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Clinical and Compliance Bulletin

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2013 Quarter 4

Coding Corner
FAQ
1. My patient developed an infection and had to have his TKR hardware removed and now has an antibiotic spacer. What ICD-9 code should I use? You should code V54.82 and V88.22. Below are all of the ICD-9 codes related to joint prosthesis explanation:

or she chooses to have the treatment and accept financial responsibility for those services you will need to have the patient sign an ABN prior to delivering the treatment. The ABN serves as proof that the beneficiary knew prior to getting the service that Medicare might not pay. If you do not issue a valid ABN to the beneficiary when Medicare requires, you cannot bill the beneficiary for the service and you may be financially liable. 4. Are infrared or anodyne covered by Medicare? The Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues (CMS Publication 100-03 Medicare National Coverage Determinations (NCD) Manual, section 270.6 and Publication 100-04, Medicare Claims Processing Manual, Chapter 5, section 20.4). 5. What are some good objective tests to use to determine G code modifiers for Low Back Pain? There are many possibilities. Here are a few that may be helpful: Oswestry LBP Disability Ques., Revised Oswestry Pain, Revised Oswestry Disability, Roland and Morris Pain Ques., and Quebec Back Pain Disability Scale. 6. Can you explain to me the difference between the ICD-9 codes for symbolic dysfunction? The most often used code for symbolic dysfunction is 784.69 which includes acalculia, agnosia, agraphia, and apraxia. ICD-9 784.61 is rarely used in the SNF setting and includes alexia and dyslexia. This code is rarely covered in the SNF setting and you should refer to your LCD. ICD-9 784.60 is an unspecified code and should only be used if 784.69 or 784.61 are not appropriate. There is limited coverage for this code and you should refer to your LCD.

Code
V54.82

Description
Aftercare following explanation of joint prosthesis Includes: aftercare following explanation of joint prosthesis, staged procedure Acquired absence of hip joint Includes: acquired absence of hip joint following explanation of joint prosthesis, with or without presence of antibiotic-impregnated spacer Acquired absence of knee joint Includes: acquired absence of knee joint following explanation of joint prosthesis, with or without presence of antibiotic-impregnated spacer Acquired absence of other joint Includes: acquired absence of other joint following explanation of joint prosthesis, with or without presence of antibiotic-impregnated spacer

V88.21

V88.22

V88.29

2. I am a therapist in WI and NGS is our MAC. Does NGS cover iontophoresis for Medicare patients? NGS LCD, LCD for Outpatient Physical and Occupational Therapy Services (L26884), allows iontophoresis only for the treatment of intractable, disabling primary focal hyperhidrosis (ICD-9-CM code 705.21) that has not been responsive to recognized standard therapy. 3. I know NGS will not cover iontophoresis for shoulder tendonitis but I feel it would be very beneficial for a patient and he would like to have the treatment, what do I do? In the event that Medicare Policy does not pay for a service and if after discussing the treatment with the patient he

7. When is it appropriate to use ICD-9 diagnosis code 438.89? ICD-9 438.89, other late effects cerebrovascular disease, should only be used when a more specific late effect of cerebrovascular disease does not describe the late effect. The code requires a second code to identify the late effect. The more specific late effect of cerebrovascular disease codes are:

Decoding CPT Codes

Each quarter we focus on decoding the mystery of a specific CPT code. This quarter we will focus on CPT codes for wound debridement, 97597 and 97598. Both codes are for the removal of devitalized tissue from a wound using a selective debridement technique (high pressure water jet, sharp selective debridement with scissors, scalpel, and/or forceps). The codes include the time spent assessing the wound, dressing change time, time providing instruction for ongoing care, and whirlpool. Debridement may be indicated when necrotic tissue is present in an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. If debridement is performed, the type of debridement should be appropriate to the type of wound and the devitalized tissue, and the patients condition. CPT code 97597 is used when the total wound(s) surface area is less than or equal to 20 square centimeters. In the event that the total wound(s) surface area is greater than 20 square centimeters, add on code CPT code 97598 is used for each additional 20 square centimeters or part thereof of the total wound(s) surface area. Billing points to remember: Only one unit of 97597 may be billed per session. CPT code 97598 may never be billed without first billing 97597 to account for the first 20 square centimeters of the wound. CPT code 97598 can be billed in multiple units depending on the total wound surface area. It accounts for each additional 20 square centimeters or part thereof of the total wound surface area. Example: total surface area is 56 sq. cm. Code 97597 (first 20 sq.cm.), 97598 (second 20 sq. cm.) and 97598 (accounts for remaining 16 sq. cm.) Application and removal of dressings to the wound is included in the work and practice expenses of 97597 and 97598 and should not be billed separately under a therapy plan of care. Charges for dressings, gauze, tape, sterile water for irrigation, tweezers, scissors, q-tips, and medications used in the wound care treatment will be denied even if the wound care service is found to be medically reasonable and necessary. Payment for dressings applied to the wound is included in HCPCS codes 97597 and 97598 and they are not to be billed separately.

Code
438.0 438.11 438.12 438.13 438.14 438.21

Description
Cognitive deficits Aphasia Dysphasia Dysarthria Fluency disorder Hemiplegia affecting dominant side. Excludes: hemiplegia not caused by 430-437. See ICD-9 342.01-342.82 Hemiplegia affecting non-dominant side. Excludes: hemiplegia not caused by 430-437. See ICD-9 342.01-342.82 Monoplegia upper limb dominant side. Excludes: monoplegia not caused by 430-437. See ICD-9 344.41 Monoplegia upper limb non-dominant side. Excludes: monoplegia not caused by 430437. See ICD-9 344.42 Monoplegia lower limb dominant side. Excludes: monoplegia not caused by 430-437. See ICD-9 344.31 Monoplegia lower limb non-dominant side. Excludes: monoplegia not caused by 430437. See ICD-9 344.32 Alterations of sensation Disturbances of vision Apraxia Dysphagia **Use additional code to identify phase (787.21-787.29) Facial weakness/droop Ataxia Vertigo

438.22

438.31

438.32

438.41

438.42

438.6 438.7 438.81 438.82 438.83 438.84 438.85

97022 (whirlpool) and codes 97597/97598 (selective wound debridement) should not be billed together as the whirlpool treatment is a component of the selective wound debridement code (unless there is a separately identifiable condition being treated and documentation supports this treatment). Patient and caregiver instructions are included in codes 97597 and 97598. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.

Documentation tips: Documentation for each treatment must include a detailed description of the procedure and the method (e.g., scalpel, scissors) used when billing 97597 and 97598. Because the correct debridement code is dependent on type of debridement and wound size, documentation should include frequent wound measurements. The documentation should also include a description of the appearance of the wound (especially size, but also depth, stage, bed characteristics), as well as the type of tissue or material removed. Medicare coverage for wound care on a continuing basis for a particular wound requires documentation in the patients record that the wound is improving in response to the wound care being provided. It is not medically reasonable or necessary to continue a given type of wound care if evidence of wound improvement cannot be shown. Evidence of improvement includes measurable changes (decreases) in at least some of the following: o drainage; o inflammation; o swelling; o pain; o wound dimensions (diameter, depth); o necrotic tissue/slough.

non-payable G-codes and modifiers, which describe a beneficiarys functional limitation and severity level, at specified intervals during the episode of care. Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy without notice. MLN Matters SE1307 clarifies that when a beneficiary discontinues therapy without notice, and returns less than 60 days from the last recorded DOS to receive treatment for: the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the Required Reporting of Functional Codes subsection; or a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.

CMS Released SNF PPS FY 2014 Final Rule On July 31, 2013, the Centers for Medicare and Medicaid Services (CMS) released the Fiscal Year (FY) 2014 Prospective Payment System (PPS) Final Rule for Skilled Nursing Facilities (SNFs). The Final Rule finalizes a market basket update of 1.3% (the proposed rule had proposed an update of 1.4%) which is estimated to increase payments to SNFs by $470 million for FY 2014. In addition to the payment update, CMS finalized the proposal to add an item to the Minimum Data Set (MDS) to record the number of distinct calendar days of therapy (PT, OT, and SLP) to SNF residents over the seven-day look-back period. CMS clarifies that the qualifying condition for the Medium Rehab (RM) Category requires five distinct calendar days of therapy and that the qualifying condition for the Low Rehab (RL) Category requires three distinct calendar days. GAO Report Issued July 2013: Medicare Outpatient Therapy: Implementation of the 2012 Manual Medical Review (MMR) Process The Middle Class Tax Relief and Job Creation Act of 2012 required CMS to conduct MMRs of requests for exceptions for outpatient services provided on or after October 1, 2012, over an annual threshold of $3,700. The act also mandated that the GAO report on the implementation of the MMR process. The GAO issued its report entitled Medicare Outpatient Therapy: Implementation of the 2012 Manual Medical Review Process in July 2013. The GAO found:

Keeping Straight on the Regulation Road


MLN Matters SE1307 Provides G Code Reporting Clarification for Unanticipated Discharges

The Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 required the Centers for Medicare & Medicaid Services (CMS) to implement a claims-based data collection strategy for outpatient therapy services. Functional Reporting collects data on patient function during the therapy episode of care to understand beneficiary functional limitations and outcomes. Effective January 1, 2013, claims for outpatient therapy services were required to include

CMS implemented two types of MMRs, but the process lacked timely guidance and fully automated systems. The GAO found that the Centers for Medicare & Medicaid Services (CMS) did implement two types of manual medical reviews (MMR). However, they also found that CMS did not issue complete guidance on how to process preapproval requests before the implementation of the MMR process in October 2012 and the Medicare Administrative Contractors (MAC) that conducted the MMRs were unable to fully automate systems for tracking preapproval requests in the time allotted. The GAO found that the MACs faced particular challenges with implementing reviews of preapproval requests because CMS continued to issue new guidance on how to manage preapproval requests after the MMR process started. In addition, all three MACs interviewed told the GAO that MMRs of preapproval requests were especially challenging because they did not have time to fully automate systems for tracking and processing the requests before the start of the MMR process, although they adapted their systems to manage the requests in different ways. The final outcomes of these reviews remain uncertain: o Preapproval requests and claims for over o MACs reviewed an estimated 167,000 pre-

115,000 beneficiaries were subject to MMRs

approval requests and claims and affirmed 60% o Because providers can appeal denials of pay ment, the final outcome of the MMRs remains uncertain
GAO Report Issued July 2013: Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency In fiscal year 2012, CMS estimated that $32.4 billion in Medicare FFS payments were improper. CMS uses several types of contractors to conduct postpayment claims reviews to identify improper payments. Recently, questions have been raised about the efficiency and effectiveness of these contractors efforts and the administrative burden on providers leading to the GAO Report which (1) describes these contractors and (2) assesses the extent to which requirements for postpayment claims reviews differ across the contractors and whether differences, if any, could impede effective and efficient claims reviews. Below are some of the GAO findings: Four types of CMS contractors conducting postpayment reviews have different primary functions and characteristics. Postpayment claims reviews are the main focus of the RAC and CERT contractors functions, but that is not the case for MACs and ZPICs.

The contractors vary in the number of states and size of their geographic jurisdictions and the volume of claims they review CMS sets more limits on RACs through review requirements than on other contractors due to experience in the demonstration. Example: RACs cannot make claim denials for lapses in documentation standards unrelated to reasonableness or medical necessity, such as illegible physician signatures or dates and making claims reviewers credentials available upon provider request Other differences in CMS requirements across Contractors can impede effectiveness and efficiency by Complicating providers responses to and understanding of claims reviews o ADR differences in contractors requirements for sending ADRs and timelines for providers responses o Different types of contractors are subject to different requirements regarding the formats in which they will accept providers documentation, whether paper, fax, or electronic submission o CMS requirements for staffing, including claims reviewers qualifications, vary depending on the type of contractor o While CMS requires QA processes to ensure the quality of claims reviews, the requirements differ by contractor type

Based on its findings, the GAO recommended that CMS (1) examine all contractor postpayment review requirements to determine those that could be made more consistent, (2) communicate its findings and time frame for taking action, and (3) reduce differences where it can be done without impeding efforts to reduce improper payments. In its comments, the Department of Health and Human Services concurred with these recommendations, agreed to reduce differences in postpayment review requirements where appropriate, and noted that CMS had begun examining these requirements.
PEPPER Reports Mailed to SNF Providers August 30, 2013

PEPPER Reports shipped on August 30, 2013 to Free-standing SNFs and SNFs administered through long-term acute care hospitals and inpatient rehabilitation facilities. The SNF PEPPER is a report that summarizes a SNFs Medicare claims data in areas that may be at risk for abuse or improper payment. PEPPER compares a SNFs claims data statistics with aggregate

statistics for other SNFs in the state, MAC/FI jurisdiction and the nation. SNFs with high billing patterns (at or above the national 80th percentile) are identified as outliers and are encouraged to ensure that they are complying with Medicare payment policy, that services provided to beneficiaries are medically necessary and that medical record documentation supports the services that are billed.
OIG Report: Medicare Recovery Audit Contractors and CMSs Actions to Address Improper Payments, Referrals of Potential Fraud, and Performance

CMS concurred with the OIGs first, second, and fourth recommendations. CMS did not indicate whether it concurred with the third recommendation but noted that it has reviewed the six RAC referrals of potential fraud in the OIG review.
ALJ Hearings Delayed Up to 28 Months

Due to prior identified problems with CMSs actions to address improper payment vulnerabilities, CMSs actions to address referrals of potential fraud, and identified vulnerabilities in CMSs oversight of its contractors the OIG completed a study into Medicare Recovery Audit Contractors and CMSs Actions to Address Improper Payments, Referrals of Potential Fraud, and Performance. The OIG Report found that in FYs 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments totaling $1.3 billion and that CMS took corrective actions to address the majority of vulnerabilities it identified in FYs 2010 and 2011; however, it did not evaluate the effectiveness of these actions. Additionally, CMS did not take action to address the six referrals of potential fraud that it received from RACs. Finally, CMSs performance evaluations did not include metrics to evaluate RACs performance on all contract requirements. As a result of these findings, the OIG recommended CMS: (1) Take action, as appropriate, on vulnerabilities that are pending corrective action and evaluate the effectiveness of implemented corrective actions; (2) Ensure that RACs refer all appropriate cases of potential fraud; (3) Review and take appropriate, timely action on RAC referrals of potential fraud; and (4) Develop additional performance evaluation metrics to improve RAC performance and ensure that RACs are evaluated on all contract requirements.

The Office of Medicare Hearings and Appeals (OMHA) is responsible for Level 3 of the Medicare claims appeal process and certain Medicare entitlement appeals and Part B premium appeals. OMHA was created by the Medicare Modernization Act of 2003 to simplify the appeals process and make it more efficient. During an appeal, an OMHA Administrative Law Judge conducts a new (de novo) review of an appellants case and issues a decision based on the facts and the law. Appeals are assigned by a Centralized Docketing Division in accordance with standardized procedures. On its website OMHA has posted that due to the overwhelming number of receipts and the existing workload within the Agency, OMHA implemented a program that defers the assignment of most requests for hearing received after July 15, 2013. Under this new docketing process, new requests for hearing will be entered into the case processing system, then held until they can be accommodated on an Administrative Law Judges docket for adjudication. Due to the volume of requests being received, OMHA anticipates that assignment of requests for hearing to an Administrative Law Judge may be delayed for up to 28 months.

All Eyes on Therapy


Therapy remains the focus of many Medicare Administrative Contractors (MACs)/Fiscal Intermediaries (FIs) as well as the Regulatory and Law Enforcement Agencies of the Federal Government as the commitment to deterring fraud, waste and abuse in the Medicare and Medicaid systems has increased.
CGS J15 Probe Medical Review Results for RUB10

The J15 Part A Medical Review department performed a service-specific probe review on Resource Utilization Group Code (RUG) RUB10 in Kentucky from March

through May 2013. Based on a 28.8 (56 of 97 claims) percent error rate and the percentage of medical necessity denials, the edit was advanced to a complex edit review. The top denial reasons were:
Denial Code 5D504/5H504 - Need for Service/Item Not Medically Reasonable and Necessary (60.73 percent of dollars denied) Denial Code 5DOWN/MRDWN - Medical Review Downcode (33.89 percent of dollars denied). The services billed were paid at a lower payment level for multiple reasons including due to the documentation submitted for review not meeting the criteria for the RUG code(s) billed. Denial Code 56900 - Requested Records Not Submitted (5.37 percent of dollars denied)

therapy files was to sign documents and progress notes indicating he had provided physical therapy services to particular Medicare beneficiaries, when in fact he had not. Shah admitted to knowing that the documents he falsified were used to support false claims billed to Medicare by his co-conspirators at Prestige. In his plea, Shah also acknowledged that in approximately August 2009, he became an owner of Royal Home Health Care, Inc., a home health agency located in Troy, Mich., along with other co-conspirators. He and his co-conspirators at Royal billed Medicare for home health visits that never occurred and were not medically necessary. Shah and his co-conspirators paid kickbacks to Shah and other patient recruiters in exchange for Medicare beneficiary information, which was then used to bill Medicare for services that were not provided and/or were not medically necessary. Shah admitted that he and his co-conspirators created fictitious therapy files, reflecting services that had not been provided and/or were not medically necessary. He knew the documents he falsified would be used to support false claims by Royal to Medicare for home health services. Shah submitted or caused the submission of claims to Medicare for services that were not medically necessary and/or not provided, which in turn caused Medicare to pay approximately $5,925,843. According to the indictment, two additional home health agencies were involved in the alleged conspiracy. In total, the four home health agencies at the center of the indictment received more than $22 million from the Medicare program.
Michigan Physical Therapist and Home Health Agency Owner Pleads Guilty for Role in Medicare Fraud Scheme

Michigan Physical Therapist Assistant/Home Health Agency Owner Pleads Guilty for Role in Medicare Fraud Scheme

Syed Shah, 51, of West Bloomfield, Mich., pleaded guilty to one count of conspiracy to commit health care fraud. At sentencing, scheduled for Nov. 19, 2013, Shah faces a maximum penalty of 10 years in prison. According to information contained in plea documents, Shah, a licensed physical therapist assistant, admitted that beginning in or around October 2008 and continuing through approximately September 2012, he conspired with others to commit health care fraud by billing Medicare for home health care services that were not actually rendered and/or not medically necessary. Shah admitted that he began working in approximately October 2008 for Prestige Home Health Services, Inc., a home health agency located in Troy, Mich., owned by alleged co-conspirators. His co-conspirators at Prestige paid him kickbacks in exchange for his obtaining the information of Medicare beneficiaries, which the co-conspirators then used to bill Medicare for services that were not provided and/or were not medically necessary. Shah and his co-conspirators then created fictitious therapy files appearing to document physical therapy services provided to Medicare beneficiaries, when in fact no such services had been provided and/or were not medically necessary. Shah admitted that his role in creating the fictitious

Hemal Bhagat, 32, of Troy, Mich., pleaded guilty on Aug. 14, 2013 to one count of conspiracy to commit health care fraud. At sentencing, scheduled for Nov. 12, 2013, Bhagat faces a maximum penalty of 10 years in prison and a $250,000 fine. According to information contained in plea documents, Bhagat admitted that from approximately May 2009 through October 2011, he conspired with others

to commit health care fraud through billing Medicare for home health care services that were not actually rendered and/or not medically necessary. A licensed physical therapist, Bhagat began working in June 2009 for Troy-based Prestige Home Health Services Inc., a home health agency owned by alleged co-conspirators. In approximately August 2009, he and other co-conspirators became owners of Royal Home Health Care Inc., a home health agency also located in Troy. Bhagat admitted that his co-conspirators at Prestige and Royal paid kickbacks to patient recruiters to obtain the information of Medicare beneficiaries, which the co-conspirators then used to bill Medicare for services that were not provided to these beneficiaries and/ or were not medically necessary. He and his co-conspirators then created fictitious therapy files appearing to document physical therapy services provided to Medicare beneficiaries, when in fact no such services had been provided and/or were not medically necessary. Bhagats role in creating the fictitious therapy files was to sign documents including physical therapy evaluations, supervisory patient visits, and patient discharge forms indicating that he and others had provided physical therapy services to particular Medicare beneficiaries, when in fact they had not. Bhagat admitted to knowing that the documents he falsified would be used to support false claims to Medicare by his co-conspirators at Prestige and Royal. He submitted or caused the submission of claims to Medicare for services that were not medically necessary and/or not provided, which in turn caused Medicare to pay approximately $4,767,359.03.
Therapy Staffing Company Owner and Patient Recruiter Plead Guilty in $7 Million Health Care Fraud Scheme

Morales each face a maximum penalty of 10 years in prison. Alejo worked as a patient recruiter at Anna Nursing, a home health care agency in Miami Springs, Fla., that purported to provide home health and therapy services to Medicare beneficiaries but in reality billed Medicare for expensive physical therapy and home health care services that were not medically necessary and/or were not provided. Morales owned Professionals Therapy Staffing Services Inc., which provided therapists to Anna Nursing. From approximately October 2010 through approximately April 2013, Anna Nursing was paid by Medicare approximately $7 million for fraudulent claims for home health care services that were not medically necessary and/or not provided. Alejo and his co-conspirators negotiated and paid kickbacks and bribes to patient recruiters in return for the recruiters providing patients to Anna Nursing for home health and therapy services that were medically unnecessary and/or not provided. He and others also paid kickbacks and bribes to co-conspirators in doctors offices and clinics in exchange for home health and therapy prescriptions, medical certifications, and other documentation. Alejo and his co-conspirators would use the prescriptions, medical certifications and other documentation to fraudulently bill the Medicare program for home health care services. Morales and others created fictitious progress notes and other patient files indicating that therapists from Professionals Therapy had provided physical or occupational therapy services to particular Medicare beneficiaries, when in many instances those services had not been provided and/or were not medically necessary. Morales knew the falsified documents were used to support false claims for home health care services billed to Medicare by his co-conspirators at Anna Nursing.

Ivan Alejo, 48, and Hugo Morales, 36, pleaded guilty to one count of conspiracy to commit health care fraud. At sentencing, scheduled for Nov. 5, 2013, Alejo and

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Vice President of Compliance