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Tag Archives: 2017

New clinical criteria definitions in 2017 Official Guidelines up the ante for coders

New clinical criteria definitions in 2017 Official Guidelines up the ante for coders

by Laura Legg, RHIT, CCS, CDIP, and AHIMA-approved ICD-10-CM/PCS trainer

The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.

Up the ante means to increase the costs, risks, or considerations involved in taking an action or reaching a conclusion. With the new coding guideline for clinical validation that went into effect October 1, the stakes remain high for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.

It is not that the information was not there before, but now the issue is finally getting attention. When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present. But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this has been a haunting issue for a very long time.

The ICD-10-CM Official Guidelines for Coding and Reporting are the foundation from which coders assign codes. Coders need to review the new guidelines in detail to understand the changes and implications for their facilities.

The Centers for Disease Control and Prevention published these new guidelines which can be read in their entirety here:


Taking a closer look

The coding guideline for section A.19 (code assignment and clinical criteria) has been labeled as controversial and, at this point, we have more questions than answers. Denials issued by payers due to the absence, or perceived absence, of clinical indicators by which the payer lowers the DRG is now being called DRG downgrading and it’s getting attention.

The code assignment and clinical criteria states:


Physicians and other providers document a patient’s condition based on past experience and what the clinician learned in medical school, which often differs from clinician to clinician. When you put a patient in front of a group of clinicians you will most likely get differing documentation. So how do we fix that?

The diagnosis of sepsis is a good example. There does not appear to be a universally accepted and consistently applied definition for the condition of sepsis.

In a patient record with the principal diagnosis code of sepsis, followed by the code for the localized infection, pneumonia, a payer denial could occur.

Payer denials often deny the sepsis diagnosis code stating that "the diagnosis of sepsis was not supported by the clinical evidence. Therefore, as a result of this review, the diagnosis code A41.9 [sepsis, unspecified organism] has been removed and the principal diagnosis re-sequenced to code J18.9 [pneumonia, unspecified organism] for pneumonia and to the lower paying DRG 193." This is now being referred to as a DRG downgrade. DRG downgrades can occur for different reasons including both DRG coding changes and clinical validation downgrades.


What is a coder to do?

What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart? Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of this coding guideline to coding practices.

Remember the section that reads: "the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient."

This represents a catch-22. If the diagnosis is not clinically validated, both recovery auditors (RA), as well as commercial insurance auditors, are going to deny the claim. On the other hand, if coders or the facility decide not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.

AHIMA’s 2016 Clinical Documentation Toolkit offers this advice:

The toolkit is available here:


Increasing clinical documentation

As the healthcare industry experiences an increased number of external audits, both federal and private, the need to up the ante on clinical documentation has become essential. The answer is not to let this guidance prompt lazy documentation, which has far reaching consequences, but to use it as a catalyst for improvement.

The goal of any clinical documentation improvement (CDI) program is to ensure a complete and accurate patient record, and this cannot be done without the presence of documentation supporting the clinical indicators and clear and consistent documentation regarding the condition. The provider’s documentation of their full thought process will accomplish this. If medical staff can come together and agree upon a definition for a certain condition, they can begin the process of being consistent with how the description is presented in the patient record.

CDI specialists and coders should not use the new guideline as an excuse not to query. Coders are not clinicians and, therefore, should not be expected to evaluate clinical criteria. Coding and CDI were separate functions, but, as audits from outside organizations expand, there is more emphasis on correct coding, DRG assignment, and the use of clinical criteria to support the reported codes, which means these entities need to work together.

The American Hospital Association’s Coding Clinic for ICD-10 instructs coders not to use background clinical information contained in their responses for code assignment. This information is only provided so the coders can make a judgment to query where there is incomplete documentation. Coders and CDI staff should review all chart documentation and data, and query when necessary to clarify inconsistencies in physician documentation.

Query the provider to support their diagnostic and procedural documentation by making a specific reference to the clinical basis of the diagnosis, and also by noting the absence of specific expected criteria such as radiographic findings, lab values, or patient manifestations.

External auditors in turn need to be following the same rules and coding guidelines as we do. Reviewers for facilities plagued by copious denials are finding auditors making up their own rules, using obsolete or outdated criteria, and clearly not understanding basic terminology used in the 2017 IPPS final rule.

DRG downgrading may be illegal, and some states intend to find out using state level legislation. Downgrading is, at the very least, disregarding the physician’s clinical judgment. We can’t forget who has eyes on the patient. Coders and CDI specialists should take documentation one step further and ask physicians to document their thought processes, the clinical indicators they are seeing, and their rationale for diagnosis determination.

Remember, coding is not based on clinical criteria. Coders cannot disregard physician documentation based on clinical indicators in the patient record, so, we will always need to ensure documentation is complete, accurate, and reflective of the patient’s clinical condition.


Editor’s Note:

Laura Legg, RHIT, CCS, CDIP, is an AHIMA-approved ICD-10-CM/PCS trainer, and director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. For questions, please contact editor Amanda Tyler at Opinions expressed are that of the author and do not represent HCPro or ACDIS. – Briefings on Coding Compliance Strategies

Updated 2017 ICD-10-CM guidelines come ‘with’ controversial changes

Updated 2017 ICD-10-CM guidelines come ‘with’ controversial changes

by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS


Just like the lyrics to the popular Gap Band song say, "You dropped a bomb on me… I won’t forget it," there are definitely some changes in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting that some of us may wish the Cooperating Parties will forget were ever mentioned.

Generally, changes to the guidelines are minor and rarely cause the chaos and confusion that will certainly ensue with the most recent release, effective October 1. This release includes some contradictory guidance and downright concerning statements that appear as if no one really thought through the repercussions. These revisions will certainly have an impact not only on code assignment, but also specifically on reimbursement.


The guidelines state:

The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.


I consider this paragraph the most controversial addition to the guidelines. We’ll look at the impact the guideline has on previous examples relating to conditions such as diabetes mellitus, hypertensive heart disease, and some other conditions.

The guidance most commonly discussed is that for "diabetes with," which was stated in the AHA’s Coding Clinic for ICD-10-CM/PCS, First Quarter 2016, and reconfirmed in the following quarter. To summarize, the AHA guidance stated:

The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system and ANY condition listed under the term "with" in the Alphabetic Index is intended to be interpreted as a related condition/manifestation.


It appears that someone has never looked in the actual ICD-10-CM index file, because all conditions related to diabetes mellitus are indented under the word "with," not just isolated ones as in the ICD-9-CM manual.

Here is the comparison (from the ICD-9-CM index):

Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0

Compare to this excerpt from the ICD-10-CM Alphabetic Index:

The most surprising aspect to me in the repeated guidance is the contradiction to not assume a relationship between osteomyelitis and diabetes mellitus, which Coding Clinic originally stated in Fourth Quarter 2013 and reiterated in First Quarter 2016, writing:

ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.


Coders understood back in 2013 to not assume relationships between diabetes and other conditions that coexist in a diabetic patient. But this recent guidance creates more questions than answers. This very specific guidance about osteomyelitis leads me to imagine the scenario of a patient who has a relationship created between osteomyelitis and diabetes mellitus by a provider documenting "osteomyelitis due to diabetes mellitus." What codes would be reported?

The correct answer would be to assign the code for other specified complication (e.g., E11.69) since there is no entry specifically for osteomyelitis under diabetes mellitus. It would be classified to the "other" category per the ICD-10-CM conventions. If we examine this a bit closer, E11.69 is listed under the word "with" in the Alphabetic Index.

So, is it assumed or not? The guidance and guidelines directly contradict each other.

Some have argued that the ICD-9-CM index included a specific entry for diabetes with osteomyelitis, and I agree that the word "osteomyelitis" is there in black and white, but take a look at the code title: 250.8 (other specified manifestation of diabetes mellitus). There wasn’t a specific code in ICD-9-CM that said "diabetes with osteomyelitis," just like there isn’t in ICD-10-CM.

Diabetes, diabetic (brittle) (congenital) (familial) (mellitus) (severe) (slight) (without complication) 250.0

I suggest if the Cooperating Parties truly plan on keeping osteomyelitis separate, there should be a separate entry in the Alphabetic Index where it is not at the second indentation level under the word "with," but is under diabetes as a main term with a singular indentation.

The "with" guidance extends much further than I think the Cooperating Parties have considered. For risk-adjusted plans, the assumption of linking diabetes and other related conditions (acute and/or chronic) without necessitating providers document it will have a direct impact on a patient’s overall risk score.

The risk score uses many factors, but chronic conditions like diabetes mellitus are a key component in determining how much CMS should pay an insurance plan for care for Medicare beneficiaries covered under plans like Medicare Advantage (i.e., Part C). Being able to assume a relationship is a major change and will ultimately have a big impact on spending for any risk-adjusted plan, considering diabetes is such a common condition.

The reason this hasn’t really been considered an issue yet is that Medicare Advantage data is compiled based on the previous year’s diagnosis codes to prospectively estimate spending in the upcoming year.

Therefore, CMS is currently using ICD-9-CM data for encounters through September 30, 2015. Hopefully, this new guidance valid for encounters as of January 1, 2016, will be considered a factor, because patients with diabetic complications are certain to increase.

If the word "with" couldn’t get any more controversial, it ventured out of the endocrine system to the very "heart" of every coder’s cardinal rule. We learned, as fledgling coders, to never assume heart disease (like heart failure) is directly related to hypertension unless the provider documents the two conditions as related, like hypertensive heart failure or heart failure due to hypertension.

Well, no more, my friends?this is the dawn of a new age of coding. We can assume away, not only for hypertension and (chronic) kidney involvement, but also for hypertension and heart involvement because they are both indented under the word "with" in the Alphabetic Index.

The revised guideline states (bolding is mine)’:

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.


Please notice that the past statement does identify that if the provider specifically states another cause, the conditions should be coded as unrelated.

The larger issue I have with assuming anything under "with" is seen in the ICD-10-CM Alphabetic Index and is yet another direct contradiction to the guidelines. If the guidance regarding "with" is truly universal within the Alphabetic Index, then it implies a relationship for diseases extending beyond just diabetes mellitus and hypertensive heart disease. For example, it seems that coders could begin to assume, based on the guidelines, that patients who have sepsis with a coexistence of organ dysfunction have severe sepsis, even though the guidelines specifically state "an acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code."

Who knew that a little word like "with" could cause so many issues?


Excludes1 notes

The guidelines also include an update on reporting Excludes1 conditions. The updated guidelines state:

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.


The Excludes1 conventions clarify what was addressed in the interim guidance provided in October 2015 and in the AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2015, to address situations where Excludes1 notes should be considered Excludes2 or had other exceptions. Category I63 (cerebral infarction) excludes subcategory I69.3- (sequela of cerebral infarction). This guidance directly contradicted the guidelines for Chapter 9, which state: "Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease."

For 2017, subcategory I69.3- has been revised to be included in an Excludes2 note. Exceptions have been added to the guidelines when the exclusion was for a category that may include a number of different conditions, like the "other" category. Some of those inclusive conditions should never be coded with the diagnosis the Excludes1 note appears under, others may be completely unrelated.

This opens the door for a third-party auditor to debate the application of the Excludes1 note if coding the two conditions separately creates a financial impact.


Edito’?s note

McCall is the director of HIM and coding for HCPro, a division of BLR, in Middleton, Massachusetts. She oversees all of the Certified Coder Boot Camp programs. McCall works with hospitals, medical practices, and other healthcare providers on a wide range of coding-related custom education sessions. For more information, see – Briefings on APCs

A new Webinar for me – July 2017

I will be doing another AudioEducator Webinar in July. I will be doing a webinar regarding Ultrasound Services in the physician office. We’ll be discussing both Obstetric Ultrasound and Gyncologic Ultrasound. If you’d like to join me – Here’s a $ 20.00 off “coupon code” … and as always… I’ll be Packing in a LOT of info in a short amount of time!!! You always get your $ ‘s worth of info!
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Lori-Lynne’s Coding Coach Blog

4 Initiatives Advancing Healthcare Interoperability in 2017

Healthcare interoperability has been a priority for vendors and providers since the advent of health data exchange.

Timely access to accurate health information regardless of health IT system or location improves provider communication and patient care delivery across the care continuum.

This year, healthcare organizations, health IT developers, and federal agencies alike have made a concerted effort to push the industry closer to its goal of true interoperability.

The following are four recent initiatives and forthcoming projects aimed at transforming interoperability in healthcare in 2017…


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The post 4 Initiatives Advancing Healthcare Interoperability in 2017 appeared first on Outsource Management Group, LLC..

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Proposed Rules for Calendar Year 2017 Released by CMS

On July 7, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. This year, CMS is proposing a number of new physician fee schedule policies that will improve Medicare payment for those services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities.

CMS is proposing to expand the Diabetes Prevention Program model starting January 1, 2018.  This is the second CMS Innovation Center – and first preventive services – model that has been certified for expansion.  Expansion of this model will enhance access to these important services for Medicare beneficiaries who are at risk for developing diabetes. 

In addition CMS is also:

• Proposing modifications to the Medicare Shared Savings Program to update the quality measures set and align with the proposals for the Quality Payment Program, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) 3-day waiver rule;
• Requiring health care providers and suppliers to be screened and enrolled in Medicare in order to contract with Medicare Advantage health plans to provide Medicare-covered items and services to beneficiaries enrolled in Medicare Advantage;
• Increasing transparency of Medicare Advantage pricing data and medical loss ratio (MLR) data from Medicare health and drug plans, and;
Continuing to implement Appropriate Use Criteria for advanced diagnostic imaging services, including proposals for priority clinical areas and clinical decision support mechanism (CDSM) requirements, among other proposals as detailed in this fact sheet.

    The CY 2017 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.

    Background on the Physician Fee Schedule

    The PFS pays for services furnished by physicians and other practitioners in all sites of service. These services include but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. 

    In addition to physicians, the physician fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. 

    Payments are based on the relative resources typically used to furnish the service.  Relative value units (RVUs) are applied to each service for physician work, practice expense and malpractice. These RVUs become payment rates through the application of a conversion factor, updated each year as specified in the statute.


    Improving Payment Accuracy for Primary Care, Care Management, and Patient-Centered Services 

    CMS is continuing the Agency’s ongoing efforts to improve payment within traditional fee-for-service Medicare for primary care and patient-centered care management. CMS is proposing several revisions to the PFS billing code set to more accurately recognize the work of primary care and other cognitive specialties to accommodate the changing needs of the Medicare patient population. 

    Historically, care management and cognitive work has been “bundled” into the evaluation and management visit codes used by all specialties. This has meant that payment for these services has been distributed equally among all specialties that report the visit codes, instead of being targeted toward practitioners who manage care and/or primarily provide cognitive services. 

    To improve payment accuracy for such care, in recent years, CMS created new codes that separately pay for chronic care management and transitional care management services, and solicited public comment on additional policies the Agency should pursue. Consistent with the public comments received, for CY 2017, CMS is proposing a number of coding and payment changes to better identify and value primary care, care management, and cognitive services:

    • Make separate payments for certain existing Current Procedural Terminology (CPT) codes describing non-face-to-face prolonged evaluation and management services.
    • Revalue existing CPT codes describing face-to-face prolonged services.
    Make separate payments using new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).
    • Make separate payments using new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions. Several of these codes describe services within behavioral health integration models of care, including the Collaborative Care model that involves care coordination between a psychiatrist or behavioral health specialist and the primary care clinician, which has been shown to improve quality.
    • Make separate payments using new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments.  Like several of these proposed codes, this is especially relevant for the Medicare-Medicaid dually-eligible population.
    • Make separate payments for codes describing chronic care management for patients with greater complexity.
    • Make several changes to reduce administrative burden associated with the chronic care management codes to remove potential barriers to furnishing and billing for these important services. 

      CMS believes that these coding and payment changes could improve health care delivery for the types of services holding the most promise for healthier people and smarter spending, and advance our health equity goals.

      CY 2017 Identification and Review of Potentially Misvalued Services

      Section 3134(a) of the Affordable Care Act requires the Secretary to periodically identify potentially misvalued services and to review and make appropriate adjustments to the relative values for those services.

      Through the Achieving a Better Life Experience (ABLE) Act of 2014, Congress set a target for adjustments to misvalued codes in the fee schedule for 2016, 2017, and 2018. The target was one percent for 2016, and will be 0.5 percent for 2017 and 2018.

      If the net reductions in misvalued codes in 2017 are less than 0.5 percent of the total revenue under the fee schedule, a reduction equal to the percentage difference between 0.5 percent and the percent of expenditures represented by misvalued codes reductions must be made to all PFS services. 

      In this proposed rule, CMS has proposed misvalued code changes that would achieve 0.51 percent in net expenditure reductions. If finalized, these changes would meet the misvalued code target of 0.5 percent, therefore avoiding a broad overall reduction to PFS services.

      Valuation of Moderate Sedation Services 

      In prior rulemaking, CMS noted that it appeared that practice patterns for certain endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures even though payment for sedation services was automatically included in payment to the physician furnishing the primary procedure.

      In response to CMS’ requests in prior rulemaking, the American Medical Association CPT Editorial Panel created separate codes for reporting moderate sedation, and the Specialty Society Relative Value Update Committee provided CMS with recommended values for the moderate sedation codes and recommended adjustments to valuation of the procedure codes. 

      In the CY 2017 PFS proposed rule, CMS is proposing values for the new CPT moderate sedation codes and proposing a uniform methodology for valuation of the procedural codes that currently include moderate sedation as an inherent part of the procedure.  CMS is also proposing to augment the new moderate sedation CPT codes with an endoscopy-specific moderate sedation code, and proposing valuations reflecting the differences in physician survey data between gastroenterology and other specialties. 

      Medicare Telehealth Services: End-Stage Renal Disease (ESRD) and Advanced Care Planning

      CMS is proposing to add several codes to the list of services eligible to be furnished via telehealth.  These include:

      • End-stage renal disease (ESRD) related services for dialysis;
      • Advance care planning services;
      • Critical care consultations furnished via telehealth using new Medicare G-codes.

        CMS is also proposing payment policies related to the use of new place of service code specifically designed to report services furnished via telehealth.  

        Payment for Mammography Services

        CMS is proposing to implement new CPT coding for mammography services. The coding revision reflects use of current technology used in furnishing these services, including a transition from film to digital imaging equipment and elimination of separate coding for computer aided detection services. CMS is proposing to maintain current valuation for the technical component of mammography services in order to implement coding and payment changes over several years.

        Updated Geographic Practice Cost Indices (GPCI) for CY 2017

        General GPCI Update

        As required by the Medicare law, CMS adjusts payments under the PFS to reflect local differences in practice costs using GPCIs for each component of PFS payment—physician work, practice expense, and professional liability insurance. Consistent with the law, CMS is proposing new GPCIs using updated data to be phased in over CY 2017 and CY 2018.

        In conjunction with this proposed update, CMS is proposing to revise the methodology used to calculate GPCIs in the U.S. territories for consistency among the Pacific and Caribbean islands.  This proposed revision would increase overall PFS payments in Puerto Rico.

        California Localities

        The Protecting Access to Medicare Act of 2014 requires that, beginning in CY 2017, CMS use new locality definitions for California based on a combination of Metropolitan Statistical Areas as defined by the Office of Management and Budget and the current locality structure.  The California locality provision is not budget-neutral, meaning that payments to physicians in California will increase in the aggregate without across-the-board reductions in physician services elsewhere.

        The movement to the new locality structure in California may increase payment to many physicians in urban parts of California without any reductions in specified counties that the law “holds harmless” from payment reductions.  In a few areas of California, the new locality structure may decrease Medicare PFS payments.

        Collecting Data on Resources Used in Furnishing Global Services

        Under the misvalued code initiative in the CY 2015 final rule, CMS finalized a policy to transform all 10- and 90-day global codes to 0-day global codes, beginning in CY 2018. Under this policy, CMS would have valued the surgery or procedure to include all services furnished on the day of surgery and paid separately for visits and services furnished after the day of the procedure. Subsequently, Congress enacted Section 523 of the Medicare Access and CHIP Reauthorization Act of 2015 prohibiting CMS from implementing this policy and requiring the agency to gather data on visits in the post-surgical period that could be used to accurately value these services. In this year’s proposed rule, CMS proposes a data collection strategy, including claims-based data collection and a survey of 5,000 practitioners, to gather data on the activities and resources involved in furnishing these services.  To the extent that this data results in proposals to revalue any surgical services, that revaluation will be done through notice and comment rulemaking at a future time.

        0-day Global Services that are Typically Billed with an Evaluation and Management (E/M) Service with Modifier 25

        CMS has noted that several high volume procedure codes are typically reported with a modifier that unbundles payment for visits from the procedure, even though the modifier should only be used for reporting services beyond those usually provided. Therefore, CMS believes the services may be misvalued. As a result, CMS is proposing to prioritize 83 services for review as potentially misvalued.


        The Diabetes Prevention Program is a structured lifestyle intervention that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are pre-diabetic. The clinical intervention consists of 16 intensive “core” sessions of a curriculum in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After the 16 core sessions, less intensive monthly follow-up meetings help ensure that the participants maintain healthy behaviors. The primary goal of the intervention is at least 5 percent average weight loss among participants.

        In March 2016, the Department of Health and Human Services announced that the CMS Office of the Actuary certified that expansion of the Diabetes Prevention Program model would reduce net Medicare spending.  The expansion was also determined by the Secretary to improve the quality of patient care without limiting coverage or benefits. These are the requirements a CMS Innovation Center model test must meet in order to be eligible for expansion as outlined in Section 1115A of the Social Security Act. The Diabetes Prevention Program is the second CMS Innovation Center – and the first preventive – model to meet these requirements.

        Today, CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. Through its expansion, more Medicare beneficiaries would be able to access the benefits of the Diabetes Prevention Program, which could lead to the prevention of diabetes, improved health, and reduced costs. The Medicare Diabetes Prevention Program section included in the PFS proposal specifically seeks comment on the following:

        Medicare Diabetes Prevention Program Supplier EnrollmentCMS seeks comment on a proposal to allow CDC-recognized Diabetes Prevention Program organizations to enroll in Medicare beginning on January 1, 2017. CMS is contemplating requiring each person who provides services as part of a CDC-recognized Diabetes Prevention Program organization delivering these services to obtain a National Provider Identification number in order to provide Medicare Diabetes Prevention Program services.                                                    

        Payment StructureCMS seeks comment on a Medicare Diabetes Prevention Program payment structure, which ties payment to the number of sessions attended and the achievement and maintenance of a minimum weight loss. Claims for payment under the Medicare Diabetes Prevention Program would be submitted following the achievement of core session attendance and minimum weight loss, and following maintenance session attendance and maintenance of minimum weight loss.

        IT Considerations and CapabilitiesCMS seeks comment on requiring CDC-recognized Diabetes Prevention Program entities to submit claims to Medicare using standard claims forms and procedures, submitted electronically in batches. Claims submitted would be required to be traceable to care documented by the entity’s beneficiary records, which should include the requisite amount of detail associated with participation. Entities would also be required to maintain and handle any beneficiary Protected Health Information or Personally Identifiable Information, in compliance with HIPAA and CMS standards.

        Eligible BeneficiariesCMS seeks comment on defining an eligible pre-diabetic patient as a beneficiary having a body mass index (BMI) of 25 or greater (a BMI of 23 or greater for Asian beneficiaries) in addition to a hemoglobin A1c test with a value of 5.7-6.4 percent, or a fasting plasma glucose of 110-125 mg/dL within the last 12 months, or 2-hour plasma glucose of 140-199 mg/dl after the 75 gram oral glucose tolerance test, and no previous diagnosis of diabetes or life-threatening conditions, mobility issues, etc. that would prohibit them from participating in the program.

        Program Integrity InitiativesCMS intends to develop policies to monitor and audit Medicare Diabetes Prevention Program entities and is seeking comment on approaches to mitigate program integrity risks.

        Site of Service RequirementsCMS seeks comment on allowing service delivery in-person or virtually, clarifying that virtual services would not be considered part of current telehealth benefits.

        Learning and Technical Assistance RequirementsCMS seeks comment on providing education, training, and technical assistance on Medicare enrollment, data security, claims submission, and medical record keeping for Medicare Diabetes Prevention Program entities.

        Quality Measurement and ReportingCMS seeks comment on the quality metrics that should be reported by Medicare Diabetes Prevention Program entities in addition to the reporting elements required on Medicare claims submissions outlined above (attendance and weight loss) or by the CDC recognition program. CMS specifically seeks comment on what quality metrics should be considered for public reporting (not for payment) to guide beneficiary choice of entities.

        TimeframeCMS seeks comment on whether the Medicare Diabetes Prevention Program should be expanded nationally in the first year of the program or whether it should be phased in. If it is phased in, then the rule proposes that the Medicare Diabetes Prevention Program would be offered initially for a period in certain geographic markets or regions or to a subpopulation of provider/suppliers. The goal of the phased-in approach will be to anticipate and refine technical issues prior to consideration of broader model scaling. CMS seeks comment on such an approach generally, and specifically on what factors the agency should consider in the selection of initial sites or Medicare Diabetes Prevention Program entities.


        The proposed regulations will require health care providers and suppliers to be screened and enrolled in Medicare in order to contract with a Medicare Advantage organization to provide Medicare-covered items and services to beneficiaries enrolled in Medicare Advantage health plans.

        Background on Medicare Advantage Provider and Supplier Enrollment in the PFS  

        This proposal creates consistency with CMS’s current health care provider and supplier enrollment requirements for all other Medicare (Part A, Part B, and Part D) programs. It is also consistent with a recently published Medicaid Managed Care Rule that requires health care providers in a Medicaid managed care plan’s network to be screened and enrolled with the state Medicaid program.

        CMS believes this proposed rule is necessary to help ensure that Medicare enrollees receive appropriate or medically-necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements. The Medicare enrollment process helps to protect Medicare beneficiaries and the Medicare Trust Funds by carefully screening health care providers and suppliers, especially those that could pose an elevated risk to Medicare, to ensure that they are qualified to furnish Medicare items and services.

        Medicare beneficiaries, the Medicare Trust Funds, and the program at large are at risk when providers and suppliers that have not been adequately screened and enrolled. We believe our program integrity efforts in the Medicare enrollment process should be extended to all health care providers that receive Medicare payments, even when payment is received through an intermediary source such as a Medicare Advantage plan. 

        For instance, Medicare Advantage network providers that perform medically unnecessary tests, treatments, or procedures could threaten enrollees’ welfare, as could a physician who routinely overprescribes prescription drugs. Requiring providers and suppliers that contract with a Medicare Advantage organization and furnish Medicare-covered items and services to enroll in Medicare allows CMS to provide more robust and consistent oversight of these health care providers and suppliers. Anytime a health care provider or supplier fails to meet CMS requirements or violates federal rules and regulations, CMS may revoke enrollment and prevent them from billing Medicare’s Part A or B programs and from prescribing prescription medications covered by Medicare and Medicare Advantage Prescription Drug (MA-PD) Part D programs. This proposed rule also prevents Medicare Advantage participation by health care providers or suppliers that have had their Medicare enrollment revoked or have been excluded by the Office of the Inspector General.   

        Health care providers or suppliers – either as individuals or entities – can enroll in Medicare programs in accordance with the Social Security Act. For Medicare Advantage, the proposed enrollment and approved status requirement applies to:

        • Network providers and suppliers;
        • First-tier, downstream, and related entities (FDR);
        • Health care providers and suppliers in Program of All-inclusive Care for the Elderly (PACE) plans;
        • Suppliers in Cost Health Maintenance Organizations (Cost HMOs) and or competitive medical plans (CMPs). Medicare Cost HMOs and CMPs are types of Medicare health plans available in certain areas of the country. Some Cost HMOs or CMPs only provide coverage for Part B services. These plans do not include Medicare Part D prescription drug benefits; they are sponsored by employer or union group health plans or offered by companies that do not provide Part A services; 
        • Health care providers and suppliers participating in demonstration and pilot programs; 
        • Locum tenens suppliers that provide physician staffing services for hospitals, outpatient medical centers, government and military facilities, group practices, community health centers, and correctional facilities; and, 
        • Incident-to-suppliers that furnish integral, but incidental, professional services in the course of diagnosis or treatment of an injury or illness.


          As part of the proposed changes, the enrollment provisions would be included in CMS contracts with MA and MA-PD plans. Plans that do not meet these requirements may be subject to contract actions ranging from intermediate sanctions to contract termination. When final, these provisions will begin two years after publication of the final rule and will be effective on the first day of the plan year. 


          Consistent with the Administration’s commitment to transparency and making data publicly available, CMS is proposing to release two new sets of data related to plan participation in Medicare Advantage and the Part D prescription drug program. CMS hopes that making this data publicly available will assist public research that will support future policymaking efforts in the Medicare program and provide valuable information to beneficiaries in making enrollment decisions.

          Medicare Advantage Bid Pricing Data

          Each year, Medicare Advantage organizations (MAOs) apply to participate in the Medicare Advantage program through a bidding process.  MAOs submit bids to CMS that reflect the MAO’s estimated costs associated with providing benefits to enrollees.  CMS approves bids that meet a variety of statutory and regulatory conditions. 

          CMS is proposing to release data associated with these bids on an annual basis.  The data released would be at least five years old and would exclude information treated as proprietary.  CMS is also soliciting comment on what factors CMS should consider when proposing to release data that is more recent than five years old.

          Medical Loss Ratio Data

          The Affordable Care Act created a Medical Loss Ratio (MLR) for Medicare Advantage organizations and Part D plan sponsors, comparable to the standard created for commercial plans.  Under the MLR standard, at least 85 percent of revenues must be attributed to claims and quality improvement activities. 

          The Affordable Care Act required CMS to make commercial MLR data public, but did not require publication of Medicare MLR data. CMS is proposing to release Medicare health and drug plan MLR data on an annual basis for use by beneficiaries making enrollment decisions. 


          Section 218(b) of the Protecting Access to Medicare Act (PAMA) of 2014 establishes a new program under the statute for fee for service Medicare to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. 

          CMS established the first of the four components of this program in the CY 2016 Physician Fee Schedule final rule focusing on requiring an evidence-based and transparent process for developing AUC. AUC under this program may only be developed by qualified provider-led entities (the initial list of qualified entities is posted on the CMS website at This year’s proposed rule focuses on the next component of the Medicare AUC program and includes proposals for priority clinical areas, clinical decision support mechanism (CDSM) requirements, the CDSM application process, and exceptions for ordering professionals for whom consultation with AUC would pose a significant hardship. CDSMs are the electronic tools through which a clinician consults AUC to determine the level of clinical appropriateness for an advanced diagnostic imaging service for that particular patient’s clinical scenario. CMS has indicated in this proposed rule that the third component of the program (when ordering professionals must begin consulting CDSMs and furnishing professionals must append AUC related information to the Medicare claim) will not begin earlier than January 1, 2018. 


          The Medicare Shared Savings Program was established to promote accountability for a patient population, coordinate items and services under parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery through provider and supplier participation in an Accountable Care Organization (ACO).  The CY 2017 PFS proposed rule includes the following proposed policies specific to certain sections of the Shared Savings Program regulations:

          • Updates to ACO quality reporting, including changes to the quality measure set and the quality validation audit, revisions to terminology used in quality assessment, revisions that would permit eligible professionals in ACOs to report quality apart from the ACO, and updates to align with the Physician Quality Reporting System and the proposed Quality Payment Program;
          • Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care;
          • Establishing beneficiary protection policies related to use of the SNF 3-day waiver; and,
          • Technical changes to certain rules related to merged and acquired TINs and for reconciliation of ACOs that fall below 5,000 beneficiaries, and other program refinements.

            CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule. The proposed rule will appear in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at:

            The Medical Management Institute – MMI – Medical Coding News & MMI Updates

            Telehealth Services See Little Growth in 2017

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            Multiple Diagnostic Imaging Procedures Pay More in 2017

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            5,500 New ICD-10 Codes for FY 2017 – CM and PCS

            It was announced last month that CMS plans to add 5,500 diagnosis and procedure codes to the ICD-10 coding system in October of this year, right when the grace period is ending. These codes will be applicable for fiscal year 2017.


            New ICD-10-CM (clinical) Codes: 1,900
            New ICD-10-PCS (procedural) Codes: 3,651


            Why are there new ICD-10 codes being released now?

            The 5,500 new codes are a result of a backlog of proposals for changes to the code set due to a partial freeze. A partial freeze was actually implemented by the ICD-9-CM Coordination and Maintenance Committee prior to the implementation of ICD-10 back in 2014. According to CMS, the partial freeze would only allow very limited code updates to capture new technologies and diseases, and on October 1st, regular updates to ICD-10 would begin again.

              Where can I access the new ICD-10 codes?
              The new PCS (procedural) codes are available on the CMS website and the new CM (clinical) codes are available on the CDC website. Generally, the -PCS codes are used in the inpatient hospital setting while the -CM codes are used in the outpatient/physician office setting.


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                The Medical Management Institute – MMI – Medical Coding News & MMI Updates