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News to Note – April 2021

  • The Office of the Inspector General (OIG) released two reports recently worth noting.
    • The review of facet joint injection billing was fairly unremarkable. However, it is worth noting that in that report the OIG created a new term “beneficiary day.” A beneficiary day is the compilation of all claim lines submitted for one date of service. In this case it would include the claim line for the procedure and the medication and any imaging performed.
    • The second OIG report looked at hospital billing of inpatient admissions and what they see as a worrisome shift to more admissions with major complication comorbidities (MCCs) on the claim suggesting upcoding. Interestingly, the Center for Medicare and Medicaid Services (CMS) did not agree with the OIG. They feel that they are properly educating providers and sufficiently auditing for over coding with the RACs auditing for clinical validation and that the higher number of MCCs is likely due to higher acuity patients being admitted to the hospital with more advanced therapies provided. Also of note, the OIG report claims they have noticed more admissions in the higher weighted DRGs with a shorter lengths of stay. Part of the issue may be that it seems throughout the report they imply that CC and MCC are abbreviations for “complications” and “major complications” and totally ignore the comorbidity part. This may explain why the OIG is worried about the results and CMS is not if the OIG thinks hospitals are causing more complications than in the past and CMS recognizes that this is due to better capture of comorbid conditions and as CMS has said, there is nothing wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.
  • Medical necessity for that second midnight stay that moves patients from outpatient with observation to inpatient continues to be tricky. In many cases it is obvious (since we cannot send a patient getting iv pain medications home with a handful of syringes of Dilaudid nor the patient needing oxygen to avoid becoming anaerobic). Other examples are less clear. A recent case involved a patient hospitalized after a fall with ongoing vertigo. There was no acute injury, but the physical therapist documented that the patient needs to remain in the hospital and was not safe to go to a SNF. The physician ordered inpatient admission based on that assessment by that therapist. The problem of course was that there was no justification given. Therapists provide an important perspective but just like doctors we need to know the “because” behind their recommendations.
  • Make sure you understand context if you are being labeled a data “outlier.” There was a recent case of a doctor who was audited by a government contractor because his data stood out as an outlier. This doctor is a gastroenterologist, but he specializes in diseases of the lower colon, which used to be called a proctologist (and was classified by Medicare as a proctologist). But many years ago, Medicare changed the taxonomy and eliminated proctology, moving all those doctors into colon and rectal surgery. He had no idea he was classified as a surgeon since he was not a surgeon. As a result, his data stood out. He did many more anoscopies and treated many more hemorrhoids than a colorectal surgeon. And as you’d expect the audit found his care was appropriate, but it was an audit that did not need to happen. The moral here is if they call you an outlier, find out who they are comparing you to.
  • Reminder, Medicare requires a physician on the utilization review (UR) committee to review of condition code 44s and self-denials. And to be on that committee, a physician needs to be a member of the medical staff since only members of the medical staff who have voting privileges can act on behalf of the committee. If those doctors are not on the medical staff, then they can recommend a change but cannot make the official determination. In other words, outside physicians can provide input but cannot be the official UR committee member reviewing the code 44s and self-denials.
  • Update on the new CMS pricer. There have been some error messages when trying to load. However, if you add an HTTPS:// before the, it appears to resolve this issue.
  • CMS has their prior authorization program in place since July and that includes a provision that if a hospital gets at least 90% of requests affirmed, they get an exemption from having to continue getting the procedures authorized in advance. In July, this program is expanding to include cervical spine fusion and implantation of a spinal neurostimulator. Additionally, if a hospital is exempted based on their performance from September 2020 to January 2021, they do not have to submit prior authorizations for any procedure from May this year until March of next year. A word of caution; the previous procedures were relatively low cost and these spine procedures significantly more expensive. But those who get an exemption will have 10 charts audited starting in October to ensure they are still compliant so no hospital can sit back and let the neurosurgeons run wild. As with every surgery, the medical record should always indicate the medical necessity for performing the surgery itself. Do not wait until a medical record request arrives months later when you realize the patient never had a trial of physical therapy or tried medications.
  • With regards to heart failure, two recent points of interest.
    • A recent conversation on Twitter noted Michelle Kittleson, MD, PhD (a cardiologist) posting “If a HF patient who works at Waffle House, can’t take his Entresto due to it being cost-prohibitive, and has had four recent admissions due to decompensation, it may be time to consider a different therapy.” Another doctor then posted, “and do not label the patient as non-compliant.” Make sure the medical record clearly documented that the patient was unable to take the prescribed medication due to insurance and cost so that it is clear that the hospital was not at fault for the readmissions when the insurer tries to deny payment for the readmissions.
    • The standard classifications of heart failure (based on whether systolic function as reduced or preserved) may be changing. Heart failure professional societies are adding two subgroups, mildly reduced and improving ejection fraction. More to come on coding these new terms.
  • There was a recent bar association conference on whistleblower lawsuits and an US assistant attorney general spoke about the government’s false claims act priorities and stated that they are relying more on data. He stated the Civil Division has increasingly been undertaking sophisticated analyses of Medicare data to uncover potential fraud schemes. It is unclear what the impact of that is/will be. Recently the OIG announced a takedown of a $134 million DME scheme by a pharmacist. One would think that “data analysis” should have identified such a case before $134 million of fraudulent claims were submitted and paid.
  • CMS delayed the implementation of two big rules.
    • The first was the Medicare Coverage of Innovative Technology Final Rule which would have allowed certain new technologies deemed by the Food and Drug administration as a breakthrough device to be covered by Medicare much quicker. The problem here appears that although there was support for the concept, when the rule was written there was no thought given to how these new devices would be coded and paid. Medicare decided to take a little more time to work out the logistics.
    • They also are delaying for a year a rule that requires every HHS policy to be reviewed every 10 years or automatically be cancelled. This rule was quite controversial when proposed and finalized and quickly led to several lawsuits and so they chose to wait for the courts to review it before implementing now and then having to change.
  • Elective surgery basically stopped with reports of mortality rates as high of 25% for COVID positive patients who had any type of surgery. In a recent study, the 30-day mortality rate after any surgery was significantly higher for patients who had COVID for up to 6 weeks after their date of diagnosis. But by week 7 their mortality risk was back to baseline. It is nice to have some data to support what was already happening in many practice locations.
  • There was an opinion piece published on MedPage Today entitled Fraud Is Rampant in Medicare Advantage. While the title is a little provocative the premise is that the Medicare Advantage (MA) plans scour the records for every possible diagnosis to report to CMS to get a higher monthly payment for themselves for each member and at the same time try to remove every possible diagnosis from a provider’s claim to pay them the lowest amount possible. The authors contend that the MA plans remove diagnoses from provider’s claim as unsupported then but never notify CMS to remove the diagnosis from the calculation of the monthly payment they receive. Will we be seeing a big lawsuit soon?
  • Misinformation about the demise of the inpatient only list continues. A couple examples:
    • The Washington Post published an article that contained several of the same errors that keep coming up. One hospital administrator is quoting as saying there are safety issues. Another expert lamented the increased costs to patients even though these surgeries are paid as a comprehensive APC. A finance person talked about an extra facility fee that does not actually exist.
    • There was also a recent podcast on the same topic and words cannot begin to describe how inaccurate it was. This podcast also noted safety issues that have no basis in data. They also noted that Medicare states that patients over the age of 85 having hip replacement can be admitted as inpatient which is also not true. Medicare allows doctors to consider the patient’s risk in determining the admission status and extreme age certainly is a risk, but Medicare never set an age cut off. Then, the inpatient only list was described as differentiating surgeries that can and cannot be performed at an ambulatory surgery center. Of course, that is incorrect since there is a separate list for that called addendum AA. Surgeries that are removed from the inpatient only list may be added to the ASC list but that is a different process. In fact, there are actually four categories for procedures –surgeries that are inpatient only, surgeries that must be done in a hospital, surgeries that can be done at a surgery center, and finally surgeries that can be done in a physician office. It was also stated that a surgery at a would cost a patient a lot more out of pocket than a surgery at a surgery center. While it is true that the payment to the facility goes down as a surgery moves from inpatient to outpatient to ambulatory surgery center, and therefore you would think the patient obligation would go down, there is an out-of-pocket limit for services performed in a hospital and there is no limit at the surgery center so a joint replacement or spine surgery will result in a higher out of pocket obligation at the surgery center than the hospital.
    • These changes are very confusing. The two-midnight rule is 2,736 days old and it still confuses people. Just be careful where you get your information. Trust but verify.

**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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