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June 2021 Medicare Educational Resources, COVID-19, and Other Medicare Updates
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Medicare Educational Resources

Revised MLN Fact Sheet: Medicare Disproportionate Share Hospital

CMS issued a revised edition of the Medicare Disproportionate Share Hospital MLN Fact Sheet (link). Specifically, the Fact Sheet includes information about how CMS calculates uncompensated care payments for FY 2021 and FY 2022.

Revised MLN Fact Sheet: Medicare Billing for Cardiac Device Credits

This revised Fact Sheet (link) includes the following two changes highlighted in dark red font in the text:

  • When a hospital gets a replaced device credit 50% or greater than the device’s cost, report the amount in the claim’s FD code value portion.
  • Beginning in 2020, Medicare applies a device offset cap to the Ambulatory Payment Classification (APC) claims that require implantable devices and have significant device offset (greater than 30%) based on the FD value code’s listed credit amount.”
MLN Educational Tool: Medicare Preventive Services Revised

CMS updated this Education Tool (link) in May. Information available in this tool includes:

  • Link to National Coverage Determination (NCD) services webpage when applicable to a service,
  • HCPCS and CPT codes,
  • Prolonger Prevention Services information,
  • ICD-10-CM diagnosis codes,
  • Billing for telehealth during COVID-19,
  • Coverage Requirement,
  • Frequency Requirements,
  • Patient liability, and
  • Telehealth eligibility.

COVID-19 Updates

June 3, 2021: Myths and Facts about COVID-19 Vaccines

The CDC developed this webpage (link) to help stop common myths and rumors such as:

  • The COVID-19 vaccine can make you be magnetic,
  • The COVID-19 vaccine will alter my DNA, or
  • The COVID-19 vaccine will make me sick with COVID-19.
June 9, 2021: Medicare to Increase Payment for Medicare Vaccination Administration in the Home

In a Special Edition MLN Connects, CMS announced additional payment for administering in-home COVID-19 vaccinations to Medicare beneficiaries (link). A related infographic (link) was also updated to include this information.

June 17, 2021: CMS MLN Connects – Emergency Use Authorization (EUA) for Monoclonal Antibody Updates

CMS noted that on May 26, 2021, the FDA released an EUA for the COVID-19 monoclonal antibody product sotrovimab. Coinciding with the FDA release, CMS created new HCPCS codes also effective May 26th for sotrovimab. This drug can be administered in health care setting and the home. The following is an excerpt from the MLN Connects newsletter:


  • Long descriptor: Injection, sotrovimab, 500 mg
  • Short descriptor: Sotrovimab
  • Price: The government won’t provide this drug for free; visit the COVID-19 Vaccines and Monoclonal Antibodies webpage for pricing information (available soon)


  • Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
  • Short Descriptor: Sotrovimab infusion
  • Price: $450.00 per infusion


  • Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
  • Short Descriptor: Sotrovimab inf, home admin
  • Price: $750.00 per infusion

On June 3rd, the FDA released a revised EUA for Regnereon’s COVID-19 monoclonal antibody combination product casirivimab and imdevimab. Updates includes new dosing regimen and allows a new route of administration. “In response to this change, CMS created a new HCPCS code, effective June 3, and updated the short and long code descriptors. This information is detailed in the MLN Connects newsletter (link).

Other Medicare Updates

July 1, 2021: Interim Final Rule Banning Surprise Billing and Certain Out-of-Network Charges

HHS issued the interim final rule, “Requirements Related to Surprise Billing: Part 1,” that will restrict surprise billing for insured patients that receive emergency care, non-emergency care from out-of-network providers at their in-network facility, and air ambulance services from out-of-network providers. One way this helps patient, as noted in a Related CMS Fact Sheet (link), is that “if your health plan provides or covers any benefits for emergency services, this rule requires emergency services to be covered:

  • Without any prior authorization (meaning you no not need to get approval beforehand).
  • Regardless of whether a provider or facility is in-network.”

This rule will take effect on January 1, 2022. CMS is excepting written comments through 5 p.m. 60 days after the rule is displayed in the Federal Register. At the time of this article, the interim final rule had not been published in the Federal Register. You can learn more about the interim rule requirements in another CMS Fact Sheet (link).

Beth Cobb

June 2021 Medicare Transmittals and Coverage Updates
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Medicare MLN Articles & Transmittals – Recurring Updates

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 0240U, 0231U and 87637
  • Article Release Date: June 11, 2021
  • What You Need to Know: The FDA has issued Emergency Use Authorizations (EUAs) for the COVID-19 tests represented by these three HCPCS codes. “For Medicare to recognize these tests performed under a CLIA certificate of waiver or a CLIA certificate for provider-performed microscopy procedures, you must add the modifier QW.”
  • MLN MM12318: (link)
July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • Article Release Date: June 14, 2021
  • What You Need to Know: This article provides a summary of changes to and billing instructions for payment policies to be implemented by CMS on July 1, 2021.
  • MLN MM12316: (link)
July 2021 Update of the Ambulatory Surgical Center [ASC] Payment System
  • Article Release Date: June 25, 2021
  • What You Need to Know: For the July 2021 Update there are 8 new CPT Category III codes, a new device pass through code, new HCPCS codes for drugs and biologicals, a change to a skin substitute HCPCS code from the low to the high-cost skin substitute group and a new technology HCPCS code as been established to describe the technology associated with vaginal colpopexy by sacrospinous ligation fixation.
  • MLN MM12341: (link)

Revised Medicare MLN Articles & Transmittals

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update
  • Article Release Date: February 23, 2021 – Most recent revision June 3, 2021
  • What You Need to Know: In the third iteration of this MLN article, important information about the use of the QW modifier was added in red print on page 10 of this document.
  • MLN MM12131: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2021
  • Article Release Date: May 18, 2021 – Revised June 3, 2021
  • What You Need to Know: This article was revised to reflect NCD specific changes made in a revised Change Request (CR) 12124.
  • MLN MM12124: (link)
July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
  • Article Release Date: April 27, 2021 – Revised June 8, 2021
  • What You Need to Know: This article was revised to reflect a revised CR 12244 which added language about Section 405 of the Consolidated Appropriates Act, 2021.
  • MLN MM12244: (link)
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Amount
  • Article Release Date: May 24, 2021 – Revised June 15, 2021
  • What You Need to Know: This article was revised due to a revised Change Request (CR) 12885 which included the addition of new codes to the national HCPCS file.
  • MLN MM12285: (link)

Medicare Coverage Updates

June 10, 2021: NGS Reminder Regarding General Anesthesia, Conscious Sedation and Facet Joint Interventions

NGS posted a reminder regarding the recent revision to Local Coverage Determination (LCD) (L35936) “Facet Joint Interventions for Pain Management” and Local Coverage Article (LCA) (A57826) “Billing and Coding: Facet Joint Interventions for Pain Management.” As of April 25, 2021, one Limitation of LCD L359356 (link) indicates that “general anesthesia is considered not reasonable and necessary for facet joint interventions.” Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.”

National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs)
  • Article Release Date: June 11, 2021
  • What You Need to Know: Effective December 1, 2020, CMS covers VADs under certain criteria. Change Request (CR) 12290 revises NCD 20.9 in the Medicare NCD Manual and Chapter 32, Section 320 of the Medicare Claims Processing Manual.
  • MLN MM12290: (link)
July 2, 2021: Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches

CMS issued Proposed Decision Memo CAG-00296R2 (link). Two changes being proposed includes:

  • Remove NCD 240.2.2 of the Medicare NCD Manual, ending coverage with evidence development, and allow the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for cluster headaches (CH), and
  • Modify NCD 240.2 Home Use of Oxygen to expand patient access to oxygen and oxygen equipment in the home, and to permit MACs to cover the use of home oxygen and equipment in order to treat CH and other acute conditions.

You can submit comments through August 1, 2021. The related National Coverage Analysis (NCA) Tracking Sheet for this Decision Memo CAG-00296R2 (link) will enable you to follow the progress of this proposal.

FY 2022 ICD-10-CM Code Updates
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 | Coding 

In late June, the FY 2022 ICD-10-CM diagnosis code updates were posted to the CMS website (link) and the CDC website (link). Since then, the CDC updated their announcement on July 2, 2021. Specifically, they advise, if you downloaded the following two documents prior to June 30, 2021, you would need to download them again:

  • A new version of the ICD-CM-tabular addenda for FY 2022 has been added to correct the missing I5A, Non-ischemic myocardial injury (non-traumatic) code for the addenda, and
  • A new version of the FY 2022 Conversion table has been added.

Social Determinants of Health (SDOH)

Of the 159 new codes for FY 2022, I want to focus on the code additions to code categories Z55-Z65. These codes identify persons with potential health hazards related to socioeconomic and psychosocial circumstances.

Social Determinants of Health Defined

The World Health Organization defined SDOHs as being “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”

New and Revised SDOH Z Codes for FY 2022:
  • Z55.5 Less than a high school diploma
  • Z58 Problems related to physical environment
  • Z58.6 Inadequate drinking-water supply
  • Z59.00 Homelessness unspecified
  • Z59.01 Sheltered homelessness
  • Z59.02 Unsheltered homelessness
  • Z59.4 was revised from “Lack of adequate food and safe drinking water” to
    • Z559.4 “Lack of adequate food”
  • Z59.41 Food insecurity
  • Z59.48 Other specific lack of adequate food
  • Z59.81 Housing instability, housed
  • Z59.811 Housing instability, housed with risk of homelessness
  • Z59.812 Housing instability, housed, homelessness in past 12 months
  • X59.819 Housing instability, housed unspecified
  • Z59.89 Other problems related to housing and economic circumstances
Coding Clinic Guidance

A question was asked, in Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, to verify whether these Z codes could be assigned based on non-physician documentation. Advice provided indicated that these codes represent social information, and it would be acceptable to report them based on documentation from other clinicians following the patient.

ICD-10-CM Official Guidelines for Coding and Reporting

Guidance related to coding SDOH category Z codes first appeared in the FY 2019 ICD-10-CM Official Coding Guidelines in Section B.14: Documentation by Clinicians Other than the Patient’s Provider:

“For social determinants of health, such as information found in categories Z55- Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.”

In FY 2021, the following additional statements was added to the guidelines:

“Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”
CMS Acknowledges Impact of SDOH on Health

In January of this year, CMS issued guidance to state health officials to drive the adoption of strategies addressing SDOH in Medicaid and the Children’s Health Insurance Program (CHIP) to help improve beneficiary outcomes. CMS ends a related Press Release (link) by indicating that they have “placed an emphasis on addressing SDOH across all of its programs in its continued efforts to move toward a value-based model of care delivery.”

With the addition of new ICD-10-CM codes specific to SDOH, hospitals could assist in identifying “at risk” patient. Hospital coding professionals should be aware of these codes and look to documentation by a Social Worker, Case Manager, or the admitting nurse as socioeconomic issues can be identified as part of the admission history and discharge planning process.

If you are interested in learning more about SDOH, visit the CDC’s SDOH website (link) that will connect you to CDC resources for SDOH data, research, tools for action, programs and policy.

Cataract Awareness Month Focus: Coverage Policies & MAC Reviews
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 | Billing 
 | Coding 
 | Quality 

MMP and RealTime Medicare Data (RTMD) have collaborated to highlight Health Awareness Month topics throughout the year with an infographic spotlight on Medicare Fee-for-Service (FFS) paid claims data comparatives and a related article. June is Cataract Awareness Month. The American Academy of Ophthalmology notes that “cataract is one of blindness in the United States. If not treated, cataracts can lead to blindness. In addition, the longer cataracts are left untreated, the more difficult it can be to successfully remove the cataract and restore vision. During Cataract Awareness Month in June, the American Academy of Ophthalmology reminds the public that early detection and treatment of cataracts is critical to preserving sight.”

Did You Know?

According to (link) the average amount that a patient pays for extracapsular lens removal with insertion of intraocular lens prosthesis (CPT 66984) is $316 in the Ambulatory Surgery Center (ASC) setting and $524 in a Hospital Outpatient Department.

Several Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) related to cataract removal.

Why Does this Matter?

The CERT, Recovery Auditors and a two of the MACs are reviewing cataract procedure records. Reviews include the ASC and Hospital Outpatient Department Settings.

Comprehensive Error Rate Testing (CERT)

In the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data (link), the CERT review contractor indicates they reviewed 209 Part B claims and identified a 6% improper payment rate that equates to a projected improper payment amount of $111,696,441.

Recovery Auditors

There are currently three approved RAC issues related to cataracts:

  • Issue 0002: Cataract Removal: Medical Necessity & Documentation Requirements,
  • Issue 0083: Cataract Removal: Excessive Units (partial), and
  • Issue 0084: Cataract Removal: Partial Payment.

Provider Types they have been approved to review includes ASC, Outpatient Hospitals and specific to Issue 0083 and 0084 Professional Services.

CGS MAC for Jurisdiction 15 (J15)

Prior to CMS temporarily pausing the Targeted Probe and Educate (TPE) Program, reviewing Medicare Part A claims for cataract removal was part of CGS’, the MAC for Kentucky and Ohio, list of review topics. A Cataract Extraction with IOL ADR Checklist (link) is available on the CGS website.

Palmetto GBA JJ and JM

Palmetto GBA, the MAC for Jurisdictions J (Alabama, Georgia, and Tennessee) and M (North and South Carolina, Virginia and West Virginia) recently published service-specific post payment probe review results of CPT 66984, Extracapsular Cataract Removal with insertion for both Jurisdictions. Both articles include state specific findings, reasons for claims denials and recommendations to prevent future denials.

  • April 14, 2021, Palmetto GBA JJ Part B results (link): 680 claims were reviewed, with 110 (16.17%) claims being completely or partially denied. The charge denial rate of 15.65% equated to $59,466.77 in denials.
  • May 11, 2021, Palmetto GBA, JM Part B results (link): 2,508 claims were reviewed, with 128 (5.1%) claims being completely or partially denied. The charge denial rate of 5.13% equated to $76,598.10 in denials.

Based on their findings, Palmetto plans to continue post-payment reviews of CPT 66984 in both Jurisdictions.

What You Can Do About It?
  • Identify whether there is an applicable LCD and LCA for your MAC jurisdiction.
  • Read Palmetto GBA’s Cataract Removal article (link) which provides conditions or circumstances when lens extraction is considered medically necessary and therefore covered by Medicare.
  • Share this information with Providers performing these procedures at your facility.
  • Review a sample of your cataract claims for documentation supporting the medical necessity of the service.
  • CMS MLN Matters SE1319: Cataract Removal, Part B: (link)

Beth Cobb

June 2021 PAR Focus: OIG Workplan
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Prior to 2017, the Office of Inspector General’s (OIG) Work Plan was published on an annual and sometimes semi-annual basis. The OIG began updating the Work Plan on a monthly basis effective June 15, 2017. The change was made as the OIG acknowledged that the “work planning process is dynamic, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.” The Work Plan includes items for several agencies (i.e., Centers for Medicare & Medicaid Services (CMS), Administration for Children and Families, Office of Civil Rights (OCR)). There are two recent additions to the Work Plan that I would like to share with you.

Active Work Plan Item: Impact of Expanding the Hospital Transfer Payment Policy for Early Discharges to Post-acute Care

This item (link) was added to the Work Plan in May 2021. The OIG plans to determine the impact for Medicare and hospitals if the Post-Acute Care (PAC) MS-DRG list was expanded to include all MS-DRGs. In the detail of this Work Plan item, the OIG notes that “Analysis of Medicare claims data demonstrates significant occurrences of early discharges from hospitals to PAC facilities for MS-DRGs that are not currently subject to the PAC transfer payment policy. Medicare pays a full prospective payment system (PPS) rate to hospitals for these early discharges.”

The Post-Acute Care Transfer (PACT) Policy was implemented to prevent Medicare from paying for the same care twice. This policy currently reduces reimbursement to a hospital when:

  • A hospitalization codes to an MS-DRG designated as a Transfer MS-DRG,
  • The patient’s length of stay (LOS) is at least 1 day less than the geometric mean length of stay (GMLOS) for the MS-DRG, and
  • The patient is discharged to one of the “qualified discharges” (03-Skilled Nursing Facility (SNF), 05-Children’s Hospital or Designated Cancer Center, 06-Home with Home Health within 3 days of discharge, 50-Discharges/Transferred to Hospice Home, 51-Discharged/Transferred to Hospice, General Inpatient Care or Inpatient Respite, 62-Inpatient Rehabilitation Facilities & Units, 63-Long Term Care Hospitals, and 65-Psychiatric Hospitals & Units)

Annually, CMS publishes a list of MS-DRGs subject to the PACT policy in Table 5 of the applicable Fiscal Year IPPS Final Rule. For FY 2021 there are 765 MS-DRGs and 280 (36.6%) have been designated a PACT MS-DRG.

Discharge Dispositions hospice home (50) and hospice general inpatient care/respite (51) were added to this policy in FY 2019 as required by the Bipartisan Budget Act of 2018. At that time, CMS actuaries estimated that the change would “generate an annual savings of approximately $240 million in Medicare payments in FY 2019, and up to $540 million annually by FY 2028.” With these estimates it is no wonder the OIG has added this item to their Work Plan. The OIG has an expected issue date for a report in FY 2022.

Active Work Plan Item: Audit of the Effectiveness of HHS’s Governance to Ensure Hospitals Implement Measures to Prevent, Detect, and Recover from Cyberattacks

This item (link) was also added to the Work Plan in May 2021. As an active member of MMP’s HIPAA/HITECH Privacy Committee, I felt it was important to make our readers aware of this item. If you listen to the news, this is a very timely item as hospitals are constantly under threat of the theft of electronic protected health information (ePHI) by ransomware, malware, insider threats, and even honest mistakes.

“In October 2020, the Cybersecurity and Infrastructure Security Agency, Federal Bureau of Investigation, and Department of Health and Human Services (HHS) issued a joint cybersecurity advisory (link) regarding ransomware activity targeting the health care and public health sector. The advisory stated that threat actors have continued to develop new functionality and tools, thereby increasing the ease, speed, and profitability of ransomware attacks.”

OIG Audit Plan
  • “Audit HHS's governance over its programs to determine whether HHS's Office of Civil Rights (OCR) has performed periodic audits of hospitals to assess compliance with Health Insurance Portability and Accountability Act (HIPAA) Security, Privacy, and Breach Notification rules and determine whether these audits effectively assessed ePHI protections.”
  • “Determine whether CMS's certification process for participation in the Medicare program requires hospitals participating in the Medicare program to implement minimum security safeguards to prevent and detect cyberattacks, ensure continuity of patient care, and protect beneficiary data.”
  • Conduct security assessments at 10 U.S. hospitals to determine whether they have adequately implemented HIPAA security requirements or effective cybersecurity measures to prevent, detect, and recover from cyberattacks.”

The OIG has an expected issue date for a report in FY 2022.

2016-2017 OCR HIPAA Audits Industry Report

As mentioned above, the OIG plans to determine if the OCR has performed periodic audits of hospitals. On December 17, 2020, the Office for Civil Rights (OCR) released its 2016-2017 HIPAA Audits Industry Report. The Health Information Technology for Economic and Clinical Health (HITECH) Act requires HHS to periodically audit covered entities (CEs) and business associates (BAs) for compliance with the HIPAA Rules. This Industry Report was published to share overall findings from audits conducted with 166 CEs and 41 BAs. To provide insight into what was included in the audit, following is the summary of audit findings from the December HHS Press Release (link):

  • Most covered entities met the timeliness requirements for providing breach notification to individuals,
  • Most covered entities that maintained a website about their customer services or benefits satisfied the requirement to prominently post their Notice of Privacy Practices on their website,
  • Most covered entities failed to provide all the required content for a Notice of Privacy Practices,
  • Most covered entities failed to provide all the required content for breach notification to individuals,
  • Most covered entities failed to properly implement the individual right of access requirements such as timely action within 30 days and charging a reasonable cost-based fee,
  • Most covered entities and business associates failed to implement the HIPAA Security Rule requirements for risk analysis and risk management.

The HHS Press Release ended with the following statement from OCR Director Roger Severino, “The audit results confirm the wisdom of OCR’s increased enforcement focus on hacking and OCR’s Right of Access initiative…We will continue our HIPAA enforcement initiatives until health care entities get serious about identifying security risks to health information in their custody and fulfilling their duty to provide patients with timely and reasonable, cost-based access to their medical records.”

Beth Cobb

June 2021 PAR Pro Tips
Published on 



As described in the Welcome to the PAR article, MMP Associates monitor websites monthly to identify new Medicare Fee-for-Service review targets and review results. Invariably, we will come across useful “Did You Know” information that we will be sharing in this monthly PAR Pro Tips article.

Pro Tip: MACs Post-Payment Reviews Expanded

In 2020, in response to the COVID-19 Public Health Emergency (PHE), CMS put a halt to the Medicare Administrative Contractor (MAC) Targeted Probe and Education (TPE) Program. In August 2020, CMS advised MACs to resume post-payment reviews with dates of service before March 2020. Most recently, CMS announced in the Thursday June 3, 2021 MLN Connects (link), that MACs can now begin conducting post-payment reviews for claims after March 2020.

Pro Tip: New April 2021 Medicare Quarterly Provider Compliance Newsletter

Also, in the June 3rd MLN Connects newsletter, CMS announced the release of the April 2021 Medicare Quarterly Provider Compliance Newsletter. Per the introduction of this newsletter, it aims to “help health care professionals to understand the latest findings identified by MACs and other contractors such as Recovery Auditors and the Comprehensive Error Rate Testing (CERT) review contractor, in addition to other governmental organizations as the Office of Inspector General (OIG).” Two RAC Issues detailed in the newsletter includes acute care hospitals claims review

Recovery Auditor (RAC Issue 0067): Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements

RAC Issue 0067 (link) was approved by CMS for the RACs to review on September 1, 2018 for provider types Inpatient Hospital and Inpatient Psychiatric Facility (IPF). The April newsletter includes a discussion of the problem, background information and guidance, and resources to assist providers in meeting medical necessity and documentation requirements for providing psychiatric services.

Did You Know?
  • Palmetto JJ, Palmetto JM, and WPS J5 are currently conducting post-payment reviews of MS-DRG 885 (Psychoses) claims,
  • Six of the twelve MACs have published a Local Coverage Determination (LCD) and Local Coverage Article (LCA) specific to psychiatric services, and
  • MS-DRG 885 claims have been a focus by the CERT review contractor since 2011. The annual improper payment rate reported by the CERT for this MS-DRG has been as high as 14.4% with the lowest rate being 2.9% in 2020.
Recovery Auditor (RAC Issue 0074): Drugs and Biologicals: Incorrect Units Billed (Single-Dose Vials)

RAC Issue 0067 RAC Issue 0074 (link) was approved by CMS for the RACs to review on December 21, 2017 for provider types Outpatient Hospital and Professional Services.

The RACs performed “complex reviews for single dose vials to assure compliance with Medicare policy. They reviewed claims to determine the actual amount administered and the correct number of billable/payable units.” You can find case examples in CMS’ newsletter.

Pro Tip: Q2 2021 Medicare Fee-for-Service Payments Integrity Scorecard (link) is an official website of the U.S. government. This website is “a gateway to ensuring federal funds reach the right recipients, preventing improper payments, and reducing fraud, waste, and abuse.” You will find “Program Scorecards”, “The Numbers” and “Resources” on this website.

The most recent Medicare Fee-for-Service Scorecard available is Q2 2021 (link). The Scorecard shares three HHS accomplishments in Reducing Monetary Loss:

  • HHS continued the process of adding two additional services (cervical fusion with disc removal and implanted spinal neurostimulator) to the Prior Authorization for Certain Hospital Outpatient Department Services Program effective July 1, 2021. You can read more about this in a related MMP article (link),
  • HHS continued RAC and MAC post-payment reviews based on data analysis and the CERT findings, and
  • HHS continued to use the Supplemental Medical Review Contractor (SMRC) to complete projects in relation to the Public Health Emergency, recent OIG reports, and CERT findings.
SMRC Project 01-043: DRG COVID 20% Add-On Payment

Specific to the PHE, the SMRC is conducting post-payment reviews of Medicare Part A COVID-19 inpatient claims with dates of service from April 1, 2020, through August 30, 2020. In general, in the inpatient setting, a diagnosis code documented at the time of discharge as being “possible”, “probable”, “suspected”, “likely”, “questionable”, or “still to be ruled out”, is coded as if the condition existed.

One exception to this guidance is coding for COVID-19. The ICD-10-CM Official Coding Guidelines (link) for COVID-19 advises coders to code only confirmed cases “as documented by the provider, documentation of a positive COVID-19 test, result, or a presumptive positive COVID-19 test result.”

While beyond the dates of service of the SMRC Project, it is worth noting that in August 2020, CMS revised MLN article SE20015 (link) by adding guidance “to address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.”

One last reminder, the add-on payment for COVID-19 claims will end when the COVID-19 PHE ends. While the Biden Administration has indicated the PHE will likely be in place until December 31, 2021, the current PHE declaration will expire in July.

Beth Cobb

Welcome to the PAR
Published on 


Steps to a Successful PAR

In a game of golf, a par 3 course usually consists of only par 3 holes. In theory, golfers are able to reach the green on their first stroke and then take two putts to get the ball in the hole. No matter the course, most professional golfers will always use a tee to prevent grass from getting between the ball and the club.

In January of 2017, the OIG, in collaboration with a group of compliance professionals, released a Resource Guide (link) to measure the effectiveness of compliance programs. Items 5.27-5.36 emphasize that a Risk Assessment is key to developing an effective Compliance audit/work plan. Identifying current Medicare review targets to consider when developing your Risk Assessment can be time consuming and overwhelming.

MMP’s PAR Tee’s the Ball

Being sensitive to our client’s already over-tasked day, MMP collaborated with RealTime Medicare Data (RTMD), to develop a proprietary Protection Assessment Report (PAR). MMP’s PAR tees the ball by compiling Medicare Fee-for-Service review targets being conducted by:

  • Office of Inspector General (OIG),
  • Medicare Administrative Contractors (MACs) – all 12 Jurisdictions,
  • Recovery Auditors – all 4 Regions,
  • Supplemental Medical Review Contractor (SMRC), and
  • Comprehensive Error Rate Testing (CERT) Program.

Additional features of the PAR:

  • Inpatient reviews targets that are included in the Program for Evaluating Payment Patterns Electronic Report (PEPPER) are highlighted in the PAR,
  • The PAR details all Medicare Contractors that may be focused on one specific review target (i.e., total knee arthroplasty).
  • Monthly, MMP Associates monitor websites for the entities listed above. Specifically, monitoring is for new review targets, review results, and new or changes to current coverage policies.
  • For review targets with an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or Local Coverage Article (LCA), the PAR also includes this information.
Successful Shot Selection

One step to improving your golf game is picking a target to use as a reference for setting up your shot. MMP’s PAR aids in your successful review target selection. This is accomplished by “dropping in” your hospital specific Medicare Fee-for-Service paid claims data (volume, charges and payments), provided by RTMD, for target areas included in the report. Sorting by volume and or payments helps you take aim on what is important for your hospital.

Third Wednesday of the Month PAR Focus

Moving forward, the third Wednesday@One of each month will include insights from our ongoing monitoring of external auditor’s websites. If you are interested in learning more about the PAR, you can contact us by completing the form below this article.

Beth Cobb

FAQ: Coding NIHSS Scores
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 | FAQ 

What is the significance of coding the National Institutes of Health Stroke Scale Scores (NIHSS) that were implemented in 2017?


The NIHSS is a neurological exam that is scored on all acute stroke patients. The provider or clinician will calculate and document the score. The coder is to assign R29.7—based on the score or scores.

Score Description
0 No Stroke
1-4 Minor Stroke
5-15 Moderate Stroke
16-20 Moderate/Severe Stroke
21-24 Severe Stroke

CMS has been gathering claims data on strokes from July 1, 2018 - June 30, 2021 which will be publically reported in FY 2022. For FY 2023 the data will start affecting hospital reimbursement as part of the 30-Day Stroke Mortality Measure. Hospitals should report the first NIHSS, which is typically documented after arrival to the hospital along with the appropriate stroke code. You may report additional NIHSS codes and use the POA indicator No for those additional codes.

In a recent Wednesday@One article (link) and related Infographic, RTMD’s claims data revealed only 40.1% of the claims included an NIHSS code. The reason the reporting of the NIHSS codes is so low may be due to the wording of the coding guideline. The guideline states, codes R29.7—may be used in conjunction with the stroke codes, so many hospitals are opting not to code them.

The main point of this article is to make sure you always report a NIHSS code with an acute stroke code and that they appear on the claim. Omitting the R29.7- code will adversely impact your hospital’s future reimbursement.

Coding Clinic, Fourth Quarter 2016, page 61
NIHSS Stroke Scale, ICD-10-CM Coding Guidelines

Anita Meyers

Coding Cataract Extraction
Published on 


 | FAQ 

During cataract extraction, the physician sometimes injects an antibiotic into a part of the eye anatomy. Can we code the injection procedure(s) in addition to the cataract extraction CPT code?


No, do not code the eye injection in addition to the CPT code for the cataract extraction. This applies to the injection of an antibiotic as well as steroids and non-steroidal anti-inflammatory drugs Specific examples of injections not separately reportable with the cataract extraction code include: anterior chamber, intravitreal, retrobulbar, Tenon’s capsule, and subconjunctival.

Reference: National Correct Coding Initiative (NCCI) Policy Manual, chapter VIII, page 18.

Jeffery Gordon

Coding Diabetic Cataracts
Published on 


 | Coding 
Did you know?

Did you know that coding advice regarding Diabetes and Cataracts has changed?

Why it matters.

You may not be capturing the most accurate severity of illness of the patient.

What can I do?

Read the following Coding Clinics: September-October 1985, page 11 and 4th Quarter 2016, page 142.

Advice from 1985 stated that Diabetic Cataracts are rare, but may appear in Type 1 Diabetics. Simply put, we were advised that most cataracts occurring in a diabetic patient were not coded as a diabetic complication.

Advice from 2016 now states that diabetes and cataracts should be coded as related conditions as they are not rare and are a major cause of eye sight issues in diabetics. The Coding Clinic advice from 1985 was revised because more is known about cataracts and that the occurrence in diabetic patients was found to be higher and occurring at younger ages than nondiabetics.

Anita Meyers

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