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News to Note – March 2021

  • Blue Cross of North Dakota released a notice that claims for any Medicare Advantage (MA) patients seen in North Dakota but who have out of state MA plans must have their claims submitted to the MA plan in North Dakota.
  • In January, Optum bought Change Healthcare, the company that produces Interqual guidelines. On February 1st UnitedHealthcare, a division of Optum, announced that they will switching from MCG Care Guidelines to InterQual on May 1st.
  • The Centers for Medicare and Medicaid Services (CMS) has released a new version of their Medicare Coverage Database website. This website helps with finding an NCD or LCD or coverage analysis. It can be found here.
  • A reminder: the JW modifier allows for payment to cover for the excess medication not able to be used after a patient receives the appropriate dose of an injectable medication from an injection vial. In order to prevent denials, make sure there is a process to properly document the wasted portion and use the appropriately sized vial.
  • Last year there was a ruling that mandated that CMS establish a process to allow inpatients whose status is changed to outpatient (via Condition Code 44) to immediately appeal their change in status. CMS has filed an appeal and asked the court to allow them to delay implementing the appeal process for patients until their appeal is heard. More to come once the ruling is final.
  • It remains important to document when patients leave Against Medical Advice (AMA) for accuracy of documentation and regulatory implications. However, it is worth documenting why the patient is leaving to avoid stigmatizing the patient in his/her current or future encounters.
  • Reminder: as of January 1st hospitals were required to post their prices on the internet for all their services for price transparency. CMS has indicated they are already auditing, but since this audit does not require requests for patient records, the normal means for knowing who is currently being looked at does not exist.
  • There have been updates regarding orthopedic bundle payments as surgeries have come off the inpatient only list.
    • When the bundles were first introduced for joint arthroplasty, the CMS specifications limited participation to only inpatient surgeries. But at the time, both hip and knee replacement were on the inpatient only list so it was not an issue. In 2018, CMS took total knee off the list. But they lagged in adjusting the bundle for a year or two, so in that timeframe if a total knee was done as outpatient, the episode of care did not fall into the bundle and there were no shared savings. CMS has since adjusted this and any joint replacement surgery initiates the bundle.
    • But, placing the patients in the hospital as observation is not correct. Observation for a scheduled surgery patient should never be ordered preoperatively. There are two potential solutions- ideally teach the surgeons to schedule the surgery as outpatient and only order observation after surgery if it is indicated or teach the coders that if they see a pre-op observation order on the chart, they should ignore it and not bill it as observation.

**The news above in addition to many other points of interest for Physician Advisors and other leaders in health care can be heard weekly during Dr. Ronald Hirsch’s Monday Rounds segment on’s Monitor Monday webcast/podcast. Learn More

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