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Healthcare Industry Updates

Compiled by:
Libbie Barron, RN

February 8, 2010 |
RACs are here—are you ready?

Louisiana hospitals have begun receiving requests for medical records from Connolly for DRG validation.

Has your hospital prepared and are you ready?

***

This is information from Day Egusquiza, AR Systems, Inc regarding Pt Supervision and Observation:

OBSERVATION is considered a 'therapeutic' service . Therefore, the new physician supervision rules from the OPPS 2010 regs apply. (http://edocket.access.gpo.gov/ 2009/E9-26499.htm begins on page 60575) In a previous Info Line, Mike Frith, one of our revenue cycle subcontractors, outlined the physician supervision issue. However, what has since continued to be clarified is that the ER physician CANNOT be utilized as the supevising physician which is heavily impacting OBS.

Many communciations have flown around (TN, KS, IA, ILL, ID, MT, WA) regarding the significant issues as outlined below:

1) The critical access hospitals will not be able to meet this requirement as most of them do not have any physician onsite 24/7. They have the on-call provision.

2) DRG/OPPS hospitals have been staffed with an ER physician to meet the 'outpt services are provided under the incident to provision." However, this change eliminates that provider group from meeting the provision. The provider must be available and able to step in and provide services. (OPPS 2010 reg)

3) The only hospitals with a chance of meeting this new requirement are those with 24/7 residents or hospitalists. Small % of compliance.

CMS was communicated with from numerous groups. The individual who has the 'fun ' job at CMS of replying is Heather Hostetler. (heather.hostetler@cms.hhs.gov) Here is her reply to a detailed list of concerns from a group of Montana hospitals.

"I hear and appreciate your concern. While direct supervision is a long standing requirement, the recent CY 2010 changes to the requirements for direct supervision of hospital and CAH outpt therapeutic services included an expansion to allow certain non-physician practitioners to directly supervise therapeutic services that are within their state scope of practice and hospital granted privileges. This includes all therapeutic services furnished in emergency departments. The policy was open for public comment thru the CY 2010 OPPS/ASC proposed rule which was published last July. We did receive many comments from CAHs and hospitals about physician supervision and we responded to those comments in the CY 2010 final rule, Nov 20, 2009. Specific discussion related to the CAHS and the definition of outpt therapeutic services which may be found in the Federal Register at 74 Fed. Reg. 60578 thru 60585. I would note, that the standard for direct supevision of outpt therapeutic services is not a new policy. We have a long standing definition of outpt therapeutic services in the Benefit Policy Manual (Chapter 6, section 20.5) as items and services that are not dx that aid the physician in the treatment of the pt. As we discussed, all services that are not soley dx are therapeutic services. This includes ED visits, clinic visits, observation services, all services that are primarily therapeutic in nature but have diagnostic elements. (Jan 28th email to CEO CAH Montana hospital)

Additionally, Ask the contractor physician, Dr. Heckler/ Noridian, The ER doctor is not allowed under the physician supervision rule due to his/her inability to be immediately available due to the need to be available for emergent care. (This is in the Final OPPS regs)

***

20 new MS-DRG Validations:

Connolly (Louisiana RAC) has added 20 new MS-DRG validations. The total for MS-DRG validations is now 80.

***

January 29, 2010 |
WPS Medicare - Increase in CERT errors related to CPT codes 85025 and 85027

WPS Medicare has noted an increase in the number of Comprehensive Error Rate Testing (CERT) errors related to Current Procedural Terminology (CPT) codes 85025 and 85027. Based on review of documentation, either the test administered or the physician order did not support the service billed to Medicare.

These codes are defined in CPT® 2009 as:

85025 - Complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.

85027 - Complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)

In most cases, services were billed under CPT 85025 - with automated differential, but the physician order indicated only "CBC," rather than "CBC w/differential." Without a valid order, the medical necessity of the billed code billed is not supported, and the Medicare payment must be adjusted to reflect the ordered test. In other cases, CPT 85027 was billed, while the results and physician orders supported CPT 85025.

***

January 5, 2010 |
Connolly has posted new CMS approved audit issues
on December 31, 2009

These are for DRG validation and discharge disposition.

Medical Necessity is excluded from review at this time.

• Other Vascular Procedures with MCC: MS-DRG 252

• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS-DRG 574

• Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC: MS-DRG 573

• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders without
  CC/MCC: MS-DRG 465

• Other Digestive System O.R. Procedures with
  MCC: MS-DRG 356

• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with
  CC: MS-DRG 623

• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with
  MCC: MS-DRG 622

• Other Digestive System O.R. Procedures with
  CC: MS-DRG 357

• Other Hepatobiliary or Pancreas O.R. Procedures with MCC: MS-DRG 423

• Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC: MS-DRG 578

• Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC: MS-DRG 576

• Skin Graft and/or Debridement for Skin Ulcer or
  Cellulitis without CC/MCC: MS-DRG 575

• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with
  CC: MS-DRG 464

• Wound Debridement and Skin Graft Except Hand, for Musculo-Connective Tissue Disorders with
  MCC: MS-DRG 463

• O.R. Procedure with Diagnoses of Other Contact
  with Health Services with CC: MS-DRG 940 O.R.

• Procedure with Diagnoses of Other Contact
  with Health Services with MCC: MS-DRG 939

• Other Circulatory System O.R. Procedures: MS-DRG 264

• Cardiac Pacemaker Revision Except
  Device Replacement without CC/MCC: MS-DRG 262

• Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders without
  CC/MCC: MS-DRG 624

• Cardiac Pacemaker Revision
  Except Device Replacement with MCC: MS-DRG 260

• Upper Limb and Toe Amputation for Circulatory System Disorders with CC: MS-DRG 256

• Other Kidney and Urinary Tract Procedures with
  MCC: MS-DRG 673

• Wound Debridements for Injuries without
  CC/MCC: MS-DRG 903

• Wound Debridements for Injuries with MCC: MS-DRG 901

• Wound Debridements for Injuries with CC: MS-DRG 902

• Postoperative or Posttraumatic Infections with O.R. Procedure with MCC: MS-DRG 856

• Postoperative or Posttraumatic Infections with O.R. Procedure with CC: MS-DRG 857

• Infectious and Parasitic Diseases with O.R. Procedure with MCC: MS-DRG 853

• Postoperative or Posttraumatic Infections with O.R. Procedure without CC/MCC: MS-DRG 858

• Infectious and Parasitic Diseases with O.R. Procedure with CC: MS-DRG 85 Infectious and Parasitic Diseases with O.R. Procedure without CC/MCC: MS-DRG 855 O.R.

• Procedure with Principal Diagnoses of Mental Illness: MS-DRG 876

• Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC: MS-DRG 928

• Other Kidney and Urinary Tract Procedures with
  CC: MS-DRG 674

• Nonextensive Burns: MS-DRG 935

• Peritoneal Adhesiolysis with MCC: MS-DRG 335

***

December 29, 2009 |
Connolly's new CMS approved audit issues:

Connolly posted twenty-five new issues to their website yesterday for complex medical review process for the
RAC program. These have been approved by CMS for DRG validation.

Issue Name:
Barium Swallow Studies Units Billed Description:

Barium Swallow Studies can only be billed with a unit of (1) per patient per date of service. Provider Type Affected: Physician (Carrier) / Outpatient Hospital

Date of Service: 10/01/2007 - Open

States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia

Issue Name:
Adenosine - Dose vs. Units billed Description:

Adenosine represents 30 mg per unit and should be billed 1 unit for every 30 mg per patient per date of service.

Provider Type Affected: Outpatient Hospital

Date of Service: 10/01/2007 - Open

States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia

Issue Name:
Nebulizer, Demonstration and Evaluation Units Billed Description:

Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPS device can only be reported as one unit per day of service per patient.

Provider Type Affected: Outpatient Hospital

Date of Service: 10/01/2007 - Open

States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia

Issue Name: Q4099 Formoterol fumarate (perforomist) Description:

By description HCPCS Code Q4099 represents 20 micrograms. Patients are allowed a maximum of two vials of formoterol (20 micrograms each) per day.

Provider Type Affected: DME

Date of Service: 10/01/2007 - Open

States Affected: Suppliers who bill CIGNA Government Services

Issue Name: J7605 Arformoterol, (Brovana) Description:

By definition Arformoterol, (Brovana) represents 15 micrograms. Patients are allowed a maximum of two vials of arformoterol (15 micrograms) per day.

Provider Type Affected: DME

Date of Service: 10/01/2007 - Open

States Affected: Suppliers who bill CIGNA Government Services

Issue Name: Budesonide - Dose vs.Billed Units Description:

Budesonide should be billed one unit of service for each vial dispensed regardless of vial dose for a maximum of 62 units per month.

Provider Type Affected: DME

Date of Service: 10/01/2007 - Open

States Affected: Suppliers who bill CIGNA Government Services

Issue Name: Medically Unlikely Edit List Description:

A Medically Unlikely Edit (MUE) applies to all HCPCS/CPT codes that are above the maximum units of service that a provider would report for the same beneficiary, on same date of service, and same provider. An error was made in billing these services because more units were billed for a beneficiary than what is medically likely.

Provider Type Affected: Outpatient Hospital

Date of Service: 10/01/2007 - Open

States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia

For additional information on all of the issues above,
please click here

***

December 4, 2009 |
Connolly 25 New Issues

Connolly posted twenty-five new issues to their website yesterday for complex medical review process for the
RAC program. These have been approved by CMS for DRG validation.

The issues posted by Connolly yesterday:

• Upper Limb and Toe Amputation for Circulatory System Disorders with MCC: MS-DRG 255

• Cirrhosis and Alcoholic Hepatitis with
  MCC: MS- DRG 432

• Septicemia without Mechanical Ventilation 96+ Hours without MCC: MS-DRG 872

• Nonextensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC - MS-DRG 989

• Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 987

• Other Respiratory System O.R. Procedures without CC/MCC: MS-DRG 168

• Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983

• Extensive O.R. Procedure Unrelated to Principal Diagnosis without CC/MCC: MS-DRG 983

• Other Respiratory System O.R. Procedures with
  CC: MS-DRG 167

• Other Digestive System Diagnoses with
  CC: MS-DRG 394

• Inflammatory Bowel Disease with
  CC: MS-DRG 386

• Major Gastrointestinal Disorders and Peritoneal Infections without CC/MCC: MS-DRG 372

• Other Respiratory System O.R. Procedures with
  MCC: MS-DRG 166

• Major Small and Large Bowel Procedures without CC/MCC: MS-DRG 331

• Major Small and Large Bowel Procedures with
  CC: MS-DRG 330

• Major Small and Large Bowel Procedures with
  MCC: MS- DRG 329

• Major Chest Procedures without
  CC/MCC: MS-DRG 165

• Major Chest Procedures with MCC: MS-DRG 163

• Major Chest Procedures with CC: MS-DRG 164

• Respiratory System Diagnosis with Ventilator Support 96+ Hours: MS-DRG 207

• Septicemia without Mechanical Ventilation 96+ Hours with MCC: MS-DRG 871

• Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC: MS-DRG 981

• Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC: MS-DRG 982

• Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with CC - MS-DRG 988

• Coagulation Disorders: MS-DRG 813

Please see Connolly’s web site for more
in depth explanation of codes.

http://www.connollyhealthcare.com
/RAC/pages/approved_issues.aspx

***

December 3, 2009 |
CMS Announces Major Change in Additional Documentation Request (ADR) Limits for RACs

Written by Cheryl E. Servais, MPH, RHIA
(DECEMBER 2, 2009)

CMS has just modified the limits it set in October 2008 for the number of records that can be requested every 45 days. The announcement, posted today on the agency's Web site, suggests that in some situations the new system could result in more provider records being submitted to the RAC.

Rather than split out Inpatient claims and outpatient claims, the limit will be set on the total number of claims submitted in the prior calendar year by a "campus." A campus is defined as all the facilities/practices organized under one Tax ID Number (TIN) and with the same first 3 digits of a zip code.

Examples:

Provider A with TIN 123456789 has two locations: one in ZIP 12345 and one in ZIP 12346. This is one campus.

Provider B with TIN 123456780 has two locations: one in ZIP 12345 and one in ZIP 21345. These are two campuses.

The limit per campus will be 1 percent of all claims of all types submitted by the "campus" for the previous calendar year divided into eight periods. The claims total is irrespective of paid/denied status and/or individual lines, although interim/final and RAPs/Final claims will be considered as one claim. A RAC may only request records once every 45 days.

In comparing how CMS's hypothetical providers would do under the new system versus the old system, the follow examples are offered:

Provider C billed 156,253 claims in 2008.

New system:

The documentation limit would be (156253*.01)/8 = 195.31 or 195 requests/45 days

Old system:

Assuming these are outpatient claims (156253)/12)*.01 = 130.21 or 130 requests/45 days

Conclusion

New system could result in more records being submitted to the RAC.

Provider D billed 50,000 inpatient claims, 75,000 outpatient claims, 20,000 SNF covered stays, 20,000 home health episodes of care, 250,000 physician claims, 10,000 inpatient rehab claims and 1,000 hospice claims.

New system:

426,000 total claims. (426,000*.01)/8 = 532.5. (However, there is a cap in place of 200 - 300 records depending on the date of the request (see below for explanation).

Old system:

Total Inpatient claims = (50,000 IP + 20,000SNF + 10,000 IRF + 1000 Hospice) or 81,000.

(81,000/12) = 6750*.10 = 675 inpatient claims with a cap of 200.

Total Part B claims = (75,000 OP + 20,000 Home Health) or 95,000.

(95,000/12) = 7917*.01 + 79 part B claims

Physician claims = Assuming this is a large group - the total number of records is limited to 50 records.

TOTAL is (200+79+50) or 329 records/45 days.

Conclusion - new system could result in fewer records being submitted to the RAC.

BUT, several other interesting parts to this new formula:

1. The RAC may exercise discretion in the exact composition of the additional documentation request. So for provider D, the 200 - 300 records in the cap could all be from the physician group or the outpatient area or the inpatient area or any combination of the three.

2. CMS will allow the RACs to request permission to exceed the cap after the first six (6) months of the fiscal year. Permission will be granted on a provider-by-provider basis. If you appear to be a provider with claims issues, you could be targeted for additional documentation requests. There does not appear to be any cap on these extensions and there is no indication as to how long the higher number of requests will last.

CAP Changes: Two caps will exist in FY2010:

1. Until April 1, 2010, the cap will remain at 200 additional documentation requests/45 days for all providers/suppliers.

2. From April 1 until Oct 1, a campus that bills in excess of 100,000 total claims to Medicare will have a cap of 300 additional documentation requests/45 days.

***

Past topics include:

(Archives from August 2009 - November 2009)

November 30, 2009 | Physician Supervision for Recovery Room and Condition Code 44 Services

November 24, 2009 | CMS to resume releasing PEPPER data in 2010

November 19, 2009 | MIC is Coming. Here is a MIC Fact Sheet from CMS on MIC. The MIC for Louisiana is HMS.

November 12, 2009 | From the RAC Report:

November 5, 2009 | J7 Dispute

October 15, 2009 | PEPPER

October 5, 2009 | Outpatient Vistis with Observation

September 30, 2009 | General Information Regarding ZPIC

September 29, 2009 | RAC Discussion Period

September 21, 2009 | MIC Information

September 15, 2009 | Connolly using Milliman and InterQual

September 10, 2009 | Facet Joint Injections

September 9, 2009 | RAC Clinical Guidelines

September 3, 2009 | DRG 287 & Drug Eluting Stents

September 1, 2009 | Connolly, DME approved issues

August 20, 2009 | CMS Approved Audit Issues

August 8, 2009 | Critical Access Hospitals and RAC

ALL PAST UPDATES

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