help_outline Skip to main content

News / Articles

News to Note – December, 2020

  • A recent COVID-19-related rule from the Centers for Medicare and Medicaid Services (CMS) involves coverage of the SARS-CoV-2 vaccine. In a strange twist, the cost of vaccines given to Medicare Advantage (MA) patients will be billed directly to Medicare and will be covered by Medicare and not the MA plan.
  • CMS also extended the Comprehensive Care for Joint Replacement (CJR) bundle payment to the new Diagnosis Related Groups (DRGs) for hip replacement after hip fracture.
    • This change is retroactive to October 1st, which makes it doubly offensive to orthopedists; not only was there no opportunity to comment on this, but then they enacted it retroactively after doctors thought patients were out of the program.
    • CMS also released data on CJR patients during the pandemic compared to April 2019 and, unsurprisingly, there was an 87% drop in volume.
  • It is the responsibility of the billing provider to submit records when a claim is audited. This is fairly simple for office-based doctors as they just send the chart. It’s trickier for hospital-based doctors whose billing staff must be able to access the hospital EMR. But, think about the radiologist who is submitting a claim for reading an imaging study that was ordered for a non-hospital patient. The medical records supporting that study are at the ordering physician’s office. Last month, CMS announced that they are starting a pilot project that some Medicare Administrative Contractors (MACs) will request medical records directly from the ordering physician’s office when they are auditing the radiologist claim. This should simplify things for everyone, but only if the MACs explain to the ordering physician’s office why they are requesting the records.
  • Medicare’s decision to waive the three-day inpatient stay requirement for transfer to a skilled nursing facility (SNF) has not prevented some facilities from being reluctant to accept Medicare patients without it, fearing a claim denial. Why? When CMS initially issued the waiver, many SNFs had their claims inappropriately denied for payment by the MACs. Then, some SNFs got nervous because the wording of the waiver seemed to indicate that it could only be used for patients affected by COVID-19. One hospital came up with a brilliant solution. They developed the following and set it as a template: "Due to the COVID-19 pandemic, the patient and community's needs are most appropriately served by medically managing the patient's daily skilled needs in the SNF environment. The attending physician has determined this patient is medically stable to transfer to a Skilled Nursing Facility for continued care in order to allow for bed availability and staffing to care for more seriously ill patients and avoid further diversion of seriously ill patients." Any time a patient is sent to a SNF, the provider inserts this. As long as the SNF submits the claim properly and the MAC processes it properly, there should be no issues.
  • Some of you may have noted that during this latest surge in COVID-19 cases, CMS released the 2021 readmission penalty rates. Once again, about half of the hospitals in the country will be penalized. But, remember that for traditional Medicare unless a patient is readmitted the same day, you get a second DRG if they are readmitted back into to your hospital. Your Program for Evaluating Payment Patterns Electronic Report (PEPPER) can tell you what percent of your readmissions came back to you and what percent went to another hospital. But, you also have to remember that your readmission reduction program costs money with staff contacting patients, developing reduction programs, and so on. Should we work to reduce readmissions? Absolutely. But, the chief financial officer who tells you to increase admissions in order to increase revenue should also understand that reducing readmissions is going to require resources and has a good chance of actually reducing revenue. This argument is admittedly overly simplistic and there are other factors to consider, but it makes for an interesting discussion.
  • Audit activity from the Office of the Inspector General (OIG) was suspended during the Public Health Emergency but even prior to that, we really had no audits of short stay inpatient admissions. There continues to be some sort of contract dispute that is preventing CMS from allowing the Quality Improvement Organizations (QIOs) from resuming the audits. The Recovery Audit Contractors (RACs) have not been given permission to audit these cases, the MACs long ago lost the right to audit them, and the Comprehensive Error Rate Testing (CERT) hasn’t seemed interested. But, behind the scenes the OIG has been collecting data by asking their contracted auditors to review some of these cases when they do their routine hospital audits. They have not been recouping money, but they do get a chance to see error rates. However, things are about to change. The OIG just added short stay inpatient admission audits to their work plan.
  • An OIG audit released last month found Edward Sparrow Hospital in Michigan had errors in short inpatient admissions but also, four outpatient service billing errors where a visit was billed along with dialysis and there was no documentation to support the visit being billed separately. But, what’s really notable is that there were 438 claims in the category, 20 were selected for audit, and in those 20 there were only four errors. Those four errors were then extrapolated to the whole population of claims. Perhaps this is reasonable, but all four of those denied claims were for the same patient getting the same service – a dialysis patient who frequently needed emergent dialysis. The hospital argued and their argument was dismissed.  
  • As we have discussed before, there is a 20% addition to the DRG for COVID-19 patients if there is a positive test result in the chart. But, patients are getting tested in locations other than the hospital, so this has been a challenge. ACPA Advisory Board member and ACPA Update Editor, Dr. Ronald Hirsch, had a chance to ask CMS about this on their last office hours call. They stated if the patient had a test performed elsewhere, the hospital can get documentation that the test was positive, and the clinician includes this in the hospital medical record, the 20% will be added without repeating the test. The CMS representative did not define “clinician” but we presume anything from the testing facility itself would suffice, including an e-mail or text message if you can get it in the record, which is good news.
  • During the short Thanksgiving work week, CMS found time to make two pretty significant announcements:
    • They are now accepting waiver requests from hospitals to offer true hospital at home services.
      • Instead of admitting patients requiring hospital care to the hospital, they will be able to send the patient home and provide them hospital-level care in their home. How does CMS define hospital-level care at home? There are not many details, but there will need to be three visits per day by medical personnel, with at least one of those visits being by an RN. The other two can be by a nurse or a paramedic, and a daily doctor visit.
      • At face value this makes no sense at all. Patients are put in the hospital because they need to have immediate access to medical personnel 24 hours a day. We don’t send patients with a TIA home with a hep lock and a syringe of tPA and tell them to FaceTime the doctor for instructions on how to give themselves an injection if they get another neurologic episode. A COPD patient needing frequent nebulizers at risk of respiratory failure cannot be sent home with instructions on how to use a leaf blower to provide home biPAP if their work of breathing gets worse. And, how does a doctor obtain a STAT x-ray or blood test? The patients who qualify for this program will have to be carefully selected and probably would be unlikely to pass Milleman Care Guidelines (MCG) or InterQual criteria for inpatient admission.
      • It’s also worrisome that insurance companies which are already unwilling to approve inpatient admission for anyone but patients at death’s door will see this program as another excuse to deny more admissions and observation stays, telling hospitals the patients could have been discharged. And, while we assume the reimbursement will be a DRG payment, it is pretty unlikely that any CC or MCC on the claim will be clinically valid since the patient is at home and not getting added nursing services or demonstrating increasing risk.
      • There are many patients who are likely quite capable of being discharged to home from the Emergency Department and receive close follow-up at home but who are instead hospitalized because of liability fears or convenience factors. During a deadly pandemic with bed shortages, it would be great to allow some beds to remain open.
    • Two new condition codes were announced – 90 and 91 – for use when patients get expanded access or an emergency use authorization service, such as new medications for SARS-CoV-2. Check out MLN Matters MM12049 for details.

**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

Back to News to Note