hospitals, CAHs, IRFs, LTCHs, and HHAs. The IMPACT Act identifies LTCHs and IRFs as PAC providers, but the hospital CoPs also apply to LTCHs and IRFs since these facilities, along with short-term acute care hospital, are classifications of hospitals. All classifications of hospitals are subject to the same hospital CoPs. Therefore, these PAC providers (including freestanding LTCHs and IRFs) are also subject to the proposed revisions to the hospital CoPs.

PROVISIONS OF THE PROPOSED REGULATIONS

Hospital Discharge Planning

The Medicare CoPs and Conditions for Coverage (CfCs) set forth the federal health and safety standards that providers and suppliers must meet to participate in the Medicare and Medicaid programs. The purposes of these conditions are to protect patient health and safety and to ensure that quality care is furnished to all patients in Medicare and Medicaid-participating facilities. In accordance with section 1864 of the Act, CMS uses state surveyors to determine whether a provider or supplier subject to certification qualifies for an agreement to participate in Medicare. However, under section 1865 of the Act, providers and suppliers subject to certification may instead elect to be accredited by private accrediting organizations whose Medicare accreditation programs have been approved by CMS as having standards and survey procedures that meet or exceed all applicable Medicare requirements.

The current hospital discharge planning requirements at §482.43, “Discharge planning,” were originally published on December 13, 1994 (59 FR 64141), and were last updated on August 11, 2004 (69 FR 49268). Under the current discharge planning requirements, hospitals must have in effect a discharge planning process that applies to all inpatients. The hospital must also have policies and procedures specified in writing.

CMS believes that providing more specific requirements to hospitals on what actions they must take prior to the patient’s discharge or transfer to a PAC setting will lead to improved transitions of care and patient outcomes.

CMS is proposing to revise the existing requirements in the form of six standards at §482.43. The following tables highlight the proposed requirements for each of the six standards.

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Considerations for Hospitals

While not all inclusive, should this Proposed Rule be finalized, here are some things to think about and questions that will need to be asked and answered.

• These proposals will require collaboration from several professionals/departments within the Hospital (Hospital Medical Staff, Nursing Leadership, Case Management, Social Services, Quality, IT, Pharmacy, Physical and Occupational Therapy, Dietician).
• Issues to think about if this Proposed Rule is Finalized:
• What is our current Policy and Procedure for Discharge Planning?
• How are we going to incorporate Discharge Planning for the Outpatient Population?
• Standard 3: Discharge Planning Process (Proposed §482.43(c)(1)) “would require a registered nurse, social worker, or other personnel qualified in accordance with the hospital’s discharge planning policy, to coordinate the discharge needs evaluation and the development of the discharge plan.” Does our discharge planning policy identify the professionals that can initiate this process?
• Where do we find and who in the hospital would be involved in providing data on Quality Measures and Data on Resource Measures to the patient, their families, or their caregiver’s/support person?
• For those interested in learning more about the IMPACT Act, CMS held an MLN Connects® National Provider Cal regarding the IMPACT Act of 2014 and Data Standardization. The slide presentation can be accessed at https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-10-21-Post-Acute-Care-Presentation.pdf . CMS also has a webpage dedicated to information about the IMPACT Act and Cross Setting Measures at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html.
• Related to §482.43(d)(3), who would be responsible for sending follow-up information to the practitioner(s) responsible for follow-up care? How would you ensure a discharge summary be available within 48 hours of the patient’s discharge?
• Who will be responsible for the post-discharge follow-up process for patients being discharged to home? What will this process look like?

While, this article highlights proposals specific to Hospital Discharge Planning be mindful that this proposed rule also includes:

• Proposals for Home Health Agency Discharge Planning;
• Information Collection Requirements (ICRs) for hospital, HH and CAH discharge planning; and
• A Regulatory Impact Analysis.

MMP strongly encourages key stakeholders within your facility to read the proposed rule and submit comments. CMS has provided four was to submit comments. This information can be found on pages 1-3 of the display copy of the Proposed Rule.    

Resources

Link to CMS Press Release – Discharge Planning Proposed Rule Focuses on Patient Preferences:

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html

Link to display copy of Proposed Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-27840.pdf

This document was scheduled to be published in the Federal Register on 11/03/2015 and available online at http://federalregister.gov/a/2015-27840. There is a 60 day comment period on the proposed rule.

When you hear the word compliance, what comes to mind? The word compliance can and does actually bring to mind a varying degree of answers depending on who you were to ask in the hospital. For Example:

• A Hospital Compliance Officer among other things thinks about the fall release of the Office of Inspector General’s (OIG) annual Work Plan to guide compliance efforts for the coming year. .
• A Case Manager thinks about what is a compliant inpatient status order, does the Physician documentation support a 2-Midnight expectation, is my patient going to be compliant with his/her discharge plan instructions with a goal of preventing a 30-Day Readmission?
• For the Coder, with I-10 finally being implemented, he or she is dealing with compliance with the new coding system and I-10 Coding Clinics.
• A Clinical Documentation Specialist most likely thinks about a compliant query process.
• Infection control promotes compliance with best practices to prevent adverse outcomes for the patient.
• The billing department wants to be compliant while getting a “clean bill” out the door for payment for services rendered by the hospital.

While this is not an exhaustive list of healthcare providers who strive for compliance, it is clear that compliance is a very real concern and desired outcome and at the end of the day, each caregiver wants to “get it right” while providing the best care possible to the patient.

The Health Care Compliance Association (HCCA) defines compliance as being “the process of meeting the expectations of others. More specifically, it is the process of helping our health care professionals understand and meet the expectations of those who grant us money, pay for our services, regulate our industry, etc.” This is where MMP shines by living our mission of “Making HealthCare Make Sense.” This is what we enjoy. This is why when asked I tell people that my hobbies are my husband, my cats and reading the Federal Register.

Our Wednesday@One Newsletter already includes in our production schedule a coverage update the second week of the month and a Medical Review update the third week of each month. This week we are excited to debut a new monthly article the fourth week of each month to be known as The Making HealthCare Make Sense Spotlight. This month we begin by spotlighting free resources available to you on your compliance journey. The use of the term journey is very deliberate as the one thing that you can count on in healthcare is change and that is what makes your career a constant journey.

OIG Compliance Education Materials: Compliance 101:

The OIG developed the resources found on this web page to “help health care providers, practitioners, and suppliers understand the health care fraud and abuse laws and the consequences of violating them. These compliance education materials can also provide ideas for ways to cultivate a culture of compliance within your own health care organization” (http://oig.hhs.gov/compliance/101/).

Medicare Learning Network® (MLN) Provider Compliance page

The MLN Provider Compliance Page “contains educational products that inform health care professionals on how to avoid common billing errors and other improper activities when dealing with various CMS Programs. CMS’ claim review program’s overall goal is to reduce improper payment error by identifying and addressing coverage and coding billing errors. Since 1996, CMS has implemented several initiatives: to prevent improper payments before a claim is processed; and to identify, and recoup improper payments after the claim is processed” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html).

Examples of useful resources on this web page include:

• Provider Compliance Educational Products pdf,
• Fraud and Abuse Educational Products pdf,
• Provider Compliance MLN Matters® Articles pdf; and
• Archive of Medicare Quarterly Provider Compliance Newsletters.

Office of Civil Rights

As a Business Associate we take our HIPAA responsibilities very seriously. The Office of Civil Rights (OCR) has an entire Web page devoted to Health Information Privacy. This web page provides you with information to understand HIPAA Privacy, current enforcement activities and much more. (http://www.hhs.gov/ocr/privacy/index.html).

As we begin this series of articles, we welcome feedback and recommendations for future articles by you our reader. I also encourage you to read the related article in this week’s newsletter, Resources for your Hospital Compliance Plan.

So much of healthcare is a team effort – doctors, nurses, and ancillary services working together to care for patients; billing, coding and case management working together to ensure appropriate inpatient billing; ancillary departments and compliance working together to ensure proper documentation to support billing; and many other incidences of coordination within a hospital that are too numerous to name. The October Medicare Quarterly Provider Compliance Newsletter includes a few compliance issues related to hospitals that definitely require a team effort: one for inpatient billing and a couple regarding outpatient laboratory services.

The inpatient item addresses same-day readmissions. When a Medicare beneficiary is readmitted on the day of discharge to the same acute care PPS hospital, and the reason for the readmission is related to the condition treated in the prior admission, the hospital must combine the original and subsequent stay onto a single inpatient claim. Medicare does not specifically define “related” other than to say “for symptoms related to, or for evaluation and management of, the prior stay’s medical condition” so this can be a judgment call for the hospital. If the claims are combined, coding of diagnoses and procedures must encompass the entire “combined” stay which began when the patient was first admitted and ends with the discharge from the readmission. Present on Admission (POA) indicators are based on the original admission date since this is “one” admission for Medicare.

If the same-day readmission is not related to the prior inpatient admission, the hospital should submit separate inpatient claims and report Condition Code B4 on the second admission. Make sure your documentation clearly supports an unrelated admission because Medicare may request your records for review to support a separate same-day readmission. If hospitals fail to add the condition code B4 to a second unrelated admission, Medicare payment may be at risk of recoupment for automated reviews by Recovery Auditors or other Medicare reviewers.

Hospitals need to have a system in place to address same-day readmissions to:

• Determine if the readmission is related to the prior admission or not. This is a clinical decision and you need to involve clinical staff, such as Case Management, in this review.
• Appropriately code the entire episode for related combined admissions. Your Medical Records Coders will have to look at both records as one and appropriately apply the correct diagnosis, procedure, and POA codes. Unrelated readmissions are coded separately with each record standing on its own.
• Combine the two claims into one for related same-day readmissions by the Billing Department. If the claim for the first admission has already been submitted, it will need to be cancelled and a new or adjusted combined claim submitted. Remember that coding will need to be revised for combined claims before they are submitted. For unrelated same-day readmissions, the condition code B4 will need to be added to the second admission.

As you can see, this requires several different hospital departments working together to get this right - definitely a team effort!

The Compliance newsletter also addresses some issues related to outpatient laboratory services. Laboratory services may be denied upon review by a Comprehensive Error Rate Testing (CERT) contractor due to lack of orders and/or documentation to support medical necessity or due to services exceeding frequency limits.

The issue of the ordering physician’s signature on a laboratory requisition has been the topic of much discussion for several years. And the final CMS decision – a laboratory requisition does not have to be signed by the ordering physician - is a little misleading. Because even though the requisition does not have to be signed, somewhere there must be a valid signed physician’s order or signed documentation supporting the intent to order the laboratory tests. There also must be documentation supporting the medical necessity for the lab services - a diagnosis code or medical condition reason for which the test is being ordered. These requirements can be met by having a physician’s signature and a documented diagnosis on the laboratory requisition. If the lab requisition is not signed or does not contain a supporting diagnosis, a valid order and proof of medical necessity must be submitted to the reviewer. This could be a copy of the physician’s office notes or other types of physician documentation. CERT may send a request for documentation to the referring physician, but remember it is the responsibility of the billing provider to supply the requested documentation regardless of the place of service. This same concept applies to other types of outpatient services such as DMEPOS and ambulance services.

Laboratory services that exceed Medicare’s established frequency limits may also be denied by automated edits or when reviewed by the CERT contractor. There are a number of lab tests and other services that have frequency limits. The newsletter gives examples of a Hepatitis C Screening test exceeding one per lifetime and a screening pap smear exceeding the limit of one every two years. The lab test that MMP most commonly sees exceeding the frequency limit is HCPCS code G0103, Screening PSA which is covered once a year for asymptomatic men over 50.

You may notice that all of the services with frequency limits mentioned above are preventive or screening services. Medicare preventive services, both lab and non-lab services, generally have frequency limits and there are several resources that describe the coverage conditions for preventive services. One such resource is https://www.medicare.gov/coverage/preventive-and-screening-services.html . Some non-screening laboratory tests also have frequency limits: for example, hemoglobin A1C is generally only covered once every three months, with some exceptions, and a lipid panel is necessary once a year for monitoring or following patients with hyperlipidemia. It is often difficult for the testing laboratory or hospital to know when a patient last had a preventive service or a certain lab test. If you are concerned about loss of revenue due to exceeding frequency limits, remember it is acceptable to give patients an Advanced Beneficiary Notice of Non-Coverage (ABN) for services with frequency limits. For more information about ABNs see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf .

Hopefully healthcare professionals working together as a team can take care of patients, appropriately document their services, follow the Medicare and other payers’ rules, and submit a clean claim to obtain payment for their services. Not an easy task so working as a team is a must.

This week we introduce a new area of focus for our weekly Wednesday@One newsletter – Hospital Compliance. Most of what Medical Management Plus already does relates to compliance because we are all about Medicare’s rules and regulations, but a more intense focus on Compliance never hurts. The newsletter this week includes articles on Compliance 101 and hospital issues addressed in Medicare’s Quarterly Compliance Newsletter. One of the challenges of Hospital Compliance is deciding where to direct your efforts, as there are many issues to consider. One suggestion is to follow the leader - follow the lead of Medicare contractors and entities that pursue improper payments, fraud, waste, and abuse within the Medicare program.

Medicare Administrative Contractors (MACs) – In addition to processing Medicare claims, MACs perform medical reviews, provide education to providers, and establish coverage requirements. Being familiar with their medical review topics, LCDs, and education offerings will help lead you to what the MACs think are “risk” areas. MMP publishes new medical review announcements and findings from all the MACs in the Wednesday@One newsletter on the third week of the month. Recent review topics for MACs include:

• Laboratory BNP Test (Cahaba)
• High-cost drugs (Palmetto, Noridian JE)
• Pulmonary Rehab (Palmetto)
• Kwashiorkor (Novitas)
• Joint Replacements (Cigna)
• Facet Joint Injections (Noridian JF)

Supplemental Medical Review Contractor (SMRC) – Strategic Health Solutions is the SMRC and performs “tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.” One of their main tasks is to perform nationwide medical reviews as directed by CMS. You may want to consider their topics as your topics for addressing risks. Their website includes a list of their current projects and their completed projects. Current projects include the following topics:

• Electrodiagnostic testing
• Intensity Modulated Radiation Therapy (IMRT)
• Bariatric Surgery
• Blepharoplasty Services

Comprehensive Error Rate Testing (CERT) – CMS uses the CERT program to calculate the Medicare Fee-for-Service improper payment rate. CERT publishes an annual report that can be found on the CERT website.  The major errors identify by CERT reviews include:

• Lack of or insufficient documentation to support services
• Incorrect patient status
• Failure to meet medical necessity
• Coding errors

Program for Evaluating Payment Patterns Electronic Report (PEPPER) – A link from the CERT website labeled as “Hospital Specific Improper Payments Information and Training Resources” connects readers directly to the PEPPER Resources website. PEPPER can help guide a hospital’s auditing and monitoring activities by comparing your hospital’s statistics for discharges and services vulnerable to improper payments to the statistics of other hospitals in your state, MAC jurisdiction and nationally. This helps you identify where your hospital is an outlier. Some of the current PEPPER targets are:

• Stroke Intracranial Hemorrhage
• Septicemia
• Medical/Surgical DRGs with CC or MCC
• Excisional Debridement
• Chronic Obstructive Pulmonary Disease
• Syncope
• Thirty Day Readmissions
• One-Day and Two-Day Stays

Office of Inspector General (OIG) – The OIG protects the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. They publish an annual Work Plan that describes their target areas for the coming year and then perform audits throughout the year of the risk areas identified in the Work Plan. Compliance departments can use the Work Plan and the audit findings to select areas at risk of fraud, waste, and abuse within healthcare. Some of the topics addressed in the OIG 2015 Work Plan Mid-Year Update include:

• Outlier payments
• Provider-based status
• Mechanical ventilation
• Compliance reviews of Medicare billing requirements
• Dental claims
• Hospital wage data
• Kwashiorkor
• Intensity modulated radiation therapy (IMRT)

Recovery Auditors (RAs or RACs) – The mission of the Recovery Audit program is to identify and correct Medicare improper payments. Each RAC has their own website that list the issues they are reviewing to identify Medicare overpayments and underpayments. This is another great source for hot topics for your hospital compliance program. Although the RAC program has had to step back some lately, CMS recently released the report to Congress of the 2014 RAC activity which reported $2.39 billion of overpayments were collected, and $173.1 million of underpayments repaid to providers. For updates on the RA program, see the Medicare Recovery Audit Program webpage. We are still awaiting the Recovery Audit program to move forward to the next Scope of Work, but until then the current RACs have begun to post some new issues for review. For hospitals, these include:

• Cardiac PET Scan (Cotiviti, formerly Connolly)
• Sacral Nerve Stimulation for Urinary and Fecal Incontinence (Performant)
• Rambizumab (Performant)
• Cataract Surgery Once in a Lifetime (Performant)
• Bariatric Surgery (Performant)
• MS-DRG Validation: Cardiac Defibrillator Implantation (Performant)
• MS-DRG Validation: Permanent Cardiac Pacemaker Implant (Performant)
• Back and Neck Procedure except Spinal Fusion (CGI Federal)

Following Medicare’s lead is an easy way to begin to put together your hospital compliance plan. It gets harder, of course, as you consider what risk areas may be specific to your facility, but at least it is a place to start.

Fall has definitely arrived and with it comes memories of camping trips with Girl Scouts as well as family outings. A favorite part of these trips was the campfire, roasted marshmallows and ghost stories. Let the story begin. First, imagine sitting around a campfire huddled under a blanket on a cool fall night with a new moon and stars up above. Now, let the cautionary to some but scary to others plot unfold. The years were 2000 through 2008. The Department of Justice had alleged that hospitals were overcharging Medicare “when performing kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis. In many cases, the procedure can be performed safely as a less costly outpatient procedure, but the government contends that the hospitals performed the procedure on an in-patient basis in order to increase their Medicare billings.”¹

The characters of this tale included the Department of Justice, a whistleblower (Mr. Charles Bates former regional sales manager for Kyphon in Birmingham, AL), the U.S. Attorney’s Office for the Western District of New York, the Department of Health and Human Services’ Office of Inspector General and Office of Counsel to the Inspector General, Medtronic Spine LLC the corporate successor to Kyphon Inc., and twenty five hospitals that settled allegations of submitting false claims to Medicare.

After a lengthy investigation, this story ended with several hospitals returning millions of dollars back to the Medicare Trust Fund and it became clear that Kyphoplasty was an outpatient procedure.

Now, fast forward to 2015 when hospitals are continuing to perform these procedures just not with the beneficiary being a hospital inpatient. This story is specific to Alabama, Georgia and Tennessee. However, all of the Medicare Administrative Contractors (MACs) have a Kyphoplasty Local Coverage Determination (LCD) so all states need to be take heed of what is required to prove medical necessity of the procedure.

STORYLINE

January 7, 2015

This story begins January 7, 2015 with the MAC for Alabama, Georgia and Tennessee (Cahaba) posting a notification of an upcoming widespread probe review of CPT 22513 and/or CPT 22514 combined for Bill Type 13X.

• CPT 22513 (Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic).
• CPT 22514 (Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar).

July 6, 2015

The plot thickened when Cahaba posted widespread probe review results for review of CPT 22513 and/or CPT 22514 combined for Bill Type 13X on their website on July 6, 2015. The findings speak for themselves, not good.

Cahaba cited the following three key reasons for denials found in their widespread review:

1. The documentation did not justify the medical necessity of the services: According to LCD: Surgery: Vertebral Augmentation Procedures (VAPs) (then L30062 – post October 1, 2015 LCD L34300); the performance of VAPs are considered to be medically reasonable and necessary for persistent debilitating pain caused by the recent pathologic fracture of noncervical vertebrae, painful non-unions of Vertebral Compression Fractures (VCF), back pain associated with osteolytic metastatic disease or multiple myeloma involving a vertebral body, or painful hemangiomas. Conservative management should be implemented prior to performing a VAP. Documentation must indicate that conservative medical management has been tried and has failed or why the patient meets the exceptions to conservative management which may include a high level of pain, disability and neurologic compromise.
2. Lack of documentation: Claims were denied due to the lack of documentation to review for services provided on the claim. Claims either did not include physician orders, procedure reports, or progress notes to support the service was provided as submitted on the claim.
3. Lack of timely submission of requested documentation: Claims were denied due to a lack of record submission in a timely manner. According to the Medicare Program Integrity Manual, PUB 100-8, Chapter 3, 3.2.3.8b, “During prepayment…or post payment…review, if no response is received within 45 calendar days after the date of the ADR, the MACs and ZPICs shall deny the claim.”

Cahaba indicated that from this review finding they plan to “begin a prepayment widespread targeted review…Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS’ guidelines, contractor LCD’s, correct billing and coding).

Will there be a Happy Ending?

 

Here at MMP we have been hearing from clients that they are receiving Additional Documentation Requests (ADRs) for records where the patient has undergone a kyphoplasty. To help ensure this story has a happy ending for your hospital, here are some suggestions of what you can do:

• Timely submission of requested documentation is a must.
• Read the LCD for your MAC to understand the Coverage Guidance (Indications and Limitations, ICD-10 codes that support medical necessity) and Documentation Requirements.
• Work with your Physicians performing these procedures to ensure they are aware of the LCD requirements.

To help everyone get started, we are providing this table with a link to the current LCD for all of the MACs, post ICD-10 implementation.

‍ Resource

¹http://www.justice.gov/opa/pr/2011/January/11-civ-006.html

Q:

How do I determine which devices, APCs, and DRGs are subject to Medicare’s device credit policy?

 

A:

Medicare publishes the list of APCs subject to the device credit policy in the annual Outpatient Prospective System (OPPS) Final Rule.  For 2016, Medicare is proposing to apply the device credit to all device-intensive APCs listed in Table 38 of the Proposed Rule (see page 70 of the 2016 OPPS Proposed Rule).  In previous years, CMS also included a separate list of the devices subject to the device credit policy.  For CY 2016 and beyond, they are proposing to no longer specify a list of devices, but “apply the APC payment adjustment to all replaced devices furnished in conjunction with a procedure assigned to a device-intensive APC when the hospital receives a credit for a replaced specified device that is 50 percent or greater than the cost of the device.”

In MLN Matters Article MM9121, CMS updated the list of MS-DRGs subject to the device credit policy.  Due to changes to MS-DRGs for 2015 and 2016, Medicare deleted two expired DRGs from the list and added seven DRGs.  The complete list of MS-DRGs, including the existing MS-

DRGs and the new MS-DRGs subject to the policy for replaced devices offered without cost or with a credit, is displayed in the table attached to CR9121.

For more information about Medicare’s Device Credit Policy, see the article Learning More about Medicare’s Device Credit Policy in this week's Wednesday@One which can also be accessed through the Knowledge Base section of our website or listen to our On-Demand Webinar on Understanding and Managing Device Credits which can be purchased in the Classes section of our website.

MMP Knowledge Base Webpage: http://www.mmplusinc.com/knowledge-base

MMP Classes Webpage: http://www.mmplusinc.com/earn-ceus

Everyone loves a bargain, a special, or a deal. Package deals involve a discounted price when multiple services are bundled together. These have been especially popular with telecommunication companies lately and a lot of households have a “bundle” that includes cable or satellite television service, internet service and telephone service. Medicare, charged with efficient use of our tax dollars for healthcare services, loves a package deal also. So it is no surprise that we are seeing more and more service bundles for Medicare services.

Injections during cataract and other ocular surgeries are becoming more common, replacing the previous application of drugs via eye drops after the surgery. This technique may be referred to as “dropless cataract surgery.” In the 2015 Outpatient Prospective Payment System (OPPS) October Update, CMS reminds providers of correct coding conventions for injections provided during ocular surgery. The National Correct Coding Initiative clearly states that injection of a drug during a cataract extraction procedure or other ophthalmic procedure is not separately reportable – it is a packaged service. The CPT/ HCPCS code used to report the ocular procedure includes any injections performed during the surgery.

The injections during ocular surgery may be combined or compounded drugs such as triamcinolone and moxifloxacin with or without vancomycin. Effective June 30, 2015, the manner of reporting compounded drugs to Medicare changed. Modifier JF (Compounded drug) was discontinued and replaced with HCPCS code Q9977 (Compounded Drug, Not Otherwise Classified) effective July 1, 2015. HCPCS code Q9977 should be used to report compounded drug combinations, including the compounded drug combinations use for ocular surgeries. These drugs will be packaged as surgical supplies and separate payment will not be made for the drugs. Providers should be sure to report these drug combinations in accordance with these instructions. Providers should not:

• Report these drugs and drugs combinations with HCPCS code C9399
• Try to shift the financial liability to the patient for the drugs or injections using an Advance Beneficiary Notice (ABN) because both are a covered part of the surgical procedure
• Circumvent packaged payment by having patients purchase and bring the drugs with them to the facility for administration.

Other updates from the July OPPS update include the following:

Q:

At the August 18th Hospital Open Door Forum, the CMS representative who answered questions about the “PO” modifier stated that the modifier applied to all outpatient services “paid under OPPS.” The instructions for the “PO” modifier from the July 2015 OPPS Update state that, “This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital.” From reading of the 2015 OPPS Final Rule it appears the intent of this modifier is mainly to gather information on off-campus physician offices and clinics operating as hospital provider-based departments.

Based on differences in the above descriptions of the use of the “PO” modifier, to which types of outpatient services provided in off-campus provider-based departments (PBDs) should the PO modifier be appended?

 

A:

Medical Management Plus posed this question to CMS through the Hospital Open Door Forum email. The answer we received from Tiffany Swygert with CMS is that, “It applies to all services paid under the OPPS that are furnished in an off-campus provider based department of a hospital except for remote locations, satellite facilities and EDs. If the specific services are not paid under the OPPS, then no modifier is required under this policy.”

Ms. Swygert went on to clarify specifically that rehabilitative therapy services (PT, OT and Speech therapy) paid under the Medicare Physician’s Fee Schedule in accordance with an OPPS Status Indicator of “A” do not require a PO modifier when furnished in an off-campus PBD since they are not paid under the OPPS. Another common outpatient service not paid under OPPS is laboratory services when they are non-patient services or the only outpatient services performed. In this situation, most clinical lab services are paid under the Clinical Laboratory Fee Schedule (CLFS) and based on the same logic would not require a PO modifier. However, lab services furnished with other outpatient services are packaged services which means they are “paid under OPPS” although there is no separate payment. Therefore these lab services would require a PO modifier.

The use of the PO modifier is voluntary for 2015, but will be required on claims for off-campus provider-based departments beginning in 2016.

Hospitals should refer to the OPPS Addendum B to find a service’s status indicator and to Addendum D1 for the descriptions of the status indicators to determine which services are paid under OPPS and which are not.

 

 

Q:

How will the coding of blood transfusions change in ICD-10-PCS?

 

A:

Answer: Under I-9, the coder would search for, Transfusion in the Alphabetic Index and then look for the specific blood product to be transfused.

Example: Transfusion of PRBCs - 99.04

In I-10, much more clinical information will be required to arrive at the correct code. We will have to know the specific blood vessel that will receive the blood product and the approach/technique used to reach that blood vessel. Also, we will have to know whether the blood is Autologous (taken from the patient; auto-transfusion) or Non-Autologous (obtained from another person).

Example: Transfusion of Nonautologous Red Blood Cells into Peripheral Artery, Percutaneous Approach – 30253N1

To obtain more specific documentation from the clinician, it would be beneficial to list all of the physical locations in the hospital where the patient would have the opportunity to receive blood products, such as, at bedside, Operating Room, or Emergency Room. Inform the appropriate personnel in these areas of the documentation needed for code assignment. Or, simply request that this specific documentation be added to your hospital’s blood transfusion sheets.

 

October 1st has seen its share of historical events. Before looking forward, let’s take a look back at a few highlights from this date in history.

October 1, 1800: Spain ceded Louisiana to France in a secret treaty.

October 1, 1851: First Hawaiian stamp is issued.

October 1, 1880: First electric lamp factory opened by Thomas Edison.

October 1, 1890: Yosemite National Park forms.

October 1, 1908: Ford puts the Model T car on the market at a price of US$825.

October 1, 1942: Little Golden Books (children books) begins publishing.

October 1, 1955: “Honeymooners” premieres.

October 1, 1982: Sony launches the first consumer compact disc player (model CDP-101).

October 1, 1989: U.S. issues a stamp, labeling an Apatosaurus as a brontosaurus.

October 1, 2013: U.S. federal government shuts down non-essential services after it is unable to pass a budget measure.

As we are now 29 days from October 1st, it appears that the transition to ICD-10 won’t be shut down. While ICD-10 is and should be a main focus for hospitals right now, a gentle reminder that October 1st is also the start of the Centers for Medicare and Medicaid Services (CMS) fiscal year and the implementation of the Fiscal Year (FY) 2016 Inpatient Prospective Payment System (IPPS) Final Rule. This article highlights some of the key MS-DRG changes finalized in the Inpatient Prospective Payment System (IPPS) 2016 Final Rule that will also begin on October 1, 2015.

Documentation and Coding Adjustment

CMS is required to recover $11 billion by 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRG system that began in FY 2008. CMS finalized another -0.8 percent adjustment as begun in FY 2014 to continue the recoupment process.

Changes to Preventable Hospital Acquired Conditions (HACs), Including Infections for FY 2016

CMS finalized the proposal to implement the ICD-10-CM/PCS Version 33 HAC list to replace the ICD-9-CM Version 32 HAC list. The HAC code list translations from ICD-9-CM to ICD-10-CM/PCS are located in Appendix I of the ICD-10-CM/PCS MS-DRG Version 32 Definitions Manual that can be located in the Downloads section of the ICD-10 MS-DRG Conversion Project Web site at: https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

Finalized Changes to Specific MS-DRG Classifications for FY 2016

MDC 5: Diseases and Disorders of the Circulatory System

The CMS created 2 New MS-DRGs to classify Percutaneous Intracardiac Procedures.

Major Cardiovascular Procedures have been moved from MS-DRGs 237 and 238 to five new MS-DRGs as outlined in the following table.

‍MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Revision of Hip or Knee Replacements ICD-10-PCS Version 32 Logic

The CMS finalized the proposal to add code combinations which capture the joint revision procedure. These combination codes will be the same for MS-DRGs 466,467, 468 as well as MS-DRGs 628, 629, and 630 (Other Endocrine, Nutritional, and Metabolic Operating Room Procedures with MCC, with CC, and without CC/MCC) as the joint procedures are also included in this MS-DRG group. The table of code combinations can be found on pages 49,390 thru 49,406 of the Final Rule.

Spinal Fusion

The CMS finalized the proposal to change the title of MS-DRGs 456, 457 and 458. They indicated that by changing the reference of “9+ Fusions” to “Extensive Fusions,” this more appropriately identifies the procedures classified under these groupings. The final title revisions are as follows:

• MS-DRG 456: Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or Extensive Fusion with MCC,
• MS-DRG 457: Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or Extensive Fusion with CC; and
• MS-DRG 458: Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/Infection or Extensive Fusion without CC/MCC.

MDC 14: Pregnancy, Childbirth and the Puerperium

The CMS finalized the proposal to modify the logic for several ICD-10 procedure codes where the current logic did not result in the appropriate MS-DRG assignment. Specifically, the codes should not be designated as O.R. codes. Specific Codes where the logic was modified include:

• 3E0P7GC (Introduction of other therapeutic substance into female reproductive, via natural or artificial opening);
• 3E0P76Z (Introduction of nutritional substance into female reproductive, via natural or artificial opening);
• 3E0P77Z (Introduction of electrolytic and water balance substance into female reproductive, via natural or artificial opening);
• 3E0P7SF (Introduction of other gas into female reproductive, via natural or artificial opening);
• 3E0P83Z (Introduction of anti-inflammatory into female reproductive, via natural or artificial opening endoscopic);
• 3E0P86Z (Introduction of nutritional substance into female reproductive, via natural or artificial opening endoscopic);
• 3E0P87Z (Introduction of electrolytic and water balance substance into female reproductive, via natural or artificial opening endoscopic);
• 3E0P8GC (Introduction of other therapeutic substance into female reproductive, via natural or artificial opening endoscopic); and
• 3E0P8SF (Introduction of other gas into female reproductive, via natural or artificial opening endoscopic).

Finalized Changes to the Postacute Care Transfer MS-DRGs

Per the 2015 OPTUM DRG Expert, “CMS established a postacute care transfer policy effective October 1, 1998. The purpose of the IPPS postacute care transfer payment policy is to avoid providing an incentive for a hospital to transfer patients to another hospital early in the patient’s stay in order to minimize costs while still receiving the full DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases.”

The CMS finalized the proposal to update the list of MS-DRGs that are subject to the Postacute Care Transfer Policy to include:

• MS-DRG 273: Percutaneous Intracardiac Procedures with MCC; and
• MS-DRG 274: Percutaneous Intracardiac Procedures without MCC.

Note: MS-DRGs 273 and 274 met the criteria for the special payment methodology and therefore are also subject to the MS-DRG special payment methodology.

Please be aware that this article highlights some of the key changes. For those closely involved with coding in your facility be on the lookout for our Annual Fall Inpatient webinar.

In the meantime, the FY 2016 Final Rule can be accessed at http://www.gpo.gov/fdsys/pkg/FR-2015-08-17/pdf/2015-19049.pdf.