“Mortality rates from sepsis are higher than heart attack, stroke, or trauma. Sepsis needs to be viewed with the same urgency as these other life-threatening conditions because we know early treatment can decrease mortality.”

-       Craig M. Coopersmith, MD, FCCM, Task Force Member and Immediate Past President of the Society for Critical Care Medicine (SCCM)

On February 22, 2016 the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was released at SCCM’s 45th Critical Care Congress. The new recommendations are the result of extensive efforts by a Task Force of 19 leaders in the field of sepsis that was convened by the SCCM and the European Society of Intensive Care Medicine (ESICM). According to the SCCM announcement “the group’s recommendations have been endorsed by more than 30 medical societies from six continents, spanning disciplines from critical care and emergency medicine to infectious disease and family practice.”

Sepsis-3 Definitions

The Sepsis-3 definitions were published in the February 2016 issue of the Journal of American Medical Association (JAMA). “The task force recommended that its report be designated “Sepsis-3,” recognizing the two iterations to define sepsis (1991 and 2001) and signaling the need for future study.”  

Sepsis is now defined as “life threatening organ dysfunction due to a dysregulated host in response to infection.”

SOFA (Sequential [Sepsis-related] Organ Failure Assessment) is a tool to be used to clinically characterize the septic patient.

qSOFA (quick Sequential [Sepsis-Related] Organ Failure Assessment) is a new diagnostic tool that clinicians can conduct for patients outside a hospital, in an Emergency Department or General Hospital floor setting to identify patients at risk for sepsis. The three warning signs to assess for are:

• An alteration in mental status,
• A decrease in systolic blood pressure of less than 100mm Hg; and
• A respiration rate greater than 22 breaths/min.

Two or more of the warning signs increases the risk of a hospitalized patient having a longer length of stay in an ICU or to die in the hospital.

The task force stresses that SOFA and qSOFA are not intended to be used as a “stand alone definition of sepsis.”

Septic Shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.” The task force identified the following two new criteria for diagnosing septic shock:

• “Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg;” and
• “Blood lactate level ≥2 mmol/L despite adequate volume resuscitation.”

Sepsis (lay definition) the recently published definition that “sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues,” was endorsed by the task force as it is consistent with the new Sepsis-3 definition.

Severe Sepsis was deemed “redundant” by the task force, “as sepsis has a mortality rate of 10 percent or higher, making the condition already severe.”

Systemic Inflammatory Response Syndrome (SIRS) “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”

While SIRS due to a localized infection can no longer be coded as sepsis in ICD-10, Coding and CDI Professionals need to be mindful that at this time the code set definitions of sepsis and severe sepsis remain the same.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”

-          Mark Twain

On January 26th, 2015 Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” This was the first time that CMS had set the following explicit goals for Alternative Payment Models (APMs) and Value Based Payment goals.

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

On March 3, 2016 CMS announced in a Fact Sheet that it estimates that the first target of 30 percent of Medicare payments being tied to APMs has been met 11 months ahead of schedule. CMS indicates that “when it comes to improving the way providers are paid, we aim to reward value and care coordination – rather than volume and care duplication.”

Alternative Payment Models by the Numbers

• $411 million is the amount that Medicare Accountable Care Organizations (ACOs) saved the program in 2014 alone through markedly improved quality and patient experience over previous years.
• $3,000 saved per Medicare beneficiary on average is what was saved in just one year through the Independence at Home Demonstration.
• 17% is the reduction from 2010 to 2014 in the number of hospital acquired conditions (HACs). This represents over 87,000 lives saved and $20 billion in cost savings.
• 565,000 is the estimated number of readmissions prevented across all conditions between April 2010 and May 2015.
• Medicare spent $315.9 billion less on personal healthcare expenses between 2009 and 2013 than what would have been spent if the 2000-2008 average growth rate had continued through 2013.

Health Care Payment Learning and Action Network

CMS created the Health Care Payment Learning and Action Network (LAN) March of 2015 “to help align the important work being done across the private, public, and non-profit sectors.”

CMS notes that this network has accelerated the transition to APMs by “fostering collaboration between Department of Health and Human Services (HHS), private payers, large employers, providers, consumers, and state and federal partners.”

Ready or not, the shift in payment is happening. To learn more about LAN you can visit the LAN web page at the CMS Innovation Center as well as the LAN website where you can join the network, view their Work Products, participate in webinars and sign up for the LAN e-newsletter.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

According to Wikipedia, “foreshadowing or guessing ahead is a literary device by which an author hints what is to come. It is used to avoid disappointment. It is also sometimes used to arouse the reader.” Hospital providers may be aroused or alarmed when their MACs start auditing for high-cost drugs, but the foreshadowing has been there.

A couple of years ago Palmetto GBA, then the Medicare Administrative Contractor (MAC) for J-11 and now J-M, began posting medical reviews for high-cost drugs. As part of our series on MAC Medical Reviews, MMP, Inc. has always warned hospitals that the review issues in one jurisdiction may soon become the review issues in other jurisdictions. That is the reason we provide monthly updates on medical review activities for most of the MACs – to allow hospitals to be proactive in addressing potential at-risk issues. This warning is definitely coming to fruition regarding MAC reviews of high-cost drugs. This month Novitas, both JL and JH, added several reviews for drugs while Palmetto and Noridian continue their existing reviews.

One other warning to heed this month – the Recovery Auditors (RAs) have not gone away and from the 2nd quarter of 2015 through the 1st quarter of 2016, we begin to see an increase in RA activity after several months of significant declines due to the Probe and Educate program and the transition to a new Scope of Work. This increase is much more gradual than previous increases, so perhaps we will not see a return to the past fervor of Recovery Auditor reviews. It is interesting to note that the top issues for the last two quarters of RA reviews include:

• DMEPOS While Inpatient
• OP Rituximab 100mg Dose vs. Units Billed
• MMR of Therapy Claims Above $3,700 Threshold (OP)
• O.R. Procedures Unrelated to Principal Diagnosis MSDRGs 981–989
• MS-DRG Validation: Cardiac Valve Procedures
• Excessive or Insufficient Drug Units Billed –Outpatient
• Gastrointestinal Procedures MSDRGs 326-358, 405-416, 417-425

Amounts in Millions

■ Overpayments | ■ Underpayments

MAC Drug Reviews

In general, the drug reviews are looking for

• signed physician orders that describes drug, dosage, route of administration and date;
• documentation to support the diagnosis and the medical necessity of the drug;
• patient’s weight for weight-based dosage;
• administration record that includes patient name, date, dosage, time and route of administration and signature/initials of person administering the drug;
• appropriate units billed based on HCPCS code description and dose given;
• clinical trial information if applicable; and
• documentation of wastage, if applicable.

There are also additional, specific requirements dependent on the drug – for example, medical records must include lab results indicating the patient’s calcium level for Denosumab and CBC results for Imiglucerace. Palmetto review findings have indicated they are also reviewing for orders and administration in accordance with accepted drug protocols.

New drug reviews added by Novitas JH and Novitas JL since last month are for:

• J0221 - Alglucosidase- 10 mg
• J0897 - Denosumab- 1 mg
• J1300 - Eculizumab- 10 mg
• J1786 - Imiglucerace- 10 units
• J9228 - Ipiliumumab- 1 mg
• Q2043 - Sipuleucel T- per infusion
• Novitas was already auditing J9355 - Trastuzumab (Herceptin)

New review findings from Noridian JE since last month include:

• A 27% overall error rate for Denosumab (J0897 - brand names Xgeva and Prolia) due to lack of radiologic evidence of osteoporosis or bone metastasis, lack of a valid order, or unlabeled use. There were also claim corrections for the Denosumab injection concerning the inappropriate use of CPT 96401 for a chemotherapy injection. Although the CPT manual states that the chemotherapy drug administration codes may be used for “certain monoclonal antibody agents” a number of MACs are instructing that the appropriate injection code for some monoclonal antibodies is CPT 96732 and not 96401. Providers should check with their MAC to determine which injection code is required.
• A 26% overall error rate for Bortezomib (J9041 – Velcade) due to incomplete documentation. There were also corrections related to the correct drug administration code for a non-hormonal anti-neoplastic by injection or IV push.
• Noridian JE is discontinuing the probe review for cetuximab (J9055) due to a low error rate of 8%. The main reasons for denials were documentation did not support the KRAS mutation status of colorectal cancer or documentation was not submitted.

In addition to the above noted reviews, Noridian JE is continuing reviews of Pegfilgrastim and Rituximab. Palmetto GBA has on-going reviews of Infliximab, Bevacizumab, Pegfilgrastim and Rituximab.

Other MAC MR Findings from last month include:

• 35% error rate for DRG 470, Major Joint Replacement or Attachment of Lower Extremity without MCC, for Noridian JE. This review is being discontinued due to workload, but the topic may be referred to other Medicare contractors.
• Novitas JH and JL appear to be resuming the audit of Kwashiokor
  (ICD-9: 260; ICD-10: E40, E42) for greater than a 4 day length of stay.

New Recovery Auditor reviews include:

• Performant,, Region A – medical necessity of Cardiac PET Scans
• CGI, Region B – MS-DRG validation of Cardiac Valve and Other Major Cardiovascular Procedures, MS-DRGs 216, 217, 219, 220, 268, 269, 270, 271, 272, 273, and 274
• CGI, Region B - Emergency room services for triaged patients who are not seen by a qualified health practitioner or health practitioner extender. The facility is not entitled to emergency services payment for these patients, as these services are not provided incident to a physicians service.

MMP, Inc. encourages hospitals to use the information provided in this article to be prepared and proactive concerning potential issues at risk of review by Medicare contractors. Better to be prepared than “aroused” or “disappointed.”

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

It is that time of year to celebrate the Social Workers who you know personally or who may have been a blessing to you as a patient or a loved one during a hospitalization. It is Social Work Month! The National Association of Social Workers (NASW) theme for 2016 is "Forging Solutions Out of Challenges."

According to the NASW, “today, social work is one of the fastest growing professions in the Unites States, with more than 600,000 people employed in the field. Professional social workers tackle some of the toughest challenges facing our society. In every city and every community they develop solutions to make mental health and health care more available, to reduce poverty, to eliminate injustice and discrimination, and to protect vulnerable children and adults from harm.”

Best said by this association here are some contributions made by Social Workers:

• “Social workers are the largest group of mental health care providers in the United States.”
• “The U.S. Department of Veterans Affairs employs more than 12,000 professional social workers.”
• “After earthquakes, floods and other disasters social workers are on the front lines, helping survivors get needed services and handle stress and anxiety. In fact, more than 40 percent of mental health volunteers trained by the Red Cross are social workers. Social workers are also active in organizations such as Doctors Without Borders that address disasters that occur abroad.” It seems appropriate that March is also National Red Cross Month, doesn’t it?
• “America’s population is aging. Social workers help older Americans get the health care and mental health care they need. They also work with older people and their families to improve their quality of life and ability to live independently as long as possible.”

“As we continue moving into the 21st century our nation still grapples with complex challenges, including immigration reform, racial strife, and ensuring all citizens have access to vital services.

Social workers will be in the fray, helping our nation forge a path to a better future.”

As MMP, Inc. has done in years past, we are providing a list of free resources to assist with discharge planning.

Resources Available to Assist Acute Care Hospital Social Workers:

The Centers for Medicare and Medicaid Services (CMS) provides several educational resources to assist in the Discharge Planning Process. A few examples include:

• Resources for You:
  • Discharge Planning
  • Communicating with Your Medicare Patients
  • Inpatient Rehabilitation Facility Prospective Payment System Fact Sheet
  • Skilled Nursing Facility Prospective Payment Fact Sheet
  • Swing Bed Services Fact Sheet
  • The Medicare Home Health Benefit
  • Home Health Prospective Payment System
  • Hospice Payment System Fact Sheet
  • Inpatient Psychiatric Facility Prospective Payment System
  • Medicare Ambulance Transports
  • Home Oxygen Therapy

• Resources for your patients
  • Your Discharge Planning Checklist
  • Taking Care of Myself: A Guide for When I Leave the Hospital
  • Resources for Medicare Beneficiaries

From all of us at MMP, Inc., Happy Social Worker Month!

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just over two weeks on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

Variation in the Numbers

In a November 16, 2015 Press Release CMS announced the finalized CJR model by first stating the numbers. “In 2014, more than 400,000 Medicare beneficiaries received a hip or knee replacement, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. For instance, the rate of complications, like infections or implant failures, after surgery can be more than three times higher for procedures performed at some hospitals than others. And the average total Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.”

On April 1st, just over 800 Hospitals in 67 MSAs will begin participating in this model. Each episode of care (Anchor hospitalization) begins with an admission to one of these hospitals when a beneficiary is discharged under MS-DRG 469 (Major Joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities). The episode ends 90 days post-discharge and will include all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.

To further expose the “variation among providers,” I first pulled Medicare fee-for-service paid claims data from our sister company RealTime Medicare Data (RTMD) for MS-DRG’s 469 and 470 for 33 of the participant hospitals in 11 different states to see just how different the anchor hospitalization can be. I then turned to Hospital Compare to find the same participant hospitals Total Hip and Knee Readmission Rates. Specific data elements (i.e., hospital with lowest to highest volume compare) in the Table 1 emphasize just how varied the cost and beneficiary experience actually is and how closely the hospitals will need to work with post-acute care (PAC) providers.

Table 1: Anchor Hospitalization Compare

Preparing for Participation

As the clock counts down to April 1st, there is critical information that hospitals need to be aware of available on the CMS Comprehensive Care for Joint Replacement Model web page.

• CMS has requested that participating hospital provide two points of contact for the CJR model by emailing This email address is being protected from spambots. You need JavaScript enabled to view it.. Your hospital’s CCN should be included in the subject line. “The points of contact should be individuals employed by your hospital that would be the best people for CMS to reach out to with instructions for receiving data and other technical issues.”
• CMS has issued fraud and abuse waivers specific to the Comprehensive Care for Joint Replacement (CJR) Model that can be found on the Physician Self- Referral Fraud and Abuse Waivers web page.
• CMS has provided Beneficiary Notification Letters for Hospitals, Physicians, Post-acute care providers and Physician group practices. “CMS recommends all CJR hospitals and their collaborators maintain a list of beneficiaries that receive these notification documents.”
• In the CJR Final Rule CMS adopted two quality measures and the voluntary reporting of patient Reported Outcome (PRO) data to be use in a composite quality score methodology to link the quality to a participant hospitals payment. Detailed methodology for these measurements can be found in the CMS document Quality Strategy Supplemental Information.

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

Don’t you just love a good story? The characters, setting, plot, conflict and resolution help keep the story running smoothly. KEPRO releases an Acute Care Providers quarterly newsletter called the Case Review Connections that with a little imagination “reads like a story” and is intended to give providers “a glimpse into KEPRO, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).”

KEPRO most recently released their Winter 2016 Case Review Connections in late February. The characters in the story include KEPRO, CMS, Inpatient Prospective Payment System (IPPS) Acute Care Providers, and the Medicare Beneficiary. The setting is what happens in the Acute Care Hospital. The Plot begins with what appeal rights does the Medicare Beneficiary receiving observation services have, moves on to an update about Two-Midnight Short-Stay Reviews, dives into the BFCC-QIO annual report and ends with an opportunity for you the reader to learn more about the BFCC-QIO.

CASE REVIEW CONNECTIONS WINTER 2016 NEWSLETTER FOR ACUTE CARE PROVIDERS

FAQs – Hospital

“Q: If a beneficiary was admitted to a hospital and at one point in time was considered inpatient but is later moved to observation status prior to being discharged, would he/she still be able to have a discharge appeal conducted by the BFCC-QIO?

A: If a patient is in observation (even if the status was changed), they have no appeal rights through the BFCC-QIO. Beneficiaries can appeal through the standard appeal process conducted by the Medicare Administrative Contractors (MAC).”

Two-Midnight Short-Stay Reviews Update

“KEPRO has begun requesting medical records for the Two-Midnight Short-Stay Reviews (previously known as the MAC Probe and Educate Reviews). All appropriate providers in KEPRO's Service Areas will receive a request for 10 or 25 cases within each six-month period. These requests will be spread over the six-month period of October 2015 through March 2016. The second six-month cycle will begin shortly thereafter.”

BFCC-QIO 11th Scope of Work Annual Medical Services Report

KEPRO informs the reader that their Annual Reports have been posted on their website. These Reports “contain a wealth of information about KEPRO’s review volume and findings.” The reporting time frame for the report is August 1, 2014 through July 31, 2015.

KEPRO is the BFCC-QIO for three of the five Areas (area 2, 3 and 4) in the country. The following highlights are from the Area 3 (Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, North Dakota, New Mexico, Oklahoma, South Dakota, Tennessee, Texas, Utah and Wyoming) report.

Evidence Used in Medical Necessity/Utilization Review Decision Making

The Annual Report outlines evidence used in their review decision making. Specifically, KEPRO Review Analysts’ utilize InterQual® & CMS’ Two-Midnight Rule Benchmark criteria to support their “assessments and aids in formatting questions raised to the Peer Reviewer for his/her clinical decisions for Medical Necessity/Utilization Review and Appeals.”

Rational provided by KEPRO for utilizing these two standards are:

• InterQual® - “Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered. Its criteria cover more than 95% of admission reasons for any level of care.”
• “Under this final CMS’ Two-Midnight Rule, surgical procedures, diagnostic tests and other treatments (in addition to services designated as inpatient-only) are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the beneficiary to require a stay that crosses at least two midnights and admits the beneficiary to the hospital based upon that expectation.”

For hospitals in Area 1 or 5, LIVANTA is your BFCC-QIO. Livanta has also posted their Annual Reports to their website. LIVANTA indicates in their Reports that in addition to InterQual® and CMS’ Two-Midnight Rule guidance they utilize the Milliman Care Guidelines®.

Utilization Review Statistics by State

The following table pulls out the volume of Utilization Reviews and Acute Care Providers subject to a Utilization Review for all of the states in Area 3.

Again, this data is from August 1, 2014 through July 31, 2015. It was not until October 1, 2015 that the BFCC-QIO’s became responsible for Short Stay reviews so it will be interesting to see how these numbers compare to next year’s Annual Report.

I encourage you to sign up to receive future Case Review Connectionsnewsletters electronically. One last note, KEPRO is offering a webinar March 31st from 2 – 3 p.m. ET. This webinar will provide an overview of the role of the BFCC-QIO and the services they provide. A registration link can be found at the bottom of the newsletter.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

The month of March is National Nutrition Month and March 9, 2016 was Registered Dietitian Nutritionist Day.   According to the Academy of Nutrition and Dietetics website - “As the nation’s food and nutrition experts, registered dietitian nutritionists are committed to improving the health of their patients and community.” We at MMP, Inc. would like to acknowledge dietitians, nutritionists, and all those who work in the field of nutrition and thank them for their commitment to helping hospital patients. We also want to take this opportunity to look at some guidelines and information related to hospital dietitian services allowed and covered by Medicare.

Ordering Therapeutic Diets

Several years ago, a deficiency report released by CMS identified 147 deficiencies for hospitals related to dietary standards. In response to these deficiencies and to minimize regulatory requirements for hospitals, CMS revised the Hospital Conditions of Participation at section 482.28(b)(2) effective July 11, 2014 as follows:

§482.28(b)(2) -All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

The final rule can be read at Federal Register Final Rule May 12, 2014

The revision allows registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner, if allowed by State law and hospital privileging.

CMS made the following comments related to this change:

“[T]he addition of ordering privileges enhances the ability that RDNs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”

“We believe that the greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed will allow them to meet the needs of their patients most efficiently and effectively.”

The problem many hospitals may face with the revised rule relates to State law. Another

link from the Academy of Nutrition and Dietetics website shows the status of State laws for allowing therapeutic diet orders by dietitians, including a color-coded map. Therefore hospitals and dietitians must be familiar with the laws for their particular State before seeking hospital privileging for RDNs to order patient diets. For example, Alabama State law states in section 420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients." The Academy of Nutrition and Dietetics will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Medical Nutrition Therapy (MNT) Services

Medicare covers medical nutrition therapy (MNT) upon physician referral for beneficiaries with diabetes or renal disease when furnished by a registered dietitian or nutrition professional meeting certain requirements. Basic coverage includes initial assessment visit, follow-up visits for interventions, and reassessments within the year for a total of 3 hours for the first calendar year of a diagnosis of diabetes or renal disease and 2 hours for subsequent years for a renal disease diagnosis.

Important points about MNT services include:

• The treating physician must make a referral and indicate a diagnosis of diabetes or renal disease.
• Renal disease means chronic renal insufficiency (not severe enough to require dialysis or a transplant; GFR of 13-50) or successful renal transplant within the last 36 months.
• Diabetes Self Management Training (DSMT) and MNT can be provided within the same time period, but not on the same day.
• The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician.
• Additional covered hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary.
• Hours may not be carried over into the following calendar year.
• MNT can be provided individually (one-to-one) or in a group setting.

Dietitians and nutritionists must meet the profession standards as described in Section 300.3 of the Medicare Claims Processing Manual, Chapter 4 and be enrolled as a provider in the Medicare program.

The following codes can be paid if submitted by a registered dietitian or nutrition professional who meets the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. Payment is only made for MNT services actually attended by the beneficiary and documented by the provider. MNT is not covered for inpatients of a hospital or skilled nursing facility.

• 97802 – MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (only for the initial visit)
• 97803 - Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
• 97804 - Group (2 or more individual(s)), each 30 minutes
• G0270 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
• G0271 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (2 or more individuals), each 30 minutes

So here’s to eating right for everyone, but especially hospital patients, diabetic patients, and patients with renal disease. The knowledgeable advice and direction of a dietitian/nutritionist can make a critical difference.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

“Words … They’re innocent, neutral, precise, standing for this, describing that, meaning the other, so if you look after them you can build bridges across incomprehension and chaos.”

- Tom Stoppard, The Real Thing: A Play

A major part of my job at Medical Management Plus, Inc. is reading Medicare rules and regulations and trying to understand exactly what they mean for providers, especially hospitals. As indicated in the quote above, I hope Medicare’s words bridge across incomprehension and chaos and bring understanding and order to healthcare operations. On February 26, 2016, CMS released the April OPPS Update transmittal. In addition to some new pass-through drugs, revised status indicators (see table below), and other information, Medicare offered some “word changes” to two issues related to radiation oncology services.

IMRT Planning

A change in the wording for IMRT planning services represents a change in CMS policy and is quite significant for hospitals. In general, payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77305 through 77321, 77331, and 77370 is included in the APC payment for CPT code 77301 (Intensity Modulated Radiation Therapy (IMRT) planning). There are times when these codes may be reported separately in addition to IMRT planning - the description of these “exception times” is what changed.

Previous wording:

These codes should not be reported in addition to CPT code 77301 (on either the same or a different date of service) unless these services are being performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor.

New wording:

These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan.

This means that if after the IMRT plan is completed another simulation-aided field setting (CPT codes 77280-77290) is required (medically necessary) prior to a patient’s treatment, it would be separately billable.

Stereotactic Radiosurgery (SRS)

In the April OPPS update, CMS also revised their billing instructions for stereotactic radiosurgery (SRS) planning and delivery to be clearer. Cranial single session stereotactic radiosurgery procedures are billed with CPT codes 77371 and 77372. These are paid under a comprehensive APC (C-APC) payment which means that adjunctive and related services are packaged into the procedure payment. But there are some things about the SRS C-APC that are different.

First, the SRS comprehensive APC is the only C-APC at this time for which CMS decided to package adjunctive and related services provided on dates of service different from the date of the primary procedure. Adjunctive/related services include but are not necessarily limited to imaging, clinical treatment planning/preparation, and consultations. Services that are adjunctive or related to SRS treatment but billed on a different claim and within either 30 days prior or 30 days after the SRS treatment (CPT codes 77371 or 77372) must be reported with modifier “CP” (adjunctive service related to a procedure assigned to a C-APC procedure). There is an exception for ten (10) planning and preparation codes as discussed below. Any service related to the SRS delivery should have the CP modifier appended. The CP modifier is not to be reported with service such as chemotherapy administration because it is not directly adjunctive to SRS treatment.

As referenced above, there are ten (10) planning and preparation codes that CMS decided not to include in the C-APC from January 1, 2016 through December 31, 2017. This means that for this time frame, these codes do not require the CP modifier and they will be paid separately when furnished and reported within 30 days prior or post SRS treatment delivery. These procedures include:

There were also several new pass-through drugs and some status indicator (SI) changes in the April OPPS update:

To view all the updates, please read MLN Matters Article MM9549.

As you can see, words can be powerful in many ways, including how hospitals bill and are paid for Medicare services. Hopefully, CMS will choose their words carefully.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

When medical emergencies occur in public places, such as restaurants, movie theaters, or on airplanes, we often hear “is there a doctor in the house?” For certain diagnostic outpatient hospital procedures, Medicare wants to know if there is a doctor in the room. Descriptions of Medicare physician supervision requirements for both diagnostic and non-diagnostic services can be found in the Medicare Benefits Policy Manual, Chapter 6, sections 20.4 and 20.5.

Therapeutic Services

In 2010, CMS caused quite a ruckus when they “clarified” the physician supervision requirements for hospital therapeutic services. After several more clarifications, the final Medicare guidelines, from 2011 forward, for most hospital outpatient non-diagnostic services is “direct supervision” which means the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be in the room, on the campus, or within any other physical boundary as long as he or she is immediately available. Other factors for “direct supervision” of therapeutic services are:

• In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services.
• Immediate availability requires the immediate physical presence of the supervisory physician or non-physician practitioner.
• The supervisory physician or non-physician practitioner may not be performing another procedure or service that he or she could not interrupt.
• The supervisory physician or non-physician practitioner must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure.

Diagnostic Services

The type of supervision required for diagnostic services furnished in an outpatient hospital setting is determined by the supervision levels listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found at PFS Relative Value Files. Select the appropriate year and quarter (A correlates to 1st quarter, B to 2nd quarter, etc.). You will want to select the spreadsheet that starts with PPRRVU. The pdf document in the folder explains the various designations within the file. For example, some of the definitions related to Physician Supervision of Diagnostic Procedures are:

• 01 = Procedure must be performed under the general supervision of a physician.
• 02 = Procedure must be performed under the direct supervision of a physician.
• 03 = Procedure must be performed under the personal supervision of physician.
• 09 = Concept does not apply.

See the complete document for explanations of all the assignments.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Direct supervision for outpatient hospital diagnostic services has the same requirements that are described above for direct supervision of therapeutic services except that diagnostic services require supervision by a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

As stated above, diagnostic services require supervision by a physician and in general may not be supervised by non-physician practitioners. There are exceptions that allow some diagnostic tests furnished by certain non-physician practitioners to be furnished without physician supervision. When these non-physician practitioners personally perform a diagnostic service they must meet only the physician supervision requirements for that type of practitioner when they directly provide a service. For example, nurse practitioners must work in collaboration with a physician, and assistants must practice under the general supervision of a physician. Non-physician practitioners, including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives, cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

Hospitals need to be aware of the supervision requirements for diagnostic services, particularly those services that require personal supervision where the physician must be in the room during the performance of the procedure. There are over 200 CPT codes in the 2016 PFS RVU file that require personal supervision, with almost 150 of those being radiology procedures in the 70010-79999 CPT code range. This includes radiology procedures such as myelography, arthrography, angiography and venography, among others. Medicare allows payment for diagnostic services only when those services are furnished under the appropriate level of supervision.

Hospitals need to ensure that venograms, arthrograms and other relevant radiology services are only performed when a physician is in the room. Lack of appropriate supervision can result in an inappropriate Medicare payment. When personal supervision is required, there must be “a doctor in the room.”

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

A common mnemonic device to aid memory is to come up with a short sentence or phrase using the first letters of what you are trying to remember. Since it is spring and we are planning our vegetable garden, for PGATO I came up with “please gather all the okra.” If you have never grown okra, you may not realize the gathering demands of okra in the miserably hot, sultry days of late summer. The reward however is the delicious, Southern dish of fried okra. For Medicare services, rewards are two-fold – one is helping patients to recover or improve and two is the Medicare reimbursement you receive if you have followed all of Medicare’s requirements for billing, coding, and documentation. Like okra plants can be prickly, so can Medicare requirements.

PGATO is my memory tool for remembering all of the components for proper documentation to support billing of psychotherapy - plan, goals, activity, time, and outcomes. CPT codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy. Reviews by the Comprehensive Error Rate Testing (CERT) contractors have identified issues with missing documentation.

Plan and Goals

A recent CERT review (see Cahaba Article Psychotherapy Codes) has identified errors in outpatient psychotherapy CPT codes 90832 and 90834, Type of Bill 13X. The primary issue identified on review was the absence of a signed, individualized plan of care for the services billed.

The individualized treatment plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. Treatment goals should be measurable and objective. Documentation should include specific therapeutic interventions planned and an estimated duration of treatment.

Services must reasonably be expected to improve the patient’s condition. The treatment must be designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient’s level of functioning. Psychotherapy services are not covered for severe and profound intellectual disabilities. Also, psychotherapy services are not covered for dementia patients when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective. When a patient has dementia, the capacity to meaningfully benefit from psychotherapy must be documented in the medical record.

Activity and Time

Another CERT review as described in MLN Matters Article SE1407 identified the main error as not clearly documenting the amount of time spent only on psychotherapy services.

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy.

A variety of techniques are recognized for coverage under the psychotherapy codes; however, the services must be performed by persons authorized by their state to render psychotherapy services (such as physicians, clinical psychologists, registered nurses with special training, and clinical social workers). Medicare coverage of procedure codes 90832-90838 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.

Psychotherapy codes 90832-90838 are timed codes and the documentation must support the time billed as a psychotherapy encounter. The time associated with these codes is for face-to-face services only with the patient (or patient and family). In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:

• Code 90832 (or + 90833) 30 minutes: 16 to 37 minutes
• Code 90834 (or + 90836) 45 minutes: 38 to 52 minutes, or
• Code 90837 (or + 90838) 60 minutes: 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

CPT codes 90833, 90836, and 90838 are add-on codes for psychotherapy services provided with an evaluation and management (E&M) service. Both services are payable if they are significant and separately identifiable and billed using the correct codes. Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.

Outcomes

A periodic summary of goals, progress toward goals and an updated treatment plan must be included in the medical record. The general expectation is that the treatment plan will be updated at least every three months.

There are no specific limits on the length of time that services may be covered, but the duration of a course of psychotherapy must be individualized for each patient. As long as the evidence shows that the patient continues to show improvement in accordance with their individualized treatment plan, and the frequency of services is within the norms of practice, coverage may be continued. However, prolonged periods of psychotherapy must be well-supported in the medical record and include a description of the necessity for ongoing treatment.

You may want to come up with your own memory tool for remembering to include all the required documentation components of psychotherapy. However you choose to remember, meeting Medicare’s prickly requirements will help guarantee appropriate payments.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Remember the widespread apprehension and dire predictions of impending doom that preceded the Y2K transition. Maybe that fear was a good thing, resulting in thorough planning and preparation prior to the transition that averted the expected problems. Maybe the same applies to the I-10 conversion. Because despite predicted issues and pleas for delays, the actual implementation of ICD-10 has gone fairly smoothly. If there have been some bumps in the road of a smooth transition, one of those relates to diagnosis codes designated to cover specific services as defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

The unexpected denials of services previously covered for the same conditions have been frustrating for providers, but in defense of CMS and the various Medicare Administrative Contractors (MACs), they had a tremendous number of diagnosis codes to convert from ICD-9 to ICD-10. Due to the large volume, they likely used crosswalks between the two coding systems and as coders know, coding is more involved than simple crosswalks. CMS is addressing the need for diagnosis code deletions and additions to NCDs through quarterly maintenance updates of ICD-10 conversions. These updates may also address CPT/HCPCS code changes and routine updates of coverage. The 6th such update was Transmittal 1630, CR9540. It includes revisions made as a result of feedback received from previous ICD-10 NCD transmittals.

The coding changes addressed in Transmittal 1630 are summarized below. Refer to the transmittal and associated spreadsheets for the specific codes removed, added, or replaced. One change of note is the addition of ICD-10 diagnosis codes for current smokers to the NCD for Low-Dose CT for Lung Cancer Screening.

• Removed and added ICD-10 diagnosis codes for NCD 20.29 - HBO
• Revised verbiage in edit logic for NCD 90.1 - Pharmacogenomic Testing for Warfarin Response
• Removal and replacement of expired HCPCS codes for NCD 110.10 - Aprepitant for Chemotherapy-Induced Emesis
• Added ICD-10 diagnosis for some “other specified disorders of bone density and structure” for NCD 150.3 - Bone Mineral Density Studies
• Removed invalid ICD-10 codes and added CPT code for NCD 160.18 - Vagus Nerve Stimulation for Treatment of Seizures
• Removed and added CPT codes for NCD 160.24 - Deep Brain Stimulation for Essential Tremor
• Revised verbiage and added diagnosis and CPT codes for NCD 210.3 - Colorectal Cancer Screening Tests
• Added ICD-10 diagnosis codes representing a current smoker as covered diagnoses for NCD 210.14 - Screening for Lung Cancer with Low-Dose CT
• Instructed contractor review of spreadsheet for NCD 230.18 - Sacral Nerve Stimulation for Urinary Incontinence
• Replaced expired CPT code for NCD 260.1 - Adult Liver Transplantation
• Added ICD-10 diagnosis code for NCD 110.4 - Extracorporeal Photopheresis
• Replaced ICD-10 diagnosis code with a more specific code for NCD20.33 - Transcatheter Mitral Valve Repair
• Added a fine needle aspiration CPT code for NCD 220.13 - Percutaneous Image-Guided Breast
• Instructed contractor awareness of removal of verbiage regarding bundling of service from NCD 220.4 – Mammograms

The effective date of the transmittal is July 1, 2016 (implementation July 6, 2016) but most corrections are backdated – for I-10 code changes to October 1, 2015, to January 1, 2016 for most CPT/HCPCS code changes, and sometimes to the NCD effective date such as for the diagnosis code additions (I-9 and I-10) for lung cancer screening. The last contractor instruction in the Business Requirements section of the transmittal states: “Contractors shall be aware that any claims that are brought to their attention regarding any of the above noted NCDs and associated edits shall be adjusted accordingly.” This means providers may request claim adjustments after the implementation date of the transmittal for previously denied line items based on the backdated guidelines.

If providers have denials due to missing ICD-10 diagnosis codes they think should be included in local coverage determinations (LCDs), we recommend appealing the denials and utilizing the LCD Reconsideration process to request the addition of the missing diagnosis codes to the LCD. Like all “bumps in the road,” you just have to deal with it.

Updates to LCDs and MAC Articles from last month are detailed below.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

If you have ever audited electronic healthcare medical records, you have likely seen patients that are the same one day as another – exactly the same – no, I mean EXACTLY the same - the exact same wording of the patient’s condition, patient statements, treatment plan and/or other documentation elements. This is the result of “copy and paste” within an electronic medical record.

There are benefits and risks associated with the use of “copy and paste” within EHRs as described by the Partnership for Health IT Patient Safety. Benefits include time savings and a more efficient way to capture complex information which may result in improved tracking of multiple problems and improved continuity of care. It can also reduce transcription errors and omissions of important information. However, the outdated, inaccurate, irrelevant, and misleading information that can result from “copy and paste” erodes confidence in the record, may have medico-legal implications, and can result in more queries and work to determine if the information is correct. Charts and notes can become overwhelmingly long and effective communication is compromised because important findings and problems are intertwined with normal patient information, making it difficult to decipher what is important or current.

In response to safety concerns, the Partnership for Health IT Patient Safety developed a Toolkit for the Safe Use of Copy and Paste. Although the focus of the toolkit is patient safety, other concerns associated with “copy and paste” include billing and compliance issues and potential malpractice implications.

The recommendations provided in the toolkit and listed below are not intended to impair usability of EHR systems or impede workflow. Their goal is to allow providers the opportunity to evaluate the best ways to see the information that is being reused and to take steps toward the safe use of “copy and paste.”

Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

• Allows verification of accuracy and facilitates review for edits
• Potential Actions: Create policies and procedures; block certain areas of documentation from copying; have a different appearance for copied material (italics, different color, etc.)

Recommendation B: Ensure that the provenance of copy and paste material is readily available.

• Helps verify that the information is appropriate and accurate and increases the potential to defend the record and achieve billing compliance
• Potential Actions: Identify original source of information and track changes and authors

Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.

• Helps providers understand their liability and the potential patient safety and compliance risks of copy and paste
• Potential Actions: Provide regular training and feedback; identify methods to verify current and correct information

Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.

• Ensures the integrity of the clinical record, the quality and safety of care rendered, and compliance with state and federal regulations
• Potential Actions: Create auditing policy; perform regular audits and report findings and provide feedback

I personally think this toolkit offers excellent recommendations for the safe use of a “copy and paste” function. As explained in the Toolkit, some of the recommendations will take time to implement, particularly those that require technology changes by developers and workflow changes for providers. However, there are some steps that hospitals could implement now to improve the use “copy and paste.” A realization of the associated risks of “copy and paste” is one first step.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Generally things are categorized or classified to create a logical ordering of the items or services. Categories or classifications are based on aspects of the items/service with the intent to provide clarity. When trying to describe the basis of classifications of drug testing codes it is hard to know where to start. The codes are classified alternatively on why, what or how testing is done. And in recent years, one or more code systems have changed the codes and the classification methods annually. No wonder everyone is confused.

Back in January of this year, I wrote about the new drug testing codes for 2016. Since we are now a quarter into the new year, I thought it would be good to revisit drug testing codes in general. Hospitals need to determine if the codes in their charge description masters (CDMs) are correct and if they understand the rules for reporting both CPT and HCPCS codes for drug testing.

Therapeutic drug testing codes are performed to monitor clinical response to a known, prescribed medication. Drug assays for therapeutic reasons are reported with CPT codes 80150-80299 for both Medicare and non-Medicare payers. The descriptions of these codes do not specify a particular testing method although the result is a quantitative result. That means a specific concentration or amount of the drug present is reported.

As noted above, drug testing codes are classified based on the why, what and how of testing. Drug testing that is performed to determine the possible use or non-use of a drug (the why) is divided into presumptive and definitive testing. Definitive testing is more specific and is able to identify specific drugs, their metabolites, and/or drug quantities (the what). For both the CPT codes and the HCPCS codes required by Medicare and some other payers, presumptive versus definitive testing is based mainly on the testing methods used (the how).

Presumptive drug testing is performed by direct optical observation, direct optical observation with an instrument reader, or by chemistry analyzers that generally utilize immunoassay or enzyme assay methods. CPT further divides drugs into two Drug Class Lists – A and B – based on how complex the testing methods are. Drug Class List A is the more common drugs of abuse, whereas Drug Class List B includes such drugs as acetaminophen, fentanyl and tramadol. CPT codes for presumptive testing are 80300-80304 and the new 2016 HCPCS codes are G0477-G0479. The table below summarizes the description requirements for using both types of codes. These codes are reported once per day of service with the exception of CPT 80302 which is reported per drug class/per procedure and CPT 80304 which is reported per procedure. Medicare further specifies that only one presumptive HCPCS code should be reported per day of service.

Definitive drug testing is performed by more complex chemistry analyzers and methods such as gas or liquid chromatography with mass spectrometry. Both CPT and HCPCS code instructions clearly state that definitive testing methods exclude immunoassays and enzymatic methods – this means these codes should not be used for testing with most common chemistry analyzers. For example, a lot of hospital laboratories do not have the complex chemistry analyzers required for definitive testing. CPT codes for definitive testing are 80320-80377. These codes are reported based on drug classes as defined in the Definitive Drug Classes Listing in the CPT manual. There are three key statements from the CPT Manual to consider when reporting one of the definitive drug testing codes:

• Each category of a drug class, including metabolite(s) if performed, is reported once per date of service.
• Metabolites that are not listed should be categorized with the parent drug.
• Drug class metabolite(s) is not reported separately unless the metabolite(s) is listed as a separate category…

This means you only report one unit of the CPT code that matches the drug class tested.

Understanding the proper reporting of CPT codes for definitive drug assays makes HCPCS code selection easier since the new HCPCS codes for definitive drug testing for 2016 are based on the CPT code drug class definitions and the number of drug classes tested. This means you can count the number of definitive CPT drug test codes that would be reported to determine which of the HCPCS codes to bill.

• G0480 - 1-7 drug class(es), including metabolite(s) if performed.
• G0481 - 8-14 drug class(es), including metabolite(s) if performed.
• G0482 - 15-21 drug class(es), including metabolite(s) if performed.
• G0483 - 22 or more drug class(es), including metabolite(s) if performed.

As with the presumptive HCPCS codes, each code is reported once per date of service and only one of the definitive test codes may be reported for one date of service. All of the presumptive and definitive HCPCS codes include testing for sample validation so any testing to ensure the integrity of the specimen may not be reported separately. A number of non-Medicare payers also do not allow separate reporting of sample validation testing.

Providers need to review drug testing policies for all payers to see which type of codes (CPT or HCPCS) are required, what services may be reported (such as sample validation), and what justifies the medical necessity of testing. A number of Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) concerning the medical necessity of drug testing. Most of the policies include the following wording concerning the medical necessity of definitive drug testing.

Definitive UDT (urine drug testing) is reasonable and necessary for the following circumstances:

• Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT;
• Definitively identify specific drugs in a large family of drugs;
• Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs;
• Identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC use according to a treatment plan);
• Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient’s self-report, presentation, medical history, or current prescribed pain medication plan;
• Rule out an error as the cause of a presumptive UDT result;
• Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and
• Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.

Providers must understand the why, what, and how of drug testing to ensure that drug testing codes are reported appropriately. In healthcare it is always a challenge – that is why Medical Management Plus Inc.’s tag line is “Making Healthcare Make Sense” – we all need help making sense.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

A medical claim is a form of communication with a healthcare payer that request payment and describes the services provided to a patient, plus other pertinent information. Medicare and other payers have detailed specifications about the types of information that must be included on a claim. Modifiers are often used on claims to explain the special circumstances of a particular item or service. In honor of National Occupational Therapy (OT) month, we examine some modifiers that are often required for rehabilitative services.

The American Occupational Therapy Association website states that occupational therapists and assistants are part of a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities. In addition to clinical responsibilities, including complete and thorough documentation of their medical services, OTs and other rehabilitative therapists such as physical therapists (PT) and speech language pathologists (SLP) are required to understand some aspects of Medicare therapy billing. For example, therapists need to understand the proper use of some billing modifiers.

Therapy Discipline Modifiers

Services for Medicare patients provided by rehabilitative therapists must be appended with a modifier that describes the therapy discipline. Modifiers are used to identify therapy services whether or not financial limitations (therapy caps) are in effect. When limitations are in effect, Medicare tracks the financial limitation based on the presence of therapy modifiers. The therapy modifiers are:

• GN – Services delivered under an outpatient speech-language pathology plan of care;
• GO - Services delivered under an outpatient occupational therapy plan of care; or,
• GP - Services delivered under an outpatient physical therapy plan of care.

Modifiers GN, GO, and GP refer only to services provided under plans of care for rehabilitative therapy services. They should never be used with codes that are not on the list of applicable therapy services. For institutional claims, the modifiers must correlate with the respective revenue code (PT – modifier GP with revenue code 42x; OT – modifier GO with revenue code 43x; and SLP – modifier GN with revenue code 44x).

Modifier 59

Modifier 59 is appended to a CPT/HCPCS procedure code to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

For PT, OT and SLP services, providers should not report more than one physical medicine and rehabilitation therapy service for the same fifteen minute time period with the exception of “supervised modality” codes. Some National Correct Coding Initiative (NCCI) procedure-to-procedure edits pair a “timed” therapy CPT code with another “timed” CPT code or a non-timed CPT code as services that would not normally be reported together. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter. When modifier 59 is used, documentation in the therapy record must support that the services were performed at separate and distinct time periods.

Modifier KX

Medicare sets financial limitations on the amount of therapy services a beneficiary may receive in a calendar year. For 2016 the therapy cap amounts are $1,960 for physical therapy (PT) and speech-language pathology (SLP) services combined and $1,960 for occupational therapy (OT) services. Medicare allows an exception when the patient’s condition requires continued skilled therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Documentation in the therapy record must justify a medically necessary need for additional therapy beyond the therapy cap.

When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider must add a KX modifier to the therapy HCPCS code subject to the cap limits. By appending the KX modifier, the provider is attesting that the services billed:

• Are reasonable and necessary services that require the skills of a therapist; and
• Are justified by appropriate documentation in the medical record,; and
• Qualify for an exception using the automatic process exception.

When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be reported.

Be sure that services are medically necessary and that documentation is sufficiently detailed to support the use of the modifier. Medicare is aware of the potential for misuse of the KX modifier. Note that:

• Routine use of the KX modifier for all patients with certain conditions will likely show up on data analysis as aberrant and invite inquiry.
• Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive.
• If the use of the KX modifier is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim.

For more information on the use of the KX modifier, see the Medicare Claims Processing Manual, Chapter 5 , Section 10.3.

Functional Limitation Modifiers

In 2013, Medicare began requiring the reporting of rehabilitative therapy functional limitation information on claims. Claims for outpatient therapy services are required to include non-payable G-codes and modifiers, which describe a beneficiary’s functional limitation and severity level, at specified intervals during the therapy episode of care. The severity modifier reflects the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge.

Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals. For more information on functional limitation codes and modifiers, see the Medicare Benefit Policy Manual, Chapter 15, Section 220.4.

When communicating with Medicare and other payers, providers must know the specifics of the service and claim requirements. Proper use of modifiers to provide additional information about the services rendered is necessary for clear communication.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Senseless massacres and suicides of prominent people in recent years have drawn attention to mental health issues in America. Some in our elderly population face a diagnosis of Alzheimer’s or other forms of dementia as they age. Our youth and all ages are at risk of life-altering drug and alcohol addictions. According to a Washington Post article from 2012, although the United States spends over $113 billion on mental health treatment, that is still not enough to serve all those who need it. Costs, limited access, and attitudes about mental health remain big barriers to treatment. One positive cited by the article is that recent federal legislation requires more expansive insurance coverage for mental health services.

Medicare covers a continuum of mental health services from inpatient hospital services, to partial hospitalization, to outpatient services. The coverage requirements of psychiatric Partial Hospitalization Program services are described in the Medicare Benefits Policy Manual, Chapter 6, section 70.3.

What a PHP Is

“Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.”

What a PHP Is Not

A PHP is not a program that is:

• Comprised primarily of diversionary activity, social, or recreational therapy
• A psychosocial program which provides only a structured environment, socialization, and/or vocational rehabilitation
• Only for monitoring the management of medication for patients whose psychiatric condition is otherwise stable

Patients eligible for a PHP program are patients trying to avoid a new or continued hospitalization for psychiatric services – hence, the need for the acute, intense, structured combination of services provided by a PHP. Patients participating in a PHP program must:

• Be under the care of a physician who certifies the need for PHP
• Have a plan of care that requires at least 20 hours a week of therapeutic services
• Have a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning (generally acute in nature)
• Have an adequate support system to sustain/maintain themselves outside the PHP and must not be an imminent danger to themselves or others
• Be willing and able to participate with active treatment of their mental disorder and tolerate the intensity of a PHP

Medicare recently released a MLN Matters Special Education (SE) Article SE1607 describing edits being implemented to enforce the requirement for a minimum of 20 hours per week of therapeutic services for patients in a Partial Hospitalization Program (PHP). There are three edits that will become effective July 2016:

• IOCE Edit 95 (FISS Reason Code W7095) - Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service
• IOCE Edit 96 (FISS Reason Code W7096) - Partial hospitalization interim claim from and through dates must span more than 4 days
• IOCE Edit 97 (FISS Reason Code W7097) - Partial hospitalization services are required to be billed weekly

Initially all three edits will cause the claim to “return to provider” (RTP) for correction, but beginning with the October 2016 IOCE updates, edit 95 (insufficient hours) will cause the claim to deny.

In addition to the amount of treatment, documentation requirements for a PHP admission include an initial physician certification that identifies the patient’s diagnosis, psychiatric need, and that the patient would require inpatient treatment if not for the PHP. Recertifications, required at day 18 and at least every 30 days after that, describe the patient’s response to treatment, reason for continued need for PHP and goals to facilitate discharge. Patients in a PHP must be under a treatment plan that:

• Is prescribed and signed by a physician,
• Identifies treatment goals that directly address the presenting symptoms and are the basis for evaluation of patient response,
• Describes a coordination of services including a multidisciplinary team approach to patient care, and
• Is individualized and structured to meet the particular needs of the patient.

Documentation must also include progress notes showing the services were provided, the nature of the treatment service, the patient’s response to the therapeutic intervention and its relation to the goals indicated in the treatment plan.

Hopefully expanded mental health coverage, growing awareness of mental health issues, and programs such as the partial hospitalization programs will make a positive impact on this country’s mental health. It is an issue that could affect any of us, directly or indirectly. It is a cry for help.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

“Navin: The new phone book’s here! The new phone book’s here!
Harry: Well I wish I could get so excited about nothing.
Navin: Nothing? Are you kidding?! Page 73, Johnson, Navin, R.! I’m somebody now! Millions of people look at this book every day! This is the kind of spontaneous publicity, your name in print, that makes people. I’m in print! Things are going to start happening to me now.”

-       Quote from the 1979 Steve Martin movie The Jerk

This excerpt is one of my favorite scenes in this movie. Fast forward a few decades and I could easily replace Navin’s opening line with the First Quarter 2016 Coding Clinic is here, the First Quarter 2016 Coding Clinic is here! Especially exciting is a new Coding Clinic about documenting the type of Heart Failure and two Coding Clinics specific to Diabetes.

Heart Failure

A Physician documenting Congestive Heart Failure in the record has long been an opportunity for a Physician Query to clarify the type (systolic, diastolic, systolic and diastolic) and the acuity (acute, chronic, acute on chronic). Effective with March 18, 2016 discharges “things are going to start happening to” the need to query.

A question was asked (page 10 of the Coding Clinic) to reconsider the prior advice that coders cannot assume the type of heart failure “based on documentation of heart failure with “preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF).” Based on information from the American College of Cardiology (ACC) coders can now make the following links for the types of heart failure.

The abbreviation HFpEF may be called Heart Failure with Preserved Systolic Function which now may also be called Diastolic Heart Failure.

The abbreviation HFrEF may be called Heart Failure with Low Ejection Fraction, or Heart Failure with Reduced Systolic Function, “or other similar terms meaning systolic heart failure.”

While it’s a win for the type of heart failure, you may still need to clarify the acuity of the heart failure being treated.

Diabetes Mellitus and Osteomyelitis

ICD-9 Coding Clinic guidance advised that when a patient has diabetes and acute osteomyelitis, in the absence of any other cause of the osteomyelitis, you could assume a relationship between the two conditions. The question was asked if the relationship could be assumed in ICD-10. The short answer is no, “the provider will need to document a linkage or relationship between the two conditions before it can be coded.”

Diabetic Foot Ulcer

Another Coding Clinic asked if a relationship could be assumed between Diabetes, a foot ulcer, polyneuropathy, end-stage renal disease (ESRD) when all conditions are present in the record. In contrast to diabetes and osteomyelitis, this Coding Clinic indicates that “ICD-10-CM assumes a causal relationship between the diabetes mellitus and the foot ulcer, the polyneuropathy, as well as the chronic kidney disease.”

So let’s review, you can now make assumptions about the type of heart failure, you may need to still query about acuity heart failure, you will have to query for a link or relationship between diabetes and osteomyelitis but can assume a relationship between diabetes, a foot ulcer, polyneuropathy and end-stay renal disease. Can’t you just feel Navin’s excitement?

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

A favorite childhood memory of mine is watching old Western movies on a small, black and white television. Although the screen was really small by today’s standards and the action lacked the realism of current movies, the stories were dramatic, entertaining, and suspenseful.  It seems one group was always trying to stay ahead of another group in these movies – the wagon train ahead of the Indians, the outlaws ahead of the posse, the stagecoach ahead of the robbers, or the cattle herd ahead of the rustlers. Thankfully life isn’t quite so dramatic today, but in the world of healthcare, providers try to stay ahead of Medicare reviewers who are looking for overpayments.

Cotiviti, the Recovery Auditor for Region C, added a newly approved audit issue last month for a comprehensive review of Cataract Surgery. According to the issue details, “Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.” Several Medicare Administrative Contractors (MACs) have a Local Coverage Determination for Cataract Extraction or Cataract Surgery. I usually try to list some of the commonalities of the various MAC LCDs, but the cataract LCDs vary widely, so my advice is to concentrate on the requirements of the LCD from your MAC jurisdiction. And due to the variation between LCDs, I would caution providers to review any denials by Cotiviti carefully to make sure they also have used the requirements of coverage relevant to your jurisdiction.

In the past, one MAC, Palmetto, performed a pre-payment service-specific targeted medical review on claims for CPT code 66984, Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis, Manual or Mechanical Technique. Denial rates were initially quite high in the 70-90% range, but within two years dropped below 35% for all states involved and the reviews were discontinued. The main reasons for denials were lack of medical necessity and services not documented. More granular findings related to lack of medical necessity included:

• No evidence of patient’s Best Corrected Snellen Visual Acuity (BCVA) present in the record.
• No evidence of patient reported impairment of visual function resulting in restriction of activities of daily living.
• No evidence/documentation that comprehensive eye examination and a single diagnostic A-Scan were done.

As a proactive measure, providers may want to perform some internal audits of the documentation in their cataract surgery records against the requirements in their MAC’s LCD. The findings will either validate appropriate documentation or provide opportunities for improvements. This may allow you to stay ahead of any Medicare contractors that come looking for improper payments.

Other medical review activities from last month include:

• Noridian JF – Review of Comprehensive Metabolic Panel laboratory test (CPT 80053)
  • Error rate 17%
  • Missing valid physician’s order or test results
  • Review to continue
• Noridian JE – Review of Rituximab, HCPCS code J9310
  • Error rate 11%
  • Denials due to lack of response to ADR, missing documentation (e.g. orders, administration notes), incorrect units of drug or administration codes, or documentation did not support a history of inadequate response to TNF antagonist therapies in patients receiving rituximab for rheumatoid arthritis (RA)
  • Review is closed
• Recovery Auditor for Region D, HDI – New issue posted for Multi-use vial wastage of the drug Trastuzumab (Herceptin) , HCPCS code J9355

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.