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During the first week of 2024, the following information was posted on several of the Medicare Administrative Contractors (MACs) websites.

“On June 15, 2022, the Supreme Court held in American Hospital Association v. Becerra that because CMS had not conducted a survey of hospitals’ acquisition costs, it could not vary the payment rates for outpatient prescription drugs by hospital group. On remand, the U.S. District Court for the District of Columbia prospectively vacated-beginning September 28, 2022- adjustments CMS had made to payments under the Hospital Outpatient Prospective Payment System for drugs acquired through the 340B program.

On January 10, 2023, the U.S. District Court for the District of Columbia issued a remand without vacatur to give the Centers for Medicare & Medicaid Services (CMS) the opportunity to determine the proper remedy for the reduced payment amounts to 340B hospitals under the payment rates in the final OPPS rules beginning in CY 2018 and continuing through September 27, 2022.

Accordingly, on November 8, 2023, CMS published the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022.

Under this final rule, affected hospitals will be paid a one-time lump-sum amount based on the difference between what they were paid for 340B-acquired rugs from CY 2018 through September 27, 2022, and what they would have been paid during this time-period had the 340B Drug Payment Policy never existed. These payment amounts are listed in Addendum AAA to the final rule. This final rule ensures affected hospitals will receive the approximate payment they would have received if the original CY 2018-2022 340B payment policy had never existed.

Beginning January 8, 2024, Medicare Administrative Contractors (MACs) will begin making these one-time lump-sum remedy payments to affected providers via HIGLAS. There payments are scheduled to be completed by February 7, 2024.

The MACs will not included these lump sum payments on any cost report.

All remedy payments are subject to the MAC’s normal accounting procedures and may in effect be combined with other payment released on the same date and/or include any applicable outstanding Medicare offsets that are the result of provider-specific overpayment obligations, adjustments resulting from errors identified through the lump-sum technical correction process, any of which may impact the provider’s net payment amount.”

MAC Specific Announcements

Palmetto GBA Jurisdiction J

Palmetto GBA Jurisdiction M

NGS Jurisdiction 6

NGS Jurisdiction K

CGS Jurisdiction 15

WPS Jurisdictions 5 & 8

Question

We have outpatient lab orders on patients that frequently have a host of lab tests performed including Microalbumin/Creatinine Ratio and Urine Drug Screen, CPT® codes 82570, 82043, 80307. There are separate orders & results for all 3 tests.  All may have the same diagnoses or different diagnoses.

 

I have read the NCCI edit about specimen validity, but in this case, these tests appear to be ordered for specific diagnoses, they have separate orders and results. Would 59 be appropriate on 82570?

 

Answer

Yes, modifier 59 can be used when CPT® code 82570 (urine creatinine) is ordered and resulted separately, and when the urine creatinine is “not” performed for specimen validity testing.

 

To support this opinion, we used the NCCI policy statement you referenced above (NCCI Policy Manual, chapter X, section E.2, page X-7) Link

 

 

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2023 American Medical Association. All rights reserved.  CPT® is a registered trademark of the American Medical Association.

 

Fiscal Year 2023 Supplemental Improper Payment Data

On December 7, 2023, the Comprehensive Error Rate Testing (CERT) published the 2023 Medicare Fee-for-Service Supplemental Improper Payment Data ( https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports).

 

This report supplements the FY 2023 HHS Agency Final Report for Fiscal Year 2023, highlights common causes of improper payments, and includes tables allowing you to drill down into the review findings.

 

Estimated Improper Payment Rates

Calculation for the FY 2023 Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2021 through June 30, 2022. As compared to FY 2020 and 2021, the improper payment rate is trending up:

 

Improper Payment Rate

• FY 2020: 6.27%
• FY 2021: 6.26%
• FY 2022: 7.46%
• FY 2023: 7.38%

  Improper Payment Amount

• FY 2020: $25.74 billion
• FY 2021: $25.03 billion
• FY 2022: $31.46 billion
• FY 2023: $31.23 billion

   

  “It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements. Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).

  Unfortunately, “insufficient documentation” continues to be the main cause of improper payments. The CERT defines “insufficient documentation” as when the medical record documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.

  While the CERT data reports on improper payments in various settings (i.e., skilled nursing facilities, hospital outpatient, hospice), this article focuses on Part A (Hospital IPPS) findings.

  “0 or 1 day” Length of Stay Claims

  A compare of improper payments rates for Part A hospital claims by length of stay (LOS) has been a part of this annual report since the October 1, 2013 implementation of the Two-Midnight Rule:

   

• 2014: “0 or 1 Day” stay claims highest improper payment rate to date at 37.18%,
• 2021: “0 or 1 Day” stay claims lowest improper payment rate to date at 16.8%.
• 2022: The “0 or 1 Day” claims rate increased to 20.1% with projected improper payments of $1.5 billion.
• 2023: The “0 or 1 Day” claims rate again increased to 21.7% with projected improper payments of $1.7 billion.

 

In addition, to the CERT’s focus on claims by length of stay, short stays (“0 of 1 Day” Stays) are also actively being reviewed by the OIG as part of their Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp) and Livanta, the National Medicare Claim Review Contractor (https://livantaqio.com/en/ClaimReview/index.html), who is actively requesting short stay claims across the nation on a monthly bases.  

 

In early 2023, Livanta published their year one review results. Of the 18,672 short stay claims reviewed, 2,663 (14%) of the claims were denied. You can read more about their review results in a related MMP article (https://www.mmplusinc.com/kb-articles/national-medicare-claims-review-contractor-year-one-review-results).

 

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS

Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories.

 

Overall, 52.9% of the errors in the top 20 service types were due to error category medical necessity. This is an increase from 44.4% in FY 2022. A claim is placed in this category when the CERT contractor reviewer receives adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. The following three DRG types had the highest percent of errors attributed to medical necessity:

 

• DRG Pair 469 and 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity,
• DRG Group 091, 092, and 093: Other Disorders of Nervous System, and
• DRG Group 518, 519, and 520: Back and Neck procedures Except Spinal Fusion.

 

Medicare Transmittals & MLN Articles

 

November 22, 2023: MLN MM13452: Medicare Physician Fee Schedule Final Rule Summary: CY 2024

This article highlights changes in the CY 2024 Physician Fee Schedule final rule. For example, starting in CY 2024, telehealth services provided to people in their homes will be paid at the non-facility PFS rate. https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf

 

November 30, 2023: Change Request (CR) 13312: Indian Health Services (IHS) Rural Emergency Hospital (REH) Provider Enrollment

Beginning January 1, 2024, a tribal or IHS operated hospital that converts to an REH (IHS-REH) that provides hospital outpatient services to a Medicare beneficiary may be paid under the outpatient hospital All-Inclusive rate that is established and published annually by the IHS, rather than the rate for REH services. This CR updates Chapter 10 of the CMS Publication 100-08 (Medicare Program Integrity Manual) to include provider enrollment guidance regarding IHS-REHs. https://www.cms.gov/files/document/r12217pi.pdf

 

December 7, 2023: MLN MM13333: Medicare Program Integrity Manual: CY 2024 Home Health Prospective Payment System Updates

This article includes information about expanding the HHS 36-month rule, moving hospices into the high level of categorical risk-screening, and other updates to Chapter 10 of the Medicare Program Integrity Manual. https://www.cms.gov/files/document/mm13333-medicare-program-integrity-manual-cy-2024-home-health-prospective-payment-system-updates.pdf

 

December 7, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

The December 7^th revision of this special edition MLN article adds information on how to verify and update service locations for Medicare enrollment and what claim modifier to use. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

 

December 12, 2023: MLN MM13463: DMEPOS Fee Schedule: CY 2024 Update

Make sure your billing staff knows about CY 2024 fee schedule amounts for new and existing codes and payment policy changes. For example, the CY 2024 HH PPS final rule established a new benefit category for standard and custom fitted compression garments and additional lymphedema compression treatment items under Medicare Part B. https://www.cms.gov/files/document/mm13463-dmepos-fee-schedule-cy-2024-update.pdf

 

December 20, 2023: Change Request (CR) 13222: Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92

Effective January 1, 2024, Section 4124 of the Consolidated Appropriations Act of 2023 establishes Medicare coverage and payment for IOP services for individuals with mental health needs when furnished by hospital outpatient departments, Critical Access Hospital outpatient departments, and Community Mental Health Centers. The original Transmittal 12125 has been rescinded and replaced by Transmittal 12423 (CR 13222) dated December 20, 2023. The purpose of this CR is to implement the new condition code 92 for IOP services and enforce billing requirements (https://www.cms.gov/files/document/r12423cp.pdf). Additional information about condition code 92 is available in a related MLN article 13496. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf

 

December 21, 2023: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update

Make sure your billing staff knows about system updates for January, including new codes for covered devices for pass-through payments, biology-guided radiation therapy, dental services, surgical procedures, drugs and biologicals, and skin substitutes. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf

 

December 26, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – REVISED

This article was originally published March 26, 2019. In this most recent revision CMS clarified that these instructions do not apply to separately enrolled provider-based rural health clinics and add information on the 09/23 version of the paper-based enrollment form. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

Question

A patient was admitted to the hospital with acute renal failure and has a history of a kidney transplant.  Is acute renal failure a complication of the kidney transplant?

 

Answer

Acute renal failure is affecting the function of the transplanted kidney, but it doesn’t mean that the transplant itself has failed.  Assign T86.19 (Other complication of kidney transplant) along with N17.9 (Acute renal failure) to correctly code this case.

 

• Pre-existing conditions or conditions that develop after an organ transplant are not coded as complications unless it affects the function of the transplanted organ.

 

References:

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019:  Page 7

AHA Coding Handbook

In a November 16^th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”

 

White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)

HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

 

The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:

 

• Pillar 1: Expanding Data Gathering and Sharing,
• Pillar 2: Support Flexible Funding to Address Social Needs,
• Pillar 3: Support Backbone Organization.

   

  HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework

  In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”

   

  HHS Resource: HHS’s Call to Action to Address Health Related Social Needs

  The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”

   

  Z-Codes: Identifying and Coding Social Determinates of Health

  Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:

• Z59.00: Homelessness, unspecified,
• Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
• Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.” 

 

To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.

 

A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.

 

The OIG released its semiannual report to Congress on December 1^st. In a related fact sheet they indicated the report highlights over $3.44 billion in expected recoveries resulting from HHS-OIG audits and investigations conducted during fiscal year (FY) 2023.

 

This report “describes OIG’s work on significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations during the reporting period. In this report, we present OIG expected recoveries, criminal and civil actions, and other statistics as a result of our work for the semiannual reporting period of April 1, 2023-September 30, 2023. We also provide data for accomplishments for fiscal year (FY) 2023 and highlight some of our work completed during this semiannual reporting period.”

 

For this article, we will focus on one report completed by the OIG that impacts inpatient claims in acute care hospitals. In September 2023, OIG released the report Medicare Improperly Paid Acute-Care Hospitals for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy Over a 4-Year Period, but CMS’s System Edits Were Effective in Reducing Improper Payments by the End of the Period (A-09-23-03016), September 2023.

 

About the Post-Acute-Care Transfer Policy

Medicare makes the full Medicare Severity Diagnosis-Related Group (MS‑DRG) payment to an acute‑care hospital that discharges an inpatient to home or certain types of health care institutions but pays an acute-care hospital that transfers an enrollee to post-acute care a per diem rate for each day of the enrollee’s stay in the hospital.

 

Post-acute care settings that are subject to this policy includes transfers to:

• Inpatient rehabilitation facilities and units (Patient discharge status code 62 or planned acute care hospital inpatient readmission patient status code 90),
• Long-term care hospitals (Patient Status Code 63 or planned acute care hospital inpatient readmission Patient Status Code 91),
• Psychiatric hospitals and units (Patient discharge status code 65 or planned acute care hospital inpatient readmission patient status code 93),
• Cancer hospitals (Patient discharge status code 05 or planned acute care hospital inpatient readmission patient status code 85),
• Children’s hospitals (Patient discharge status code 05 or planned acute care hospital inpatient readmission patient status code 85),
• Skilled nursing facility (Patient discharge status code 03 or planned acute care hospital inpatient readmission patient status code 83),
• Hospice care at home (Patient status code 50) or Hospice Medical Facility (Certified) providing hospice level of care (Patient status code 51)
• Home under a written plan of care for the provision of home health (HH) services from a HH agency and those services occurs within 3 days after the date of discharge (Patient discharge status code 06 or planned acute care hospital inpatient readmission patient status code 86).

 

MS-DRGs Subject to the Post-Acute-Care Transfer Policy in the CMS FY 2024

• 764: The overall number of MS-DRGs for FY 2024
• 282: The number of MS-DRGs subject to this policy
• 148: The number of surgical MS-DRGs subject to this policy
• 134: The number of medical MS-DRGs subject to this policy

 

Specific regulations regarding the transfer policies can be found in Chapter 4 of the Medicare Claims Processing Manual, section 40.2.4.

 

Why OIG Did The Audit

OIG notes that compliance with the transfer policy has been an issue for a long time and this audit was conducted to evaluate whether Medicare properly paid acute-care hospital claims subject to the policy for claims with dates of service from January 1, 2019, through December 31, 2022.

 

About the Audit

• $198 million: The Medicare Part A payments covered in the audit.
• 12,133: the number of inpatient claims subject to the transfer policy.
• Claims included in the audit had a discharge status code to home or certain types of health care institutions on the claim.
• OIG used Medicare enrollee information to identify post-acute services settings that began on the same day as discharge for SNF claims, and within 3 days of inpatient discharge for home health claims.

 

What OIG Found

Medicare improperly paid $41.4 million to acute-care hospitals for inpatient claims subject to the post-acute-care transfer policy. This amount of money represents the difference between the amount of the full MS-DRG payments and the amount that would have been paid if the per diem rates had been applied.

 

These improper payments were made because CMS’s system edits were not effective in detecting inpatient claims subject to the transfer policy in October and November 2019 and from October 2020 through March 2022. However, after CMS fixed the edits in April 2022, improper payments significantly decreased through the end of the audit period.

October 30, 2023: MLN MM13390: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 1 of 2)

CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information.  https://www.cms.gov/files/document/mm13390-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-1-2.pdf

 

October 30, 2023: MLN MM13391: ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update (CR 2 of 2)

CMS advises providers to make sure your billing staff knows about newly available codes, recent coding changes, and NCD coding information. https://www.cms.gov/files/document/mm13391-icd-10-other-coding-revisions-national-coverage-determinations-april-2024-update-cr-2-2.pdf

 

November 3, 2023: MLN MM13244: Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Claims

Effective January 1, 2024, Medicare will make separate payment for HCPCS code A9272 on type of bill (TOB) 032x, instead of 034x. Also, Medicare Administrative Contractors (MACs) will apply deductible and coinsurance.

https://www.cms.gov/files/document/mm13244-separate-payment-disposable-negative-pressure-wound-therapy-devices-home-health-claims.pdf

 

November 6, 2023: MLN MM13055: Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order – Revised

Initially published June 1, 2023, this article was revised on November 6, 2023 to add two new CPT codes effective January 1, 2024, based on Change Request (CR) 13279.

https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf

Coverage Updates

 

October 30, 2023: MLN MM13017: Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening – Revised

The initial release of this MLN article was February 2, 2023. Now in it’s third iteration, CMS has added clarifying information about the -KX modifier for screening colonoscopy claims in the context of a complete colorectal cancer screening. https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

 

November 20, 2023: MLN MM13429: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease

On October 13, 2023 CMS published a Final Decision Memo announcing a final decision to remove this NCD and now permitting Medicare coverage determinations to be made by the MACs. Removing the NCD also removes the current limitation of one PET beta-amyloid scan per lifetime from the coverage requirements.

 

CMS notes in MLN article MM13429 that “your MAC will adjust any PET beta amyloid claims processed incorrectly that you bring to their attention, effective for claims with DOS on or after October 13, 2023. https://www.cms.gov/files/document/mm13429-beta-amyloid-positron-emission-tomography-dementia-and-neurodegenerative-disease.pdf

 

Compliance Education Updates

 

MLN Educational Tool: Medicare Payment Systems

CMS has updated this tool to include FY 2024 updates to the:

• Acute Care Hospital Inpatient Prospective Payment System,
• Hospice Payment System & Coverage,
• Inpatient Psychiatric Facility Prospective Payment System,
• Inpatient Rehabilitation Facility Prospective Payment System,
• Long-Term Care Hospital Prospective Payment System, and
• Skilled Nursing Facility Prospective Payment System.

Substantive changes to this tool are in dark red. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html

 

October 2023: MLN Booklet: Independent Diagnostic Testing Facility

CMS has updated this booklet to include more information on several topics, including supervising physicians, interpreting physicians, and technicians. https://www.cms.gov/files/document/mln909060-independent-diagnostic-testing-facility.pdf

 

New and Updated CMS National Training Program (NTP) Products

• Medicare & the Health Insurance Marketplace^®
• Medicare: Getting Started
• Medicare & Home Health Care

You can order CMS products in bulk by visiting our product ordering website.

Did You Know?

CMS announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024 that they are pausing their efforts to implement the Appropriate Use Criteria (AUC) Program for reevaluation and rescinding the AUC regulations at 42 CFR 414.94, reserving this section for future use.

Why It Matters?

On November 3, 2023, CMS posted the following notice on the AUC Program webpage:

“Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. Additionally, CMS will no longer qualify PLEs or CDSMs and will remove this information from the AUC website. The claims processing instructions and guidance for the educational and operations testing period will also be removed.”

What Can I Do?

Share this information with the appropriate stakeholders at your facility and consider this an early Thanksgiving blessing that CMS acknowledged the challenges to implementing the regulations at 42 CFR 414.94.