News to Note – April 2024

  • An article from the American College of Cardiology about their guidelines for management of patients hospitalized with heart failure include, “It is critical that patients be observed for at least 24 hours after they transition to oral agents to ensure effectiveness of oral diuretic therapy, which, in turn, is associated with a lower rate of readmission.”  How does this fit into the Medicare Two-Midnight Rule?  
    • The Centers for Medicare and Medicaid Services (CMS) allows Medicare Advantage (MA) plans to use criteria but also states, “the MA plan guidelines must be ‘based on current evidence in widely used treatment guidelines or clinical literature.’”  I think most would agree that guidelines by the American College of Cardiology meet that standard.  
    • Does this mean we should stop our doctors from discharging heart failure patients without 24 hours of all-oral therapy?  No, but this is something to investigate if your hospital’s readmission rate for heart failure patients is higher than expected.  
    • Additionally, if an MA plan denies Inpatient status for a patient who has passed two midnights because the patient was on oral therapy, inform them of the guidelines.
  • The Medicare Administrative Contractor (MAC), Palmetto, recently denied payment for a patient’s pacemaker placement due to the MAC’s determination that the National Coverage Determination (NCD) was not met.  
    • Indeed, CMS does have NCDs for pacemakers – 20.8.3 addresses single chamber and dual chamber permanent cardiac pacemakers and 20.8.4 covers leadless pacemakers as part of a clinical trial.  For single and dual chamber permanent cardiac pacemakers, the NCD states the following indications are covered:
      • “Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
      • Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.”

The NCD also lists 12 conditions for which a pacemaker is NOT covered.

    • This particular hospital involved with the denial utilizes checklists for procedures with specific NCD requirements and if a physician schedules a procedure, they are required to fill out the checklist and document which indication is met.  In this case, the box was checked “yes” for, “documented non-reversible symptomatic bradycardia due to sinus node dysfunction” and, “no” for, “documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.”  
    • As part of a routine Palmetto audit, they requested medical records to confirm that medical necessity for the procedure was present – this is when the claim was denied due to lack of medical necessity.  Palmetto denied the pacemaker because their erroneous interpretation of the NCD included the patient having BOTH sinus node dysfunction and second or third degree atrioventricular block, not one or the other.
    • If you look at the NCD, you can see that CMS put “and” at the end of the first indication.  Palmetto took that literally and inappropriately to mean that both conditions needed to be present for coverage.  Unfortunately, Palmetto has continued to deny this case and the hospital is continuing to appeal.  Something to be aware of if you are finding yourself in a similar situation – don’t give up!
  • Some have asked if CMS requires hospitals to provide the Important Message from Medicare (IM) to patients with Medicare Part B coverage but not Medicare Part A.  
    • If you look at the CMS Beneficiary Notice webpage, it states, “Hospitals are required to deliver the Important Message from Medicare to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients” which really seems to say, “yes.”
    • But, if you read the Medicare Claims Processing Manual, Chapter 30, it states, “The expedited determination process is available to beneficiaries in Original Medicare who are being discharged from a Medicare covered inpatient hospital stay.  This includes, but is not limited to, beneficiaries for whom Medicare is either the primary or secondary payer.  It does not include patients who have exhausted their benefits.”  
      • A patient without Medicare Part A who is admitted as Inpatient is not in a “Medicare-covered Inpatient stay” because they do not have the Medicare coverage (Part A) which COVERS Inpatient hospital stays.  
      • So, it stands to reason patients with Medicare Part B, only, should not receive the IM and do not have the right to an expedited appeal of their discharge.  
      • Additionally, the Medicare Claims Processing Manual is an official CMS document whereas a CMS beneficiary web page is considerably less so.
    • However, a recent case involving Atlantic Healthcare involved a situation where a patient without Medicare Part A appealed their discharge to the Quality Improvement Organization (QIO) and lost.  But, the patient persisted, continuing to appeal and even taking it all the way to the Administrative Law Judge (ALJ). There, the ALJ noted the patient had no Medicare Part A coverage and therefore, had no formal appeal rights.  It is unclear why the QIO didn’t identify this in the first place.
    • QIOs also handle quality of care complaints from patient, so a patient without Medicare Part A COULD call the QIO to file a complaint about their care and the QIO would investigate it.  But, that investigation would not involve patient appeal rights or financial protections that occur with a formal discharge appeal.  Furthermore, the patient may be none-too-happy to get an even larger bill for remaining hospitalized while waiting for the appeal decision.
  • The Office of the Inspector General (OIG) recently updated their work plan to add audits of sepsis.  If you read their introductory comments, it seems to suggest that they feel sepsis requires the presence of organ dysfunction as specified in SEP-3 and that using SIRS criteria to define sepsis is solely done for financial reasons.
    • As you have heard before from Dr. Erica Remer and many others on our ACPA Committees, on a basic level, septic patients are profoundly ill whereas many patients with fever and tachycardia may indeed have sepsis, but many are exhibiting a normal response to infection.  These patients absolutely need prompt evaluation and treatment.  But, looking for a condition and starting treatment “just in case,” then not ultimately identifying the condition, does not equate diagnosis of that condition. 
    • Many patients present with chest pain, do not have markers for myocardial infarction, but still end up getting coronary stents.  We don’t diagnose and get paid for treating a myocardial infarction in those cases because we did the right thing and prevented it.  
    • Similarly, we don’t code for heart transplants when we properly treat patients medically for their severe heart failure, preventing the need for a transplant.  Sepsis is no different.  Here’s to hoping the OIG will get CMS to clean up the mess they created.
  • The QIO, Kepro, has announced they are changing their name to Acentra.  This means every hospital they serve will need to redo all of their forms with the new name, so make sure your staff is aware.  
  • Kepro – er, Acentra – also released a newsletter with answers to questions asked on a webinar they gave about the Advance Beneficiary Notice (ABN). Unfortunately, two of their answers in the newsletter in no way answered the questions that were asked.
    • Question #1 was:  If the representative states that he/she does not want a copy of the IM or the Detailed Notice of Discharge (DND), can we document that and not provide a copy?  
      • Many patients never read the stack of papers they get while in the hospital and should rightly have the option to refuse their copy of the IM or DND.   
      • Acentra answered as follows: “The expedited determination process is available to beneficiaries in Original Medicare who are being discharged from a Medicare-covered inpatient hospital stay.  All beneficiaries receiving covered inpatient hospital care must receive an IM.”  Yes, it is true that every patient must receive the IM and sign it or refuse to sign, but the question asked was if the patient can decline receipt of the copy? We still don’t know because Acentra did not answer the question.
    • Question #2 was:  Is there any guidance on whether the discharge order needs to be in place at a hospital before the appeal is made? 
      • Even if a patient is stable to be discharged and there is a safe discharge plan, many doctors are unwilling to write the actual discharge order unless they know the patient is going to leave the building.
      • Acentra’s response was, “Hospitals must deliver the follow-up copy of the IM within two days of discharge. It may be given as late as four hours prior to discharge. However, if delivery of the first IM is within two calendar days of the date of discharge, no follow-up notice is required. For example, if a beneficiary is admitted on Monday, the IM is delivered on Wednesday and the beneficiary is discharged on Friday, no follow-up notice is required.”  Holy moly, not even a single word about the discharge order even though Chapter 30 of the Medicare Claims Processing Manual, Section 200.3.4.1, clearly states the order is not necessary to deliver the follow up copy of the IM.  And, Section 200.4.1.1 states, “A beneficiary who receives an IM and disagrees with the discharge may request an expedited determination.” The delivery of the IMM is enough for the patient to call, no discharge order is required.
    • There was SOME information in the newsletter which was useful.  They posted links to their annual statistics on their activities, including that when patients appeal their discharge, Kepro/Acentra agreed with the hospital’s assessment of the patient’s readiness to discharge over 90% of the time in all of their regions for both Medicare and MA patients.