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Did You Know?

August is National Immunization Awareness Month (NIAM). According to the CDC, NIAM “is an annual observance held in August to highlight the importance of routine vaccination for people of all ages.”

 

Why It Matters?

Immunity from childhood vaccines can wear off over time. Keeping your vaccinations up to date throughout life helps you combat vaccine preventable diseases. The CDC advises that all adults need a COVID-19 vaccine, Influenza (flu) vaccine every year, and Tetanus and diphtheria (Td) or Tetanus, diphtheria, and pertussis (Tdap) vaccine every ten years.

 

Additional Key Vaccines

 

Shingles Vaccine (Shingrix)

The two-dose series of shots to protect against shingles. The CDC cites that “in adults 50 years and older who have healthy immune systems, Shingrix is more than 90% effective at preventing shingles” and postherpetic neuralgia (PHN)< the most common complication from shingles.”

 

Pneumonia Vaccines

In 2022, the percent of adults aged eighteen and over who had ever received a pneumococcal vaccination was only 23.9%. Older adults are at greatest risk of serious illness and death from pneumococcal disease. In the United States, there are two kinds of vaccines to help prevent pneumococcal disease, Pneumococcal conjugate vaccines (PCV 13, PCV15, and PCV20), and Pneumococcal polysaccharide vaccine (PPSV23).

 

PCV13: Prevnar 13® (pneumococcal conjugate vaccine or PCV13) is a registered trademark by Wyeth LLC and marketed by Pfizer Inc. This vaccine provides protection against infections caused by six more serotypes than PCV7. This vaccine is part of the routine childhood immunization schedule. Additionally, in 2011, it was licensed by the FDA for use in adults 50 years or older.

 

The CDC recommends PCV13 for all children younger than 2 years old, and people 2 years or older with certain medical conditions.

 

The CDC advises adults 65 years and older to discuss the need for this vaccine with their health care provider.

 

PCV 15: Vaxneuvance™ (Pneumococcal 15-valent Conjugate Vaccine)

On July 16, 2021, Merck announced the FDA approval of Vaxneuvance™, a new vaccine for the prevention of invasive pneumococcal disease in adults 18 years and older caused by 15 serotypes.

 

PCV20: Prevnar 20™ (Pneumococcal 20-valent Conjugate Vaccine)

On June 8, 2021, Pfizer announced the FDA approval of the Prevnar 20™ vaccine for adults 18 years or older and noted that it is “the first approval of a conjugate vaccine that helps protect against 20 serotypes responsible for the majority of invasive pneumococcal disease and pneumonia, including seven responsible for 40% of pneumococcal disease cases and deaths in the U.S.”

 

PPSV23: Pneumovax23® (pneumococcal polysaccharide vaccine or PPSV23) is a Merck product. This vaccine was approved by the FDA in 1983 and helps protect against twenty-three types of pneumococcal bacteria.

 

The CDC recommends this vaccine for all adults 65 years or older, people 2 through 64 years old with certain medical conditions (i.e., diabetes, heart disease or COPD), and adults 19 through 64 years old who smoke cigarettes.

 

Respiratory Syncytial Virus (RSV) Vaccine

On May 3, 2023, the FDA announced they had approved Arexvy, the first RSV vaccine approved in the United States for the prevention of lower respiratory tract disease caused by RSV in people 60 years of age and older.

 

On June 29, 2023, the CDC endorsed the CDC Advisory Committee on Immunization Practices’ (ACIP) recommendations for use of the RSV vaccine in people ages 60 years or older. They noted that “Adults at the highest risk for severe RSV illness include older adults, adults with chronic heart or lung disease, adults with weakened immune systems, and adults living in nursing homes or long-term care facilities. CDC estimated that every year, RSV causes approximately 60,000-160,000 hospitalizations and 6,000-10,000 deaths among older adults.”

 

What Can I Do?

As a Healthcare Provider

Work with your patients to identify what vaccinations they have and have not received and utilize available resources on the CDC website for healthcare providers related to immunization schedules.

 

As a Healthcare Consumer

Keep your vaccination records up to date, use the CDC’s Adult Vaccine Assessment Tool to determine which vaccines are recommended for you, and share all this information with your healthcare provider so you make an informed decision on what immunizations you may need.

 

Resources

CDC webpages

• National Immunization Awareness Month: https://www.cdc.gov/vaccines/events/niam/
• Vaccine Information for Adults: https://www.cdc.gov/vaccines/adults/index.html
• Shingles Vaccination: https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

 

Merck July 16, 2021 Announcement: https://www.merck.com/news/merck-announces-u-s-fda-approval-of-vaxneuvance-pneumococcal-15-valent-conjugate-vaccine-for-the-prevention-of-invasive-pneumococcal-disease-in-adults-18-years-and-older-caused-by-15-serot/

 

Pfizer June 8, 2021 Announcement: https://www.pfizer.com/news/press-release/press-release-detail/us-fda-approves-prevnar-20tm-pfizers-pneumococcal-20-valent

 

FDA May 3, 2023 RSV Vaccine Announcement: https://www.fda.gov/news-events/press-announcements/fda-approves-first-respiratory-syncytial-virus-rsv-vaccine?utm_medium=email&utm_source=govdelivery

 

June 29, 2023 CDC Announcement Recommending RSV Vaccine for Older Adults: https://www.cdc.gov/media/releases/2023/s0629-rsv.html

June 29, 2023 HHS Press Release: CDC Recommends Older and Immunocompromised Adults to Receive the RSV Vaccine

HHS Secretary Xavier Becerra issued the following statement in response to the CDC recommendation of the Respiratory Syncytial Virus (RSV) vaccine for seniors over 60: “For the first time in U.S. history, people 60 years and older can now receive a vaccine for protection against RSV virus…As we prepare for the fall vaccine campaign, we will follow the data and science to protect our nation’s most vulnerable adults, those living in nursing or long-term care facilities, and the immunocompromised.” https://tinyurl.com/yw9buepd

June 29, 2023: MLN Connects: New TCET Pathway

CMS published the following information in the June 29, 2023 edition of MLN Connects:

CMS is committed to fostering innovation while ensuring that people with Medicare have faster and more consistent access to emerging technologies that will improve health outcomes. As part of this commitment, CMS announced a proposed Transitional Coverage for Emerging Technologies pathway. This announcement includes a proposed procedural notice and several proposed guidance documents that propose a substantial transformation to our approach to coverage reviews and evidence development. Comment on the Federal Register notice by August 28. More Information:

Related CMS Blog: https://www.cms.gov/blog/transforming-medicare-coverage-new-medicare-coverage-pathway-emerging-technologies-and-revamped, and

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/notice-comment-transitional-coverage-emerging-technologies-cms-3421-nc

June 29, 2023: MLN Connects: New Details of Plan to Cover New Alzheimer’s Drugs

CMS released new details about how people can get drugs that may slow the progression of Alzheimer’s disease covered by Medicare.  Medicare will cover drugs with traditional FDA approval when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. Clinicians will be able to submit this information through a nationwide, CMS-facilitated portal. Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-announces-new-details-plan-cover-new-alzheimers-drugs

July 7, 2023: OPPS: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022 Proposed Rule (CMS 1793-P)

In response to the Supreme Court’s decision in American Hospital Association v. Becerra (142 S. Ct. 1896 (2022), and the district court’s remand, CMS published a proposed rule to remedy the payment rates the Court held were invalid and noted that aspects of this proposed rule policy will affect nearly all hospitals paid under the OPPS. The proposed rule contains the calculations of the amounts owed to each of the approximately 1,600 affected 340B covered entity hospitals. The 60-day comment period will end on September 5, 2023.

Proposed Rule: https://www.cms.gov/medicare/medicare-fee-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations-and/cms-1793-p

Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/hospital-outpatient-prospective-payment-system-remedy-340b-acquired-drug-payment-policy-calendar

July 12, 2023: Medicare Dental Services

CMS has created a Medical Dental Coverage webpage for health care providers. You will find links to information about what Medicare does and does not cover, what are inextricably linked dental services, if Medicare pays for multiple dental visits, who can provide and bill for dental services, how to submit a claim and additional resources. https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage

Beneficiary Notice of Noncoverage, Form CMS-R-131 Renewed

Reminder, the ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The renewed form has an expiration date of January 31, 2026, and became mandatory on June 30, 2023. Any ABN signed on or after June 30, 2023, with a prior expiration date will not be considered valid. https://www.cms.gov/medicare/medicare-general-information/bni/abn

July 20, 2023: The Joint Commission Eliminates Additional 200 Standards Across All Accreditation Programs

The Joint Commission announced in a press release that they are eliminating and consolidating more than 200 standards, effective August 27, 2023. “The second phase of this project includes a focus on The Joint Commission’s other accreditation programs in addition to the Hospital Accreditation Program (i.e., Ambulatory Health Care, Behavioral Health Care, and Laboratory). https://www.jointcommission.org/resources/news-and-multimedia/news/2023/07/the-joint-commission-eliminates-additional-200-standards-across-all-accreditation-programs/

Medicare Transmittals & MLN Articles

 

June 30, 2023: MLN MM13269: ICD-10 & Other Revisions to Laboratory National Coverage Determinations: October 2023 Update

CMS advises that you make sure your billing staff is aware of newly available codes, recent coding changes, and how to find NCD coding information.  https://www.cms.gov/files/document/mm13269-icd-10-other-coding-revisions-laboratory-ncds-october-2023-update.pdf

 

July 5, 2023: MLN Matters MM13216: Ambulatory Surgical Center Payment System: July 2023 Update - Revised

Now in it’s fourth iteration, CMS has revised this MLN article to change the number of separately payable drugs in Section 5.a to 18 to agree with the change for HCPCS J9322 in Table 3 of Change Request (CR) 13216. Substantive changes are in dark red on page 3. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

 

July 11, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

Now in its fifth iteration, CMS has revised this special edition MLN article to add information on Round 5 testing and national implementation of edits. Substantive changes are in dark red on pages 1 and 4. Note that these are not new requirements, but CMS did announce a delay of activation of these edits on March 24, 2022 until further notice. On August 1, 2023, CMS will start deploying editing into full procedure and have told the MACs to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t match exactly. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

 

Coverage Updates

 

July 17, 2023: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease Proposed Decision Memo

CMS is proposing to remove National Coverage Determination (NCD) 220.6.20, ending coverage with evidence development (CED) from positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging be made by the Medicare Administrative Contractors (MACs). https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=308

 

July 20, 2023: HCPCS Modifier JZ Reminder

Palmetto GBA JJ Part B published a reminder that “the JZ HCPCS modifier is reports on a claim to attest that no amount of drug was discarded and eligible for payment. The modifier should only be used for claims that bill for single-dose container drugs. Effective July 1, 2023 providers are required to use the JZ modifier on applicable claims. https://www.palmettogba.com/palmetto/jjb.nsf/DID/1HF9LYKONE#ls

 

Compliance Education Updates

 

June 2023: Medicare’s Home Health Benefit Brochure Revised

CMS has revised their Medicare home health brochure. This brochure includes information about a beneficiary knowing their rights, where to get more information, what is covered, who can get covered home health care, what to pay, and how to protect yourself and Medicare from fraud. https://tinyurl.com/yc2ej3sv

 

June 2023: MLN Fact Sheet Telehealth Services Revised

CMS has recently updated this Fact Sheet and notes that they have made significant updates to explain recent policy changes. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf

Question:

There is confusion about coding an elevated troponin level. Should we use R77.8 per codebook or R79.89 per advice from Coding Clinic, Second Quarter 2019, pg. 6?

Answer:

The correct code assignment for an elevated troponin level is R77.8, Other Specified Abnormalities of Plasma Proteins. Coding Clinic, Second Quarter 2019, page 6 was superseded by the changes to the index that were effective with the discharges October 1, 2020. The ICD-10-CM Conventions and Coding Guidelines take precedence over Coding Clinic advice. 

 

References:

Coding Clinic Correspondence dated June 9, 2023

Coding Clinic, Second Quarter 2019, page 6

Coding Clinic, Fourth Quarter 2018, page 90

 

Did You Know?

The 2024 ICD-10-CM Official Guidelines for Coding and Reporting were posted to the CMS website on July 6, 2023 (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm). You can also find the guidelines on the CDC ICD-10-CM webpage (https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm).

Why It Matters?

“These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” As of July 19^th, there are only 73 days to become familiar with the October 1, 2023, changes.

Narrative guideline changes appear in bold text in this document.

What Can You Do?

For Coding and Clinical Documentation Integrity professionals, reading the new guidelines should be a requirement on your summer reading list. In addition to identifying the bolded text, pay attention to each time the guidelines tell you to query the provider if documentation is unclear.

For example, Section 1.A.19: Code Assignment and Clinical Criteria

“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. If there is conflicting medical record documentation, query the provider.”

Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1^st start of the 2024 CMS Fiscal Year.

 

 

There are five covered indications in section B of National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) for when PTA is covered.  

In June 2022, the Multispecialty Carotid Alliance (MSCA) submitted a letter to CMS for reconsideration of covered indication B4 (concurrent with carotid stent placement in patients at high risk for carotid endarterectomy (CEA).

Last week, on July 11, 2023, CMS published Proposed Decision Memo CAG-00085R8: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting. CMS notes, the scope of this reconsideration is limited to PTA concurrent with CAS including transcarotid artery revascularization (TCAR) procedures.

CMS summarizes that their proposals, which affect NCD 20.7 sections B4 and D, will revise Medicare coverage for PTA of the carotid arteries concurrent with stenting by:

1. Expanding coverage to individuals previously only eligible for coverage in clinical trials.
2. Expanding coverage to standard surgical risk individuals by removing the limitation of coverage to only high surgical risk individuals.
3. Removing facility standards and approval requirements.
4. Adding formal shared decision-making with the individual prior to furnishing CAS; and
5. Allowing MAC discretion for all other coverage of PTA of the carotid artery concurrent with stenting not otherwise addressed in NCD 20.7.

CAS By the Numbers

CY 2022 PTA of Carotid Artery Concurrent with Stenting Top 5 States by Volume & Overall Nationwide
Provider State	Claims Volume	Total Claims Payment
FL	1,250	$19,318,373.57
TX	1,158	$20,279,078.22
CA	1,007	$24,699,603.30
PA	541	$10,394,841.24
NY	523	$13,379,059.31
Nationwide	13,471	$246,555,039.68
Data Source: RealTime Medicare Data (RTMD) Medicare Fee-for-Service paid claims data for DOS CY 2022

Moving Forward

CMS is seeking comments on whether the shared decision-making interaction should require the use of a validated shared decision-making tool and/or if there are other options to achieve the goal of truly informed decision-making. The comment period is from July 11, 2023 through August 10, 2023.  

Resources

NCD 20.7: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=201

Proposed Decision Memo CAG-0085R8: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=311&fromTracking=Y&

July is UV Safety Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to the treatment costs of Melanoma.

 

Did You Know?

Anyone can get skin cancer, but people with certain characteristics are at greater risk—

A lighter natural skin color.

• Skin that burns, freckles, reddens easily, or becomes painful in the sun.
• Blue or green eyes.
• Blond or red hair.
• Certain types and many moles.
• A family history of skin cancer.
• A personal history of skin cancer.
• Older age.

Why It Matters?

 

Basal and Squamous Cell Carcinomas

According to the CDC (https://www.cdc.gov/cancer/skin/statistics/index.htm), skin cancer is the most common form of cancer in the United States. “An examination of Medical Expenditure Panel Survey data suggests that each year, about 6. 1 million adults are treated for basal cell and squamous cell carcinomas at a cost of about $8.9 billion.”

 

These numbers have increased exponentially from 2022 when the panel survey data suggested that each year about 4.3 million adults are treated for basal and squamous cell carcinomas at a cost of about $4.8 billion.

 

Melanoma

Following are recent National Cancer Institute cancer facts about melanoma:

• In 2020, there were an estimated 1,413,976 people living with melanoma of the skin in the U.S.
• Represents 5% of all new cancers in the U.S.
• Is more common in men than women.
• Is most frequently diagnosed among people ages 65-74 with a median age at diagnosis of 66.
• In 2023, it is estimated that there will be 97,610 new cases of melanoma of the skin and an estimated 7,990 people will die of this disease.

https://seer.cancer.gov/statfacts/html/melan.html

 

What Can I Do?

Be proactive in lowering your risk for melanoma and other skin cancers by following key sun safety tips from the FDA ( https://www.fda.gov/drugs/understanding-over-counter-medicines/sunscreen-how-help-protect-your-skin-sun):

• Limit time in the sun, especially between the hours of 10 a.m. and 4 p.m., when the sun’s rays are most intense,
• Wear clothing to cover skin exposed to the sun, such as long-sleeved shirts, pants, sunglasses, and broad-brimmed hats.
• Use broad spectrum sunscreens with SPF values of 15 or higher regularly and as directed.
• Reapply sunscreen at least every two hours, and more often if you are sweating or jumping in and out of the water.

 

Also, be mindful that certain medications can cause sensitivity to the sun, for example:

• Antibiotics (ciprofloxacin, doxycycline, levofloxacin, ofloxacin, tetracycline, trimethoprim),
• Antihistamines including Diphenhydramine (common brands include Benadryl and Nytol),
• Oral contraceptives and estrogens, and
• Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen).

 

You can read more about this on the FDA website (https://www.fda.gov/drugs/special-features/sun-and-your-medicine).

 

Coverage Updates

 

June 7, 2023: Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)

The CMS issued a National Coverage Analysis (NCA) Tracking Sheet. CMS has received a complete, formal request to reconsider NCD 110.23, they requested full coverage of allogeneic HSCT for individuals with MDS and the removal of the Coverage with Evidence Development (CED requirement currently tied to coverage for HSCT for Medicare beneficiaries with MDS. CMS is soliciting public comments relevant to the request and is accepting comments from 6/7/2023 – 7/7/2023. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=312

 

June 22, 2023: CMS Fact Sheet: Details of Plan to Cover New Alzheimer's Drugs

CMS notes that if the FDA grants traditional approval, then Medicare will cover the drug in appropriate settings that also support the collection of real-world information to study the usefulness of these drugs. This fact sheet gives more details on how a registry will work to make sure coverage will be available for any Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease that received FDA traditional approval. https://www.cms.gov/files/document/fact-sheet-june-2023.pdf

 

June 22, 2023: CMS Proposed Transitional Coverage for Emerging Technologies (TCET) Pathway

On June 22, 2023 CMS announced a proposed Transitional Coverage for Emerging Technologies (TCET) pathway as part of its commitment to fostering innovation while ensuring faster and more consistent access to emerging technologies. In addition, CMS released three proposed guidance documents: 1) Coverage with Evidence Development; 2) Evidence Review and 3) Clinical Endpoints Guidance for Knee Osteoarthritis. Additional information on today’s releases can be found here: https://www.cms.gov/blog/transforming-medicare-coverage-new-medicare-coverage-pathway-emerging-technologies-and-revamped and https://www.cms.gov/newsroom/fact-sheets/notice-comment-transitional-coverage-emerging-technologies-cms-3421-nc

 

Education Updates

 

MLN Fact Sheet: Medicare Part D Vaccines

This MLN Fact Sheet was updated this month to clarify that Medicare Part B covers vaccines and vaccine administration and Part D patient cost-sharing may include a vaccine administration fee. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/vaccines-part-d-factsheet-icn908764.pdf

 

Other Updates

June 5, 2023: OIG Publishes Spring 2023 Semiannual Report to Congress

The OIG notes that this semiannual report is intended to keep the HHS Secretary and Congress fully and currently informed of OIG’s crucial findings and recommendations during the reporting period October 1, 2022 through March 31, 2023. https://oig.hhs.gov/reports-and-publications/archives/semiannual/2023/spring-sar-2023.pdf

Medicare Transmittals & MLN Articles

 

June 1, 2023: MLN MM13055: Audiologists May Provide Certain Diagnostic Tests Without a Physician Order

Effective July 1, 2023, one visit to an audiologist without a physician or NPP order is permitted, per patient, once every 12 months. This change was finalized in the CY 2023 Physician Fee Schedule (PFS) rulemaking. https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf

 

June 2, 2023: MLN MM13056: New JZ Claims Modifier for Certain Medicare Part B Drugs

CMS advises that your billing staff know about using JW modifier data to show discarded amounts of drugs in a single-dose container or single-use package and reporting requirements for the new JZ modifier starting July 1, 2023. https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b-drugs.pdf

 

June 5, 2023: MLN MM13235: DMEPOS Fee Schedule: July 2023 Quarterly Update

Make sure your billing staff knows about the fee schedule adjustment relief for rural and non-contiguous areas and supplier education on power wheelchair repair. https://www.cms.gov/files/document/mm13235-dmepos-fee-schedule-july-2023-quarterly-update.pdf

 

June 7, 2023: MLN MM13164: Skilled Nursing Facility Probe and Educate Review

Medicare Administrative Contractors (MACs) will be reviewing a small sample of five SNF claims for each SNF in their jurisdiction. This strategy is in response to the CERT identifying SNF services as a top driver of the overall Medicare Fee-for-Service improper payment rate. CMS notes a contributing factor may be the change from the Resource Utilization Group (RUG) IV to the Patient Driven Payment Model (PDPM) for claims with dates of service on or after October 1, 2019.  https://www.cms.gov/files/document/mm13164-skilled-nursing-facility-probe-and-educate-review.pdf

 

June 13, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

CMS advised providers to make sure billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

 

June 15, 2023: MLN MM13235: New Waived Tests

This MLN highlights new waived tests effective October 1, 2023.  https://www.cms.gov/files/document/mm13253-new-waived-tests.pdf

 

June 22, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: July 2023 Update – Revised

This MLN article was initially released on May 25, 2023. With the June 22^nd iteration of this article, CMS added information about a corrected payment for CPT 0697T to agree with a revised CR 13216. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

It has been almost four years since the September 30, 2019 publication of the Discharge Planning Conditions of Participation (CoP) Final Rule in the Federal Register. At that time, CMS indicated that they would provide sub-regulatory interpretive guidance after the publication of the final rule, which will provide further clarification for implementing the final discharge planning requirements. You can read more about this final rule in a related MMP article.

In 2020, COVID-19 was declared a Public Health Emergency (PHE), and CMS used emergency waiver authorities so providers could rapidly respond to people impacted by COVID-19. Specific to the Discharge Planning CoPs, CMS waived the following requirements:

§482.43(A)(8) Quality and Resource Use Measures

“The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.”

 

§482.43 (C)(1) Patient Choice Lists

“The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.”

 

§482.61(e): Discharge Planning and Discharge Summary

“The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient’s condition on discharge.”

 

The discharge planning waivers expired on May 11, 2023 at the end of the COVID-19 PHE.

On June 6, 2023, CMS issued a Memorandum (QSO-23-16-Hospitals) to State Survey Agency Directors and noted in the Memorandum Summary that:

“CMS is committed to ensuring that the health and safety of patients are protected when discharges from hospitals and transfers to post-acute care providers occur. Therefore, we are providing the following information:

• Reminding state agencies (SAs), accrediting organizations (AOs), and hospitals of the regulatory requirements for discharges and transfers to post-acute care providers.
• Highlighting the risks to patients’ health and safety that can occur due to an unsafe discharge.
• Recommendations that hospitals can leverage to improve their discharge policies and procedures to improve and protect patients’ health and safety.”

   

  Areas of Concern

  Examples from the list of concerns identified by CMS related to missing or inaccurate patient information includes:

• Incomplete comprehensive list of all medications that have been prescribed to a patient during, and prior to, the hospitalization,
• Skin tears, pressure ulcers, bruising, or lacerations, including orders or instructions for cultures, treatments, or dressings, and
• A patient’s preferences and goals for care, such as their choices for treatment or their advance directives for end-of-life care.

 

After noting how missing and inaccurate patient information can have a negative impact for the patient, caregiver, and PAC providers, CMS reminds SAs and AOs about the discharge planning CoPs and advises that “when conducting surveys, SAs and AOs should be alert to the common issues identified above and ensure these discharges are occurring in a compliant and safe manner.”

 

Moving Forward

As of June 20, 2023, interpretive guidance for the Discharge Planning CoPs is still “pending and will be updated in future release” of the State Operations Manual – Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for hospitals. In the meantime, I encourage you to share this memorandum with your Discharge Planning staff so they can use the full list of areas of concern to make sure your medical record does not have missing or inaccurate patient information.

 

Resources

September 30, 2019 Discharge Planning CoP Final Rule: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf

Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHs: CMS Flexibilities to Fight COVID-19: https://www.cms.gov/files/document/hospitals-and-cahs-ascs-and-cmhcs-cms-flexibilities-fight-covid-19.pdf

June 6, 2023 CMS Memorandum (QSO-23-16-Hospitals): https://www.cms.gov/files/document/qso-23-16-hospitals.pdf

CMS State Operations Manual – Appendix A: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf