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May 2022 PAR Pro Tips
Published on 

5/18/2022

20220518

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on the April 2022 release of CMS’ Medicare Provider Compliance newsletter.

Background

In the Tax Relief and Health Care Act of 2006, the U.S. Congress authorized the expansion of the Recovery Audit Program nationwide by January 2010 to further assist the CMS in identifying improper payments.

The first Medicare Quarterly Compliance Newsletter was issued in October 2010 as a Medicare Learning Network® (MLN) educational product, “to help providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations such as the Office of Inspector General.”

In the second edition of this newsletter CMS indicated that it is “designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities, such as failure to submit timely medical record documentation, when dealing with the Medicare FFS program.”

Twelve years later, much has changed since the release of the first quarterly newsletter.

  • Instead of a network of contractors (i.e., Carriers and Fiscal Intermediaries) processing more than 1 billion claims each year, there are twelve Medicare Administrative Contractor (MAC) regions where the MACs process the claims,
  • In addition to the Recovery Auditors and the OIG, there are new contractors auditing claims, for example the Supplemental Medicare Review Contractor (SMRC) and the Unified Program Integrity Contractors (UPICs) who assumed the responsibilities of the former ZPIC contractor,
  • The OIG no longer publishes an annual workplan, instead the Work Plan is updated monthly to be able “to anticipate and respond to emerging issues with resources available,” and
  • As of the April 2022 edition, this newsletter is now released twice a year instead of quarterly.

What has not changed is the ongoing challenge for providers to meet Medicare rules and regulations required to accurately order, schedule, perform, code and bill medically necessary services.

April 2022 Medicare Provider Compliance Newsletter

In the April 2022 edition of the newsletter (link), you will find information about:

  • The Comprehensive Error Rate Testing (CERT) review of hospice certification and recertification of terminal illness,
  • The CERT review of refills of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items provided on a recurring basis, and
  • The Recovery Auditor review of Issue 0184: total hip arthroplasty (THA) medical necessity and documentation requirements.

This article focuses on the RAC’s review of total hip arthroplasty (link).

RAC Issue 0184: Total Hip Arthroplasty: Medical Necessity and Documentation Requirements

Total hip arthroplasty procedures were removed from the Medicare Inpatient Only (IPO) procedure list effective January 1, 2020. RAC issue 0184 was approved in August 2020. This RAC Issue entails a review of medical records (complex review) for provider types of inpatient hospital, outpatient hospital and professional services.

The review only focuses on total (involving the entire joint) hip arthroplasties to determine if documentation supports that a THA was medically necessary according to the guidelines outlined in the Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) of the following MACS:

  • Jurisdiction N MAC: First Coast Service Options, Inc.,
  • Jurisdictions H and L MAC: Novitas Solutions, Inc.,
  • Jurisdictions 6 and K MAC: National Government Services, Inc.,
  • Jurisdictions J and M MAC: Palmetto GBA LLC, and
  • Jurisdictions E and F MAC: Noridian Healthcare Solutions, LLC.

Unlike the CERT reviews included in this newsletter, the RAC review does not include an improper payment amount. What you will find are the CPT codes for review, the reminder to respond to review requests promptly and ensure records include documentation supporting the medical necessity of the THA, and links to the MAC’s LCDs and LCAs.

Total Hip Arthroplasty Removal from the Medicare Inpatient Only (IPO) Procedure List

As mentioned above THA procedures were removed from the Medicare IPO List effective January 1, 2020. CMS reminded providers in the CY 2020 Outpatient Prospective Payment System (OPPS) Final Rule that “the removal of any procedure from the IPO list, including THA, does not require the procedure to be performed only on an outpatient basis. That is, when a procedure is removed from the IPO, it simply means that Medicare will pay for it in either the hospital inpatient or outpatient setting; it does not mean that the procedure must be performed on an outpatient basis.”

CMS also finalized a two-year exemption from site-of-service claims denials, Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization referrals to Recovery Auditors, and Recovery Auditor reviews for “patient status” (that is, site-of-service) for procedures removed from the IPO list under the OPPS beginning January 1, 2020.

It is important for providers to be mindful that this exemption does not include medical necessity based on a National or Local Coverage Determination meaning irrespective of site-of-service, a short stay claim can still be denied for lack of documentation supporting medical necessity of the procedure.

THA Site of Service in CY 2020 and 2021

In keeping with the late Paul Harvey’s, The Rest of the Story segments, I turned to RTMD to see where THA’s are being performed since being removed from the IPO list. The following claims data represents Medicare Fee-for-Service paid claims data available in RTMD’s footprint which includes all U.S. states and territories except Kentucky and Ohio. The reader should be reminded that THA was added to the Ambulatory Surgery Center (ASC) Covered Procedure List (CPL) January 1, 2021.

Calendar Year 2020 THA Claims Data in RTMD Database

Inpatient Claims

  • Claims Volume: 116,804
  • Percent of All 2020 THA Claims: 56.8%
  • Sum of Paid Claims: $1,620,651,115.06

Outpatient Claims

  • Claims Volume: 88,828
  • Percent of All 2020 THA Claims: 43.2%
  • Sum of Paid Claims: $893,162,528.27
  • Calendar Year 2021 Claims Data in RTMD Database

    Inpatient Claims

    • Claims Volume: 48,330
    • Percent of All 2021 THA Claims: 24.37%
    • Sum of Paid Claims: $659,846,754.97

    Outpatient Claims

    • Claims Volume: 128,385
    • Percent of All 2021 THA Claims: 62.41%
    • Sum of Paid Claims: $1,311,707,091.83

    Ambulatory Surgery Center (ASC)

    • Claims Volume: 26,218
    • Percent of All 2021 THA Claims: 13.22%
    • Sum of Paid Claims: $64,580,122.48

    There has been a significant shift in site-of-service for THA procedures away from the inpatient hospital setting. While the patient setting should be based on each individual patient, it is also important to be aware of the difference in payment for THA based on the setting.

    • In the inpatient setting THA procedures group to MS-DRG 469 with an MCC or MS-DRG 470 without an MCC. In general, most inpatient THA procedures group to MS-DRG 470. The 2021 national average payment for MS-DRG 470 was $11,192.94.
    • 2021 ambulatory payment category (APC) national payment rate for THA: $12,314.76.
    • 2021 ASC CPL national payment rate for THA: $8,818.37.

    Whether hospital inpatient, outpatient or ASC is the most appropriate setting for your patient, you must ensure documentation in the medical record supports indications outlined in your MAC’s LCDs.

    Beth Cobb

    COVID-19 PHE and the 3-Day Prior Hospitalization Blanket Waiver
    Published on 

    5/18/2022

    20220518
     | COVID-19 

    Question:

    We are having skilled nursing facilities (SNFs) not take patients until they have had a 3 midnight stay. Is the COVID-19 waiver still in effect?

    Answer:

    Effective March 1, 2020, CMS implemented 1135 blanket waivers to expand the Administration’s efforts against COVID-19. These waivers are in effect through the end of the emergency declaration or at such time CMS believes it is appropriate to terminate them.

    The COVID-19 PHE declaration was last renewed on April 12, 2022 with an effective date of April 16, 2022 (link). When the Secretary of the Department of Health and Human Services (HHS) makes a PHE declaration, it lasts for the duration of the PHE or 90 days but may be extended by the Secretary for as long as the PHE continues to exist.

    On April 7, 2022, CMS issued a Memorandum (link) alerting certain providers (i.e., SNFs, NFs, inpatient hospices) of the termination of several COVID-19 blanket waivers. The Memorandum Summary indicates that “applicable waivers will remain in effect for hospitals and critical access hospitals (CAH).”

    The 3-Day Prior Hospitalization waiver falls under the Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or Nursing Facilities (NFs) section of the CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers document (link). That said, it is not one of the waivers that is being terminated at this time. You will find the full description of this waiver on page sixteen of the April 7, 2022, iteration of the document.

    In January 2021, acting HHS Secretary Norris Cochran sent a letter to governors across the country to share details about the COVID-19 PHE indicating that “when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”

    In a May 10, 2022 letter to HHS Secretary Becerra (link), the American Hospital Association along with several other organizations (i.e., AARP, American Diabetes Association, American Medical and Nurses Associations) urged the PHE be maintained “until we experience an extended period of greater stability and, guided by science and data, can safely unwind the resulting flexibilities.”

    As we are now less than 60 days out to the end of the current COVID-19 PHE declaration, it is likely that it will be extended at least through October 2022.

    Beth Cobb

    Assigning Pleural Effusion
    Published on 

    5/11/2022

    20220511
     | Coding 

    Question

    In I-10-CM, under J91 there is an Excludes2 instruction that excludes pleural effusion in heart failure (I50.-). Should pleural effusion also be coded any time a patient has congestive heart failure (CHF)?

    Answer

    No. As coders, we still need to follow all instructions/directions as we have previously been taught. Even though the Excludes2 instruction allows you to code pleural effusion with CHF, it doesn’t mean that it is always appropriate.

    Pleural effusion occurs when fluid abnormally accumulates within the pleural spaces and is associated with pulmonary diseases and certain cardiac conditions, but it can also involve other organs.

    In ICD-9, pleural effusion with CHF wasn’t to be coded unless it required therapeutic treatment or additional diagnostic studies, etc., e.g., (thoracentesis or decubitus X-ray). The same holds true in ICD-10. If the pleural effusion just shows up on an X-ray, is minimal, and only the CHF is treated, then it is not appropriate to code it; however, if a thoracentesis or additional diagnostic testing/evaluation is performed, then a code for (J91.8) (Pleural effusion in other conditions classified elsewhere) should be assigned in addition to the CHF. Pleural effusion, not elsewhere classified, (NEC) (J90) would not be appropriate in this case since the pleural effusion is associated with CHF.

    Pleural effusion in conditions classified elsewhere (J91.x) should also be assigned if the patient has a malignant pleural effusion, filariasis, or influenza.

    Pleural effusions that are chronic, have a known underlying cause, and cause no symptoms, are usually not treated with a thoracentesis and/or pleural fluid analysis as it is often not necessary.

    Usually, documentation indicates when pleural effusion is related to a patient’s condition. If you can’t determine the cause, query the attending physician for the etiology of the pleural effusion to obtain a more accurate diagnosis code. Pleural effusion, NEC (J90) should seldom be used.

    References:

    • Coding Clinic, Second Quarter 2015: Page 15
    • Coding Clinic, Third Quarter 1991 Page: 19 to 20
    • AHA Coding Handbook
    • Merck Manual

    Susie James

    FY 2023 IPPS Proposed Rule: Payment Rates, Relative Weights, New ICD-10 Codes and New Technologies
    Published on 

    5/11/2022

    20220511
     | Billing 
     | Coding 
     | Quality 

    CMS issued a display copy of the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) on Monday, April 18, 2022. This article contains a high-level look at the proposed operating payment rate, quality program proposals, COVID-19 claims impact on setting MS-DRG relative weights, new ICD-10 diagnosis and procedure codes, CMS’ request for comments related to Social Determinants of Health (SDOH) and New Technology Add-On Payments.

    Proposed Payment Rate Changes

    The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use is projected to be 3.2%.

    Overall, CMS estimates hospitals payments will increase in FY 2023 by $1.6 billion.

    Quality Program Proposals

    Like FY 2022, CMS is proposing to suppress or refine several measures in the Hospital Readmissions Reduction Program (HRRP), Hospital-Acquired Condition (HAC) Reduction Program, and Hospital Value-Based Purchasing (VBP) Program.

    Due to proposed measure suppression for Hospital VBP Program, CMS has proposed to award all hospitals a value-based payment amount for each discharge that is equal to the 2% withheld. They have also proposed to not impose the payment penalty on any hospitals in FY 2023 due to low performance in the HAC Reduction Program.

    One or several proposals related to the HRRP is a proposal to modify all six conditions/procedures specific to the readmissions measures to include a covariate adjustment for history of COVID-19 within one year preceding the index admission, beginning with the FY 2024 program year.

    Calculating MS-DRG Relative Weights

    CMS notes, in a related Fact Sheet, it is reasonable to assume Medicare beneficiaries will continue to be hospitalized with COVID-19 and current information available the volume of hospitalizations will be fewer than are reflected in the FY 2021 data.

    Based on these assumptions, CMS is proposing to calculate relative weights for FY 2023 by:

    • Calculating two sets of relative weights, one including and one excluding COVID-19 claims, and
    • Average the two sets of relative weights to determine the final FY 2023 relative weights.

    CMS has also proposed a 10% cap on relative weight decrease from the prior fiscal year.

    ICD-10 Diagnosis Codes by the Numbers

    There are 1,176 new diagnosis codes (Table 6A). Of these codes, thirty-five codes have been designated as an MCC and one hundred thirty-six codes have been designated as an CC. Following are examples of the types of new codes:

    • Three new acidosis codes (E87.20 acidosis, unspecified, E87.21 chronic metabolic acidosis, and E87.29 other acidosis)
    • Sixty-nine new dementia with manifestations codes,
    • Nine new codes for refractory angina pectoris (i.e., I20.2 refractory angina pectoris),
    • Eighteen new methamphetamines codes including poisoning by, adverse effect of and underdosing of codes,
    • Four hundred seventy-four codes describing electric (assisted) bicycle or motorcycle accidents,
    • Three codes related to COVID-19 vaccination and other immunization status that were effective April 1, 2022, and
    • Three new Social Determinants of Health (SDOH) codes (Z59.82 transportation insecurity, Z59.86 financial insecurity, and Z59.87 material hardship).

    Request for Information on Social Determinants of Health

    The subset of Z codes describing SDOHs are found in categories Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances).

    CMS believes reporting of SDOH Z codes may better determine the resource utilization for treating patients experiencing these circumstances to help inform whether a change to the severity designation of these codes would be clinically warranted.

    CMS also notes that, if SDOH Z codes are not consistently reported in inpatient claims data, our methodology utilized to mathematically measure the impact on resource use, as described previously, may not adequately reflect what additional resources were expended by the hospital to address these SDOH circumstances in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring or both, and comprehensive discharge planning.

    They are seeking public comment on issues related to SDOHs, including the following questions:

    • How the reporting of certain Z codes – and if so, which Z codes - may improve our ability to recognize severity of illness, complexity of illness, and utilization of resources under the MS-DRGs?
    • Whether CMS should require the reporting of certain Z codes – and if so, which ones – to be reported on hospital inpatient claims to strengthen data analysis?
    • What would be the additional provider burden and potential benefits of documenting and reporting of certain Z codes, including potential benefits to beneficiaries?
    • Whether codes in category Z59 (Homelessness) have been underreported and if so, why? We are interested in hearing the perspectives of large urban hospitals, rural hospitals, and other hospital types regarding their experience. We also seek comments on how factors such as hospital size and type might impact a hospital’s ability to develop standardized consistent protocols to better screen, document, and report homelessness.

    ICD-10 Procedure Codes by the Numbers

    There are fifty-four new procedures codes (Table 6B). Of these codes:

    • thirty-eight have been designated as O.R. procedure codes,
    • twelve have been designated as non-O.R. procedure codes,
    • nine of the twelve non-O.R. procedure codes were implemented April 1, 2022, and includes new technology codes for COVID-19 vaccines and drugs to treat COVID-19, and
    • four have been designated as non-O.R. procedure codes affecting the DRG assignment.

    You can find new ICD-10 diagnosis and procedure codes as well as proposed changes to the MCC and CC lists for FY 2023 in tables available on the CMS IPPS Proposed Rule Home Page.

    New Technology Add-On Payment (NTAP) Policy

    The NTAP policy provides additional payment beyond the MS-DRG for cases where a CMS designated new technology was used and coded on the claim. Note, this “is not budget neutral and is generally limited to the 2-to 3-year period following the date of the FDA approval or clearance for marketing.”

    CMS is proposing a one-year extension of new technology add-on payments for fifteen technologies for which the new technology add-on payment would otherwise be discontinued beginning FY 2022. Collectively in FY 2023, the estimated number of cases for the fifteen technologies is 192,455 and the estimated payment impact is $612,910,746.15.

    There are twenty-six applications discussed in the proposed rule for new technologies seeking approval for an add-on payment.

    I encourage you to submit comments to CMS. The deadline to submit comments is 5 p.m. EDT on June 28, 2021.

    Resources

    Beth Cobb

    FY 2023 IPPS Proposed Rule: Proposed Changes to MS-DRG Classifications
    Published on 

    5/11/2022

    20220511
     | Billing 
     | Coding 
     | Quality 

    CMS issued the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) display copy on Monday April 18, 2021. You can find a high level review of what is being proposed in a related MMP article by clicking here. This article focuses on three proposals in section II. Proposed Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Relative Weights, of the Proposed Rule. Each MS-DRG refinement synopsis includes the potential financial impact if the proposal is finalized.

    Calculating the potential financial impact was accomplished through a collaboration with RealTime Medicare Data (RTMD). RTMD’s database currently includes Medicare Fee-for-Service paid claims data for all U.S. states and territories except Kentucky and Ohio. RTMD claims analysis in this article represents Medicare Fee-for-Service paid claims data for CY 2021 in the RTMD footprint

    Acute Respiratory Distress Syndrome (ARDS)M

    CMS received a request to reassign cases reporting diagnois code J80 (Acute respiratory distress syndrome) as the principal diagnosis from MS-DRG 204 (Respiratory Signs and Symptoms) to MS-DRG 189 (Pulmonary Edema and Respiratory Failure). The requestor noted that in the ICD-10-CM Tabular List of Diseases, per the Excludes 1 note under category J96 (Respiratory Failure, not elsewhere classified) only code J80 should be assigned when respiratory failure and ARDs are both documented. Currently, a principal diagnosis of J80 groups to MS-DRG 204.

    CMS data analysis supports that cases reporting ARDS (J80) are more appropriately aligned with the average length of stay and average costs of the cases in MS-DRG 189 and they have proposed to reassign cases with ARDS (code J80) as the principal diagnosis from MS-DRG 204 to MS-DRG 189.

    RTMD Claims Analysis

    In Calendar Year (CY) 2021, in the RTMD database, there were 255 claims sequenced to MS-DRG 204 (Respiratory Signs and Symptoms) with a principal diagnosis of J80 (ARDS). Based on the CMS FY 2022 Final Rule, the shift from MS-DRG 204 to MS-DRG 189 would result in:

    • An increase in the MS-DRG Relative Weight (R.W.) of 0.4325, and
    • An increase in the MS-DRG National Average Payment of $2,612.56.

    For the 255 claims with a principal diagnosis of J80 (ARDS) in CY 2021, the reassignment to MS-DRG 189 would results in a $666,202.80 increase in payment for this group of claims.

    Cardiac Mapping

    CMS identified a replication issue from ICD-9 based MS-DRGs to ICD-10 based MS-DRGs for procedure code 02K80ZZ (Map conduction mechanism, open approach). Cardiac mapping describes the creation of detailed maps to detect how the electrical signals that control the timing of the heart rhythm move between each heartbeat to identify the location of rhythm disorders. Cardiac mapping is generally performed during open-heart surgery or performed via cardiac catheterization.

    This code is currently recognized as a non-O.R. procedure that affects the MS-DRG to which it is assigned. CMS is proposing to reassign this code from MS-DRGs 246, 247, 248, 249, 250, and 251 to MS-DRGs 273 and 274 (Percutaneous and Other Intracardiac Procedures with and without MCC, respectively)

    RTMD Claims Analysis

    There were no claims in the RTMD database for CY 2021 where MS-DRGs 246, 247, 248, 249 and 250 included procedure code 02K80ZZ (Map conduction mechanism, open approach).

    Laparoscopic Cholecystectomy with Common Bile Duct Exploration

    A requestor noted that when a laparoscopic cholecystectomy is reported with any one of the listed procedure codes with a common bile duct exploration and gallstone removal procedure that is performed laparoscopically and reported with procedure code 0FC94ZZ, the resulting assignment is MS-DRGs 417, 418 and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC, respectively). This MS-DRG assignment does not recognize that a common bile duct exploration (C.D.E.) was performed.

    CMS’ clinical advisors agreed that procedure code 0FC94ZZ describes a common bile duct exploration procedure with removal of a gallstone and should be added to the logic for case assignment to MS-DRGs 411, 412, and 413 for clinical coherence with the other procedures that describe a common bile duct exploration. CMS has proposed to redesignate procedure code 0FC94ZZ from a non-O.R. procedure to an O.R. procedure and add it to the logic list for common bile duct exploration (CDE) in MS-DRGs 411, 412, and 413 (Cholecystectomy with C.D.E. with MCC, with CC, and without CC/MCC, respectively).

    RTMD Claims Analysis

    In CY 2021, in the RTMD database, there were 188 claims that sequenced to the MS-DRG group 417, 418, and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC respectively) that included the procedure code 0FC94ZZ describing a common bile duct exploration procedure with removal of a gallstone.

    Based on the CMS FY 2022 Final Rule, following are the shifts in R.W. and national average payment by DRG severity levels:

    • The increase from MS-DRG 417 to MS-DRG 411 (Chlecystectomy w/C.D.E. w/MCC) in R.W. is 1.3120 and national average payment of $8,029.19,
    • The increase from MS-DRG 418 to MS-DRG 412 (Cholecystecomy w/C.D.E. w/CC) in R.W. is 0.5885 and national average payment of $3,554.90, and
    • The increase from MS-DRG 419 to MS-DRG 413 (Cholecystecomy w/C.D.E. w/o CC/MCC) in R.W. is 0.4156 and national average payment of $2,510.48.

    I encourage key stakeholders take the time to review the proposed rule and remember that CMS is accepting comments on the proposed rule through 5 p.m. EDT on June 17, 2022.

    Resources

    Beth Cobb

    May is Bladder Cancer Awareness Month
    Published on 

    5/4/2022

    20220504

    Did You Know?

    According to a National Cancer Institute, bladder cancer:

    • Is the fourth most commonly diagnosed malignancy in men in the United States,
    • Occurs about four times higher in men than in women,
    • Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
    • The incidence of bladder cancer increases with age.

    Blood in the urine is the most common presenting sign of bladder cancer, occurring in about 90% of cases. Other presenting symptoms include dysuria, urinary frequency or urgency, and less commonly, flank pain secondary to obstruction, and pain from pelvic invasion or bone metastasis.

    Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer.

    Why it Matters?

    There are risk factors related to being diagnosed with bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

    • Having a family history of bladder, cancer,
    • Having certain changes in the genes that are linked to bladder cancer,
    • Being exposed to paints, dyes, metals, or petroleum products in the workplace,
    • Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
    • Taking Aristolochia fangchi, a Chinese herb,
    • Drinking water from a well that has high levels of arsenic,
    • Drinking water that has been treated with chlorine,
    • Having a history of bladder infections, and
    • Using urinary catheters for a long time.

    What Can You Do?

    First and foremost, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with you physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current five years relative survival rate is 77.1%.

    What Can You Do?

    April 2022 Medicare Transmittals, Coverage Updates and Education Resources
    Published on 

    4/27/2022

    20220427

    Medicare MLN Articles & Transmittals

    Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
    • Article Release Date: March 30, 2022
    • What You Need to Know: This article provides information about regulatory changes for mental health visits in RHCs and FQHCs, and billing information for mental health visits done via telecommunications.
    • MLN SE22001: (link)
    Updates to MS-DRGs Subject to IPPS Replaced Devices Offered Without Cost or With a Credit Policy-Fiscal Years 2021-2022
    • Transmittal Release Date: April 7, 2022
    • What You Need to Know: CMS published this One Time Notification (Change Request 12662 / Transmittal 11346) to implement updates to the list of DRGs subject to the IPPS payment policy for reimbursement of replaced devices offered without cost or with a credit, effective for discharges on or after 10/1/2020.
    • Transmittal 11346/CR 12662: (link)

    Revised Medicare MLN Articles & Transmittals

    Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System
    • Article Release Date: February 27, 2019 – Most recent revision March 24, 2022
    • What You Need to Know: This article was revised to note that Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLs), the data reporting period has been delayed by 1 year due to the December 10, 2021, Protecting Medicare & American Farmers from Sequester Cuts Act.
    • MLN SE19006: (link)
    Claims Processing Instructions for the New Pneumococcal 15-valen Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677
    • Article Release Date: November 1, 2021 – Most recent revision March 30, 2022
    • What You Need to Know: This article was revised for a second time to show the MACs will adjust certain previously processed and rejected claims with HCPCS code 90671 after April 4, 2022.
    • MLN MM12550: (link)

    Coverage Updates

    April 7, 2022: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease Final Decision Memo (CAG-00460N)

    CMS published a final decision memo for the coverage of aducanumab (brand name Aduhelm™) and any future monoclonal antibodies directed against amyloid approved by the FDA with an indication for use in treating Alzheimer’s disease. Of note, CMS incorporated over 10,000 stakeholder comments and more than 250 peer-reviewed documents into the determination.

    CMS finalized coverage for therapies that receive traditional approval from the FDA under coverage with evidence development (CED). CMS, as a part of this decision, will provide enhanced access and coverage for people with Medicare participating in CMS-approved studies, such as a data collection through routine clinical practice or registries.

    More information:

    • Complete press release
    • Fact sheet on Medicare coverage policy for monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease
    • Final NCD CED decision memorandum

    Medicare Educational Resources

    MLN Booklet: Advanced Practice Registered Nurses, Anesthesiologist Assistants, & Physician Assistants - Revised

    This MLN Booklet (link) was updated in March 2022. A summary of changes is available on page three and substantive content updates highlighted in dark red font throughout the booklet. For example, effective January 1, 2022, Physician Assistants bill the Medicare Program directly for their services and get paid like NPs and CNSs.

    April 21, 2022: Medicare Provider Compliance Newsletter

    In the Thursday April 21st edition of MLN Connects (link), CMS provided a link to their most recent Medicare Provider Compliance Newsletter. Originally, published on a quarterly basis, this newsletter is now published twice a year. In the most recent edition, you can learn about guidance to address billing errors for three topics:

    • Hospice certification and recertification of terminal illness,
    • Refills of durable medical equipment, prosthetics, orthotics, and supplies: items provided on a recurrent basis, and
    • Total hip arthroplasty: medical necessity and documentation requirements.
      • CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

        April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

        In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

    Beth Cobb

    April 2022 COVID-19, FY 2023 Proposed Rules and Updates to CMS No Surprises Rule FAQs
    Published on 

    4/27/2022

    20220427

    COVID-19 Updates

    March 30, 2022: New COVID.gov website Launched

    The Biden Administration announced the launch of COVID.gov. (link), “a new one-stop shop website to help all people in the United States gain even better access to lifesaving tools like vaccines, tests, treatments, and masks, as well as get the latest updates on COVID-19 in their area.”

    April 14, 2022: FDA Authorizes First COVID-19 Diagnostic Test Using Breath Samples

    The FDA announced the issuance of an emergency use authorization (EUA) for the first COVID-19 diagnostic test that detects chemical compounds in breath samples association with COVID-19 (link). The test is named the InspectIR COVID-19 Breathalyzer.

    About the InspectIR COVID-19 Breathalyzer test:

    • Is authorized to be performed in environments where the patient specimen is both collected and analyzed, such as doctor’s offices, hospitals, and mobile testing sites, using an instrument about the size of a piece of carry-on luggage.
    • Is authorized to be performed by a qualified, trained operator under the supervision of a healthcare provider licensed or authorized by state law to prescribe tests and can provide results in less than three minutes.
    • Is for people ages eighteen and older without symptoms or other epidemiological reasons to suspect COVID-19.
    April 14, 2022: Update to Publication 100.04, Chapter 18 and Publication 100-02, Chapter 15, Section to Add Data Regarding Novel Coronavirus (COVID-19) and its Administration to Current Claims Processing Requirements and Other General Updates
    CDC Call: Evaluating and Supporting Patients Presenting with Cognitive Symptoms Following COVID

    The CDC will be holding a Clinician Outreach and Communication Activity (COCA) call on May 5th. During this call, presenters will discuss post-COVID conditions (PCC), that are present four or more weeks after infection. Cognitive symptoms, often described as “brain fog,” are frequently reported following a patient’s COVID-19 illness. If you are interested but unable to attend the live call, you can go to the CDC webpage specific for this call (link), after May 5th to find the call materials.

    Other Updates

    March 30, 2022: FY 2023 Hospice Payment Rate Update – Proposed Rule

    CMS announced, in a special edition MLN connects (link), the issuance of a proposed rule (CMS-1773-P) that would update hospice base payments and the aggregate cap amount for FY 2023. The comment period ends on May 31, 2022.

    March 31, 2022: FY 2023 Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules

    CMS announced, in a special edition MLN connects (link), the issuance of the Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules. You will find links to a summary of key provisions for each proposed rule as well as the proposed rules in this edition of MLN connects. The comment period for both proposed rules end on May 31, 2022.

    April 6, 2022: CMS Updates FAQ Document for Providers about the No Surprises Rules

    CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

    April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

    In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

    Beth Cobb

    April 2022 PAR Pro Tips
    Published on 

    4/20/2022

    20220420

    MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide updates and educate resources from the CERT, two MACs and Livanta, the National Medicare Review Contractor.

    CMS Q1 2022 Program Scorecard

    The U.S. government website PaymentAccuracy (link) publishes program scorecards “to assist the public in understanding what agencies are doing to overcome unique challenges and obstacles to ensure federal funds reach the right recipient.” More specifically, program scorecards are published for high-priority programs such as the Department of Health and Human Services Medicare Fee-for-Service (FFS) program.

    The most recent Medicare FFS Program Scorecard published is for Q1 of the CMS fiscal year (FY) 2022 (link). Of note, actions being taken to recover overpayments includes:

    • Recovery Audit Contractors reviewing inpatient claims for medical necessity and coding purposes,
    • HHS implementation of the Review Choice Demonstration for Home Health Services in the last two states of North Carolina and Florida, and
    • HHS providing additional funding to the MACs and the Supplemental Medicare Review Contractor (SMRC) to allow for additional claims review to determine if they had been billed appropriately. You can read more about current SMRC activities in a related article in this week’s newsletter.
      • Comprehensive Error Rate Testing (CERT) Announcement

        The CERT Review Contractor has posted (link) their review year 2022 completion status. As of April 4, 2020, they have completed initial review of 34,400 claims out of 41,974 claims in the 2022 Annual Report (claims submitted to the MAC between July 1, 2020, and June 30, 2021).

        Palmetto GBA JJ/JM MAC

        New Address Information for CERT Review Contractor

        Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published an article (link) to alert providers about the CERT Review Contractor’s move to a new location. The new address will be on letters beginning April 11, 2022. You will find the CERT Review Contractor’s new address, fax number, customer service toll free number and email in Palmetto’s article.

        Cervical Discectomy Module

        Palmetto GBA, has published a Cervical Discectomy module (link) focused on the roles of cervical spine, the differences between discectomy and fusion, and documentation requirements.

        Spinal Cord Stimulatory Therapy Module

        Palmetto GBA has also recently published a Spinal Cord Stimulator module (link) focused on the purpose of the spinal cord stimulator, coverage requirements for spinal cord stimulatory (SCS) therapy, and documentation requirements.

        CERT: Inpatient Psychiatric Facility Checklist

        Palmetto GBA posted a checklist (link) for providers to use when your claim(s) are selected for review by the CERT contractor. In this notice, they also provide links to their Psychiatric Inpatient Hospitalization Local Coverage Determination and related Billing and Coding article.

        WPS J5/J8 MAC

        New YouTube Video

        WPS has released a new YouTube Video titled Transcatheter Aortic Valve Replacement (TAVR) CERT Findings (link). This video describes reasons for improper payments identified by the CERT Contractor for WPS claims and provides information on how to avoid these errors.

        Therapy Assistants: What They Cannot Do

        WPS published an article (link) noting they have identified that physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) have been providing services outside CMS guidelines. The article details what activities that Medicare does not allow PTAs or OTAs to complete.

        Livanta National Medicare Review Contractor

        Livanta’s focus as the National Medicare Review Contractor is on performing Short Stay Review (SSR) and Higher Weighted DRG (HWDRG) reviews. Monthly, they release a publication titled The Livanta Claims Review Advisor. The March 2022 edition (link) focuses on Exploring Short-Stay Claim Review Guidelines and provides information about:

        • The history and background of short stay claim reviews,
        • Short stay medical review,
        • Step-by-Step guideline for short-stay determinations,
        • Example scenarios for short-stay Part A denials, and
        • Documentation features.
          • For those interested in receiving this publication, Livanta provides a link to subscribe at the bottom of the newsletter.

    Beth Cobb

    SMRC Review Activities
    Published on 

    4/20/2022

    20220420

    Did You Know?

    The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:

    • For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
    • CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.

    Why it Matters?

    Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.

    Current Projects

    As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.

    Completed Projects

    To date, in CY 2022, the SMRC has posted project results for the following five projects:

    • 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
    • 01-036: Hospice Portfolio: Error Rates 29% and 47%,
    • 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
    • 01-044: Therapy Reviews: Error Rate 31%, and
    • 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.

    What Can You Do?

    First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).

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