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News to Note – September 2023

  • The new Alzheimer's drug, Leqembi, works by dissolving amyloid in the brain. Amyloid deposition is linked to worsening memory. In studies, the amount of amyloid in the brain reduces significantly following administration of this drug and while memory does not improve, it declines a little slower than it did prior to treatment. What are the implications of this for you in your role?
    • First, to identify amyloid in the brain, patients need a brain PET scan. The Centers for Medicare and Medicaid Services (CMS) is in the midst of revising the National Coverage Determination (NCD) for this test. The NCD for a similar PET scan has very specific documentation requirements, so if CMS uses that as a model, it will require a very careful process to ensure your hospital is paid for performing the PET scan.
    • Next, this medication is not perfectly safe. In some patients, the treatment can cause intracranial hemorrhage and has resulted in patient deaths. The risk of this bleeding is higher in patients with a specific genetic mutation, so every patient should be tested before starting treatment with the result in the hospital record.
    • Then, to receive the medication, the physician must enroll the patient in a registry and report data on the patient, regularly. As we know, providers are very busy and having to take time to go online and do this is not going to be a top priority. But, if not done, you don’t get paid for the medication. Interestingly, it appears the Alzheimer’s Association is developing their own registry and they are going to pay doctors to report data, including $2,500 to sign up for the registry and $300 for each patient enrolled.
    • All of this raises the issue of which physicians will be willing to order this medication and manage the patient. There are not enough neurologists or geriatricians already, so will primary care physicians be willing to take on the work? These patients also are required, as outlined by the Food and Drug Administration (FDA), to have an MRI of the brain performed after the fifth, eleventh, and fourteenth infusion, which will also require tracking.
    • Finally, the use of any anticoagulant – a common medication in the elderly – is contraindicated after Leqembi is given, including the use of t-PA. If a patient on Leqembi presents to the Emergency Department with a stroke, they should not receive t-PA. The one patient in the trials who did get t-PA, died of multiple brain hemorrhages.
    • We often talk about medical necessity issues and the auditors love to deny for such issues because if the documentation is not present, they get to recoup all the money. But, it is rare to have a disease where there are costly medical necessity issues every step of the way. Keep your eyes open and when your providers start ordering this medication, jump in there with this knowledge and be sure your processes are denial-proof.
  • A bill has been introduced in Congress to once again try to get Observation days to count for the three-day stay requirement for Medicare Part A skilled nursing facility (SNF) coverage. Similar bills have been proposed for over ten years and never got anywhere so there is nothing to support this one will be any different.
  • Updates on the recent Livanta memo about short inpatient stays:
    • It turns out that in March of this year, Livanta released a report on their short stay inpatient audits performed up to that time. To the amazement of many, they reported they had denied 11 short inpatient stays with the diagnosis of melena and 11 with a diagnosis of gastrointestinal hemorrhage. But, those are the exact circumstances of one of the case examples in their recent memo! In addition, they denied ten cases each with non-ST elevation myocardial infarction (NSTEMI) and ventricular tachycardia and ten with complete heart block. Those results from earlier this year are in complete opposition to what the recent memo outlined as acceptable inpatient admissions.
    • Last month, Nina Youngstrom reported in the Report on Medicare Compliance that CMS had reviewed the recent Livanta memo prior to publication. This is significant, because if CMS did not support the case examples Livanta provided, they would not have let them release it. Online discussion groups are filled with opinions that most don’t trust Livanta to abide by their own case examples, but knowing CMS reviewed it should go a long way toward reducing hesitation at least about admitting all emergent cholecystitis and appendicitis patients as Inpatient.
  • CMS has regulations about discharge planning which were modified in 2019. Most notable was the requirement to provide information on post-acute care providers’ resource use and quality of care. CMS still has not released interpretive guidelines for the new regulations, but according to a new memo to survey agencies ( ) they have received reports of patients being transferred to post-acute care providers without adequate information and CMS is not happy. They are alerting survey organizations to be on alert for some specific deficiencies:
    • Not telling the post-acute provider that the patient had behavioral issues requiring additional care like a sitter which was discontinued prior to transfer.
    • Poor medication reconciliation, especially omitting the patient’s use of psychotropics and opioids during the hospital stay.
    • Skin issues which required treatment in the hospital but were not mentioned on the transfer paperwork.
    • Lack of notification to the post-acute provider that the patient had durable medical equipment such as BiPAP or a wound vac.
    • Lack of communication about the patient’s home environment which would be relevant when planning for discharge, such as failing to note that the patient was homeless or had no caregiver.
  • CMS also noted in the memo that hospitals have been omitting information about the patient’s goals of care and treatment preferences. CMS is very big on ensuring that medical decisions are made in collaboration with the patient, so we need to ensure we are asking patients these questions, documenting their preferences, and sharing that information. They specifically called out patient’s preferences for end-of-life care, suggesting that patients who did not want resuscitation were resuscitated because that information was not conveyed to the facility.
  • Every year, CMS looks at procedures and Diagnosis Related Groups (DRGs) and costs to ensure the assignments are appropriate. As new medications, devices, and surgical techniques are developed, the DRG assignments are adjusted. Starting in October, your overall Case Mix Index (CMI) is going to be totally different than in September. For 2024, they are proposing to raise the Observation comprehensive APC payment by $166.70. That’s a decent increase even though it still comes nowhere close to covering the cost of the average observation stay. For total joint replacement as outpatient, CMS is raising the base rate by $221.32. Why did Observation get a higher rate increase than total joint? CMS sets rates based on reported costs. They take all the claims and use those costs to determine the next year’s rate. As such, we have to be sure our revenue teams are reporting costs properly.
  • There is a company out there that provides an AI-driven analysis of CT coronary angiograms. This company charges hospitals about $1,500 for each interpretation but the current payment rate is $950. To set the rate for this test in 2024, CMS looked back at 2022 claims and found 90 claims with the HCPCS code for the test with an average charge of $3.50. Yes, hospitals paid $1,500 but reported a charge of $3.50. As a result, CMS was going to lower the payment rate to $5 but wisely decided they did not have adequate data. The payment rate will remain in 2024 at $950. Few of you are likely involved in chargemaster maintenance but this is a great example of the real-life consequences of improper pricing to perhaps share with those who are involved.

**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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