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HDI posts one new issue in one category

HealthDataInsights (HDI) posted one new issue in one category to its CMS list for providers in Region D. (See link for individual state applicability.)

According to the HDI website, the new issues are:

For Inpatient Acute Care Hospitals:

  • Prospective Payment System (PPS) DRG Outliers – High Cost Implants – J5 and Legacy. Medicare pays for inpatient hospital services provided. Under PPS, hospitals are paid a predetermined rate per discharge for inpatient hospital services furnished to Medicare beneficiaries. Each type of Medicare discharge is classified according to a list of DRGs. These amounts, are, with certain exceptions, payment in full to the hospital for inpatient operating costs. In addition to the basic prospective payments, Medicare also makes payment for cases incurring extraordinarily high costs. This additional payment is known as an “Outlier”. Medical documentation will be reviewed to determine the correct units of service and charges were reported under Revenue Code 278. (Medical Necessity will be excluded at this time.)

HDI posts one new issue in one category

HealthDataInsights (HDI) posted one new issue in one category to its CMS list for providers in Region D. (See link for individual state applicability.)

According to the HDI website, the new issues are:

For inpatient acute care hospitals:

Prospective Payment System (PPS) DRG Outliers – High Cost Implants – JE and JF. Medicare pays for inpatient hospital services provided. Under PPS, hospitals are paid a predetermined rate per discharge for inpatient hospital services furnished to Medicare beneficiaries. Each type of Medicare discharge is classified according to a list of DRGs. These amounts, are, with certain exceptions, payment in full to the hospital for inpatient operating costs. In addition to the basic prospective payments, Medicare also makes payment for cases incurring extraordinarily high costs. This additional payment is known as an “Outlier”. Medical documentation will be reviewed to determine the correct units of service and charges were reported under Revenue Code 278. (Medical Necessity will be excluded at this time.)

CGI posts two new issues in one category

CGI posted two new issues in one category to its CMS list for providers in Region B. (See link for individual state applicability.)

According to the CGI website, the new issues are:

For outpatient services at Critical Access Hospitals:

The Cardiovascular Nuclear Medicine services have coverage guidelines specific to the Local Coverage Documentation and the CMS Manuals in Ohio and Kentucky. Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management. There are specific diagnoses associated with each form of testing. When an unapproved diagnosis is reported for any type of Cardiovascular Nuclear Medicine service, the service is denied.

The Cardiovascular Nuclear Medicine services have coverage guidelines specific to the Local Coverage Documentation and the CMS Manuals in Michigan and Indiana. Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management. There are specific diagnoses associated with each form of testing. When an unapproved diagnosis is reported for any type of Cardiovascular Nuclear Medicine service, the service is denied.

AHA Files Two Lawsuits Related to the 2-Midnight Rule; Still a Rule in Turmoil

Last week, the American Hospital Association (AHA), along with four hospitals/health systems and four hospital associations from New York City, New York State, New Jersey, and Pennsylvania, filed two lawsuits against the relatively controversial 2-midnight rule and some of its accompanying provisions. All this while Congress has recently extended the probe and educate period for the provision, and is considering other changes to the rule. We also expect the FY2015 IPPS proposed rule at any time, which could also make new proposals affecting the rule.

The first AHA lawsuit takes aim at the 2-midnight rule itself as well as the order and certification requirement and the Part B inpatient billing provisions. The complaint asks for the 2-midnight rule to be declared arbitrary and capricious and set aside, presumably returning to the prior guidance on inpatient admissions.

The complaint also asks that the physician order requirement be set aside as invalid, arbitrary and capricious, and contrary to the Medicare Act. While the complaint seems to discuss the new certification requirements, which are more onerous for hospitals than the order requirement, the suit only appears to ask for the order requirement to be set aside.

Finally, they ask that the one year timely filing requirement in the new Part B inpatient billing regulations be set aside as well. As the lawsuit notes, the one year timely filing limit is difficult, if not impossible, to meet for audits by external auditors.

Regardless of how the lawsuit proceeds, however, hospitals can take advantage of the new Part B inpatient billing rules by doing their own internal audits any time up to a year after the patient’s discharge and still get full Part B payment. This represents a big transition from requiring concurrent audits in order to get limited Part B inpatient payment and a big revenue opportunity for hospitals that they can take advantage of now.

The second lawsuit separately challenges the 0.2% cut in inpatient payments made by CMS in order to maintain the budget neutrality of the new inpatient status provisions in light of the additional inpatient admissions they anticipated. The complaint argues that the payment cut did not comply with the notice and comment period as required and violates technical requirements of the Medicare Act.

Meanwhile, earlier this month, the Protecting Access to Medicare Act of 2014 was passed which extended the probe and educate period for MACs to review hospitals’ application of the 2-midnight rule until March 31, 2015. It also prohibited Recovery Auditors from auditing claims until that date.  I recently wrote a white paper on this new law and the audits.

In addition to this legislation, there are also proposed laws in both the Senate and House that would restructure the 2-midnight rule or prevent its application, which can be accessed by searching “2 Midnight” at Congress.gov. This month, CMS is also set to release the FY2015 IPPS rule. Based on the multiple clarifications issued related to patient status after last year’s rule, there very well may be new regulatory clarification included in the annual proposed rule.

Hospitals must continue their compliance efforts with all the new rules adopted for FY2014 because for now there is no change in their application and probe and educate audits continue at the MAC level. CMS may continue to issue guidance on their application informally on their website. Please note the CMS’ Inpatient Review site has moved, so if you are monitoring that site for new guidance, please link to the new site here..

But hospitals must also be cognizant of all the potential changes to the rules that could be coming up and be prepared to be flexible to accommodate any new rules. We will make every effort to monitor these developments closely and keep you updated in the Medicare Insider.

Medical Necessity 2014: Inpatient Admissions and the 2-Midnight Rule

Join us at 1 p.m. (Eastern) Wednesday, April 16 for the live 90-minute webcast “Medical Necessity 2014: Inpatient Admissions and the 2-Midnight Rule.”

MACs recently selected more than 29,000 records for review as part of CMS’ probe audits of inpatient claims with admission dates on or after October 1, 2013. CMS’ effort to determine compliance with the 2-midnight rule makes it more important than ever for hospitals to avoid denials by staying on top of ever-changing guidance.

During this show, our expert speakers Ralph Wuebker, MD, MBA, and Jonathan G. Wiik, MSHA, MBA, will discuss preliminary results of the audits and provide real-world examples of denied inpatient claims. You’ll also get tips for determining medical necessity and the latest guidance on 2-midnight rule compliance.

Click to hear why speaker Ralph Wuebker, MD, MBA, thinks you should attend this program.

For more information or to register, click here or call 800-650-6787.

At the conclusion of this program, you will be able to:

  • Apply best practices for physician documentation of medical necessity at your facility
  • Recognize appropriate standard order sets and physician documentation of medical necessity
  • Identify cases that are at risk for denials or audits by MACs and Recovery Auditors
  • Discuss preliminary results of CMS’ probe audits

CGI posts one new issue

 

CGI posted one new issue in one category to its CMS list for providers in Region B. (See link for individual state applicability.)

According to the CGI website, the new issue is:

For outpatient services:

  • OP Cardiovascular Nuclear Medicine Correct Coding J6 (NGS) Rev 1. The Cardiovascular Nuclear Medicine services have coverage guidelines specific to the Local Coverage Documentation and the CMS Manuals. Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management. There are specific diagnoses associated with each form of testing, when an unapproved diagnosis is reported for any type of Cardiovascular Nuclear Medicine service, the service is denied.

Note from the instructor: Hospital Outpatient Payment Panel makes recommendations to CMS

 

This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro.

Hospital outpatient therapeutic services, such as emergency department or clinic visits, paid under OPPS or paid to critical access hospitals (CAH) on a cost basis must be furnished “incident to” a physician’s service to be covered. In order to qualify for “incident to” coverage, the service must be furnished on the order of a physician or non-physician practitioner in a hospital or provider-based department of the hospital, be furnished as an integral part of treating the patient, and be provided under the appropriate level of supervision (i.e., general, direct, or personal).

In 2012, CMS established the Hospital Outpatient Payment Panel as an independent review entity, which included stakeholders from the OPPS and CAH hospitals, to give CMS recommendations on the appropriate supervision levels for hospital outpatient therapeutic services. The panel meets in March and August and then CMS posts its preliminary decisions on the panel’s recommendations for a 30-day comment period. After the comment period, CMS issues their decisions, which become effective July 1 following the March meeting or January 1 following the August meeting.”

On March 10, the panel met and proposed several changes to the current supervision requirements. CMS accepted the panel’s recommendations on several key outpatient services but rejected several others based on safety and standards of quality care. One of the outcomes of the panel’s meeting is that CMS will change the following services from direct supervision to general supervision, meaning that the service must be furnished under the physician or non-physician practitioner’s overall direction and control but does not require they be present during the service:

  • G0176 – Activity therapy, such as music, dance, art, or play therapies not for recreation related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more)
  • 36593 – Declotting by thrombolytic agent of implanted vascular access device or catheter
  • 36600 – Arterial puncture, withdrawal of blood for diagnosis
  • 94667 – Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation
  •  94668 – Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent

However, CMS did not accept the panel’s recommendation to change eight specific chemotherapy administration services from direct supervision to general supervision because the CPT codes describe the injection and intravenous infusion of highly complex drugs or complex biological agents. Direct supervision will continue to be the requirement for these services; CMS is seeking further comment on the panel’s recommendation for consider at its August meeting. Specifically, CMS is looking for clinical input regarding the appropriate level of supervision for the initial and subsequent administrations of these drugs when provided in a hospital or CAH outpatient department.

Although the panel recommended that CPT 97597 (debridement of an open wound) be changed to general supervision, CMS did not accept the proposal, stating that this code includes sharp debridement which is generally not within the nursing scope of practice and therefore is not safe for general supervision. Keep in mind that hospitals paid under OPPS or CAHs paid under cost do not have to meet “incident to” requirements for physical therapy, occupational therapy, speech-language pathology services, diabetes outpatient self-management training, medical nutrition therapy, and kidney disease education.

In CY 2012, CMS also defined an exception to the direct supervision requirements and created a list of Non-Surgical Extended Duration Therapeutic Services (NSEDTS). These services must be provided under direct supervision during the initiation of the service followed by general supervision once the supervising physician determines the patient is stable and the remainder of the service can be delivered safely under general supervision. The supervising physician must document the transition from direct to general supervision in the patient’s medical record. This subset of services was created, in part, to assist CAHs in meeting supervision requirements for payment that were not consistent with their licensure requirements regarding physician and NPP staffing.

CMS will designate CPT code 36430 (transfusion, blood or blood components)as an NSEDTS because it warrants direct supervision initially and has a low risk of adverse effects once the transfusion has begun.

CMS agreed with the panel to change CPT code 96370 (subcutaneous infusion, each additional hour) from an NSEDTS to general supervision, since it describes a subsequent infusion of a previously administered drug that already required direct or extended duration supervision for the initial hour of infusion. However, CMS did not accept the panel’s recommendation to change the following services from NSEDTS to general because they involve administration of a new drug or substance:

  • 96369 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)
  • 96371 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug)

These preliminary decisions by CMS remain open to public comment through April 30; comments can be submitted via email to HOPSupervisionComments@cms.hhs.gov. Hospitals are always encouraged to provide their input and suggestions to CMS so that they may be considered in the final decisions that will become effective July 1, 2014.

Note from the instructor: As the healthcare world turns…

This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

While healthcare providers waited for the outcome of the Senate vote on H.R. 4302: Protecting Access to Medicare—which will impact Medicare payments to physicians and non-physician practitioners, as well as delay ICD-10 implementation until October 1, 2015 and extend the 2-Midnight Rule review period by an additional six months in FY2015—I thought I would take a few minutes to point out the highlights of the latest information from CMS regarding the latter topic.

On March 12, CMS posted two new documents to its Inpatient Hospital Reviews website. These documents were posted not long after the most recent version that was published on February 24.

In the document titled “Questions and Answers Related to Patient Status Reviews” there is some new information as well as updated or clarified questions that providers should review in greater detail. Here are some highlights that I think are worth mentioning: 

  • (A1.3) If a MAC identifies no issues (defined as 0–1 claim denials) during the probe review, the MAC will cease further such reviews for that hospital for dates of admission spanning October 2013 to September 2014, unless there are significant changes in billing patterns for admissions.
    Comment:
    I have often wondered what “minor, ” “moderate, ” “significant, ” or “major” concerns are when reviewing the document “Selecting Hospital Claims for Patient Status Reviews: Admissions On or After October 1, 2013.” There does not appear to be any written guidance to providers to know which category they clearly fall into and why. At least now providers will know that if they have one claim denied out of their sample of either 10 or 25 records, they will not have further reviews conducted unless their billing patterns change. I am not sure if this clarification will be very comforting to providers overall.
  • (A2.2) The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital.
    Comment:
    If a hospital is going to use the outpatient time spent at a transferring hospital to count toward their 2-midnight benchmark time, clear documentation should be obtained and maintained in the receiving hospital’s medical record to support their claim.  

 

  • (A4.10) …Thus, CMS does not require the treating physician to admit the beneficiary as an inpatient in these or any other circumstances…Accordingly, where the treating physician expects a beneficiary to require medically necessary hospital care spanning 2 or more midnights, we encourage the physician to consider ordering an inpatient admission, with the understanding that such a claim will not be denied by a Medicare review contractor for inappropriate status if all other requirements are met. CMS may monitor hospital outpatient billing trends for the incidence of prolonged outpatient stays so that we can provide education on when an inpatient admission is generally appropriate under the 2-midnight rule.
    Comment: 
    Although CMS may not require admission as an inpatient, the fact that prolonged outpatient stays may be monitored by CMS should give pause to hospitals that continue to have more than 24 hours of observation services. Hospitals should consider reviewing these records in addition to their 0–1 midnight inpatient stays.
  • (A4.11) MACs will issue determinations for such claims based on the general 2-Midnight benchmark instruction. In other words, if the physician reasonably expects the beneficiary to require a hospital stay for 2 or more midnights at the time of the inpatient order and formal admission, and this expectation is documented in the medical record, the inpatient admission is generally appropriate for Medicare Part A payment.
    Comment:
    This is a new Q&A and is referring to cancelled surgical procedures after inpatient admission. However, if an inpatient surgery is cancelled and the stay is no longer medically necessary, hospitals could fall into a trap similar to what hospitals experienced with OIG audits for cancelled inpatient-only procedures. In these scenarios, Condition Code 44 should be considered in a timely manner.

In the other document, titled “Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013,” there were two items that may be of interest to providers.

 

  • (III.D.1.) If an unforeseen circumstance results in a shorter beneficiary stay than the physician’s reasonable expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A…Examples include unforeseen: death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital.
    Comment:
    An unforeseen circumstance that was clarified in this section is the election of hospice care.
  • In the section titled Patient Status Reviews, hospitals need to be aware that the Medicare review contractors are also assessing compliance with the admission order and certification requirements. Specifically, hospitals should verify that the orders and all elements of the certification are appropriately signed prior to discharge. This may cause challenges for facilities that are using a variety of areas in the medical record for the certification elements (i.e., history and physical, progress notes, order, etc.).

 

One other nugget I wanted to point out to hospitals that may have skimmed over it comes from the “Hospital Inpatient Admission Order and Certification” document that came out on January 30. This excerpt is in regards to the responsible physician not countersigning an initial or verbal order when they are in disagreement with the admission order.

 

  • (B.2.d.) Inpatient status begins at the time of formal admission by the hospital pursuant to the physician order, including an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)) that is countersigned timely, by authorized individuals, as required in this section. If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered to be an inpatient. The hospital stay may be billed to Part B as a hospital outpatient encounter.
    Comment:
    When appropriate, hospitals should consider this guidance carefully as an option to using Condition Code 44 or Part B inpatient billing.

 

It is getting more and more difficult to keep an eye on these moving targets as CMS continues to clarify and add new information to the 2-midnight rule documents, although it does not appear that it is always indicated with red italic writing. All providers impacted by the regulations would be well served to monitor the CMS website and review any new posts with a fine tooth comb. Each time I read these documents I seem to discover something new.

Connolly posts two new issues in one category

Connolly posted two new issues in two categories in to its CMS list for providers in Region C. (See link for individual state applicability.)

According to the Connolly website, the new issues are:

For DME:

  • Speech Generating Devices & Accessories – CGS – C004962013. Overpayments were identified where claims billed for suction catheters were not in accordance with billing requirements outlined in Local Coverage Determinations.
  • Suction Catheters for Tracheostomy – CGS – C000362014. Medical documentation will be reviewed to determine if the Speech Generating Device and/or Accessories met coverage indications, limitations, and/or medical necessity as outlined in CGS LCD.

 

CGI posts one new issue

CGI posted one new issue in one category to its CMS list for providers in Region B. (See link for individual state applicability.)

According to the CGI website, the new issue is:

For outpatient services:

  • Cetuximab Medical Necessity OP WPS.   A semi-automated edit to identify potential incorrect billing occurring for Cetuximab claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations. Payment will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.