Provider Consulting Solutions (PCS) would like to offer you the
following alerts and updates on issues that may have a large impact
on your staff and facility.
The New York State
budget agreement for fiscal year 2008-2009 mandated a shift in
New York State Medicaid reimbursement methodology to a
prospective payment system (PPS). The NYS DOH selected
Ambulatory Patient Groups (APGs) as the new payment methodology
for Medicaid outpatient services. The implementation of APGs is
the first major change to the New York Medicaid outpatient
reimbursement methodology in over 20 years. Hospitals will need
to make significant changes to their billing and receivables
management systems for outpatient Medicaid services. To see how PCS is uniquely
equipped to help your organization,
In October 2007, the Medicare Inpatient Prospective Payment System
(IPPS) adopted changes in the Diagnosis Related Group (DRG) grouper
logic to better reflect severity of illness, complexity of service
and resource utilization. The Medicare-Severity DRG (MS-DRG) changes
include an extensive revision to the list of diagnoses that are
considered complications and comorbidities (CC). Two separate lists
now identify Major Complications and Comorbidities (MMC) and "regular"
CCs. The number of DRGs has increased to 745 MS-DRGs from 538.
Hospital Case-Mix changes will be influenced by the degree to
which hospitals and professional staff understand the heightened
importance of documentation and coding for MS-DRGs. Medicare reduced
DRG rates in FY2008, and plans greater reductions in the future;
the rate reduction is intended to compensate for case mix increases
resulting from improved coding. Medicare's assumption may not reflect
what's happening in your HIM Department. PCS can tailor
for your facility based on a review of your records and coding.
Let our experienced consultants help your Hospital rise to the challenge
posed by MS-DRGs.
Centers for Medicare and Medicaid Services (CMS) has retracted
the change found in the October 2007 edition of the National Correct
Coding Initiative (NCCI) Policy Manual which impacted the reporting
of therapeutic vascular procedures in the same peripheral vessel
(Chapter 5, section 16 of the NCCI Policy Manual Version 13.3).
In summary, the revised policy stated that when multiple therapeutic
procedures (i.e., angioplasty, atherectomy, stent placement) are
performed in a single vessel only the most successful may be reported.
Due to tremendous backlash from hospitals, providers and professional
organizations, NCCI will revert back to the following text, originally
published in 1996,
(see Chapter 5, section D-16 of the NCCI Policy Manual Version 14.3).
The change will be retroactive to claims with dates of service on
or after October 1, 2007.
"When percutaneous angioplasty of a vascular lesion is followed
at the same session by a percutaneous or open atherectomy, generally
due to insufficient improvement in vascular flow with angioplasty
alone, only the most comprehensive atherectomy that was performed
(generally the open procedure) is reported (see sequential procedure
policy, Chapter I, Section M)."
It is now appropriate to report both angioplasty (or atherectomy)
and stenting of the same vessel when the documentation supports
that the stent was required due to sub-optimal angioplasty (or atherectomy)
results. However, as before, when both an angioplasty and an atherectomy
are performed on the same vessel, then only the atherectomy may
Hospitals should be aware of these changes and make modifications
- Diversified Collection Services, Inc. of Livermore,
California, in Region A, initially working in Maine, New
Hampshire, Vermont, Massachusetts, Rhode Island and New York.
- CGI Technologies and Solutions, Inc. of Fairfax, Virginia,
in Region B, initially working in Michigan, Indiana and Minnesota.
- Connolly Consulting Associates, Inc. of Wilton, Connecticut,
in Region C, initially working in South Carolina, Florida, Colorado
and New Mexico.
- HealthDataInsights, Inc. of Las Vegas, Nevada,
in Region D, initially working in Montana, Wyoming, North Dakota,
South Dakota, Utah and Arizona.
Be prepared. RAC audits are scheduled to begin in the next several
months. PCS can give you a comprehensive compliance profile. Our
RAC risk assessment reports and claim identification encompass the
New York, California and Florida demonstration experience. Additionally,
these reports focus on possible future RAC risk areas.
Contact PCS today to quantify your RAC financial exposure.
Within the Outpatient setting, billed services are currently
reviewed against Medically Unbelievable Edits (MUE). MUEs are applied
to billed HCPCS and, if flagged, the claim is returned to the provider
(RTPd). Hospitals have reported varying degrees to which they can
determine whether the RTPd claim was attributable to an MUE edit.
And sometimes, where MUE was determined, the MUE result has been
questioned. To minimize the risk of fraud and potential gaming by
the billing provider, the RTPd claim is not available for appeal
and the specific MUE unit was not made available to the public.
The hospital is left to request a reconsideration of the MUE value
by contacting the National Correct Coding Initiative*.
In this setting, hospitals have been forced to write off untold
revenue; the ambiguity to billing regulations has caused frustration
in the hospital community. This is about to change.
Effective October 1, 2008, CMS made public a set of existing
MUEs on the CMS website at
At this time, CMS will only publicize HCPCS and unit pairs with
MUE values of less than three (3). Due to ongoing concerns related
to fraud and abuse, some lower value MUEs and MUEs with values greater
than three (3) still remain elusive. CMS anticipates updating the
MUE values on a quarterly basis and potentially increasing the threshold
for publication. Edits will also be available through NTIS in the
Contact PCS to implement the MUE thresholds and help you correct
your billings going forward.
*National Correct Coding Initiative - Correct
Coding Solutions, LLC - Fax: (317) 571-1745
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