MACRA Affects MACs Effective Immediately

By Renee Dustman
Jan 16th, 2017

The Medicare Access and CHIP Reauthorization Act (MACRA), enacted on April 16, 2015, extended Medicare administrative contractor (MAC) contract terms from five to 10 years. The legislation also requires the Centers for Medicare & Medicaid Services (CMS) to publish performance information on each MAC, to the extent that such information does not interfere with contract procurements.

MAC Performance

CMS is using the following strategy to implement this legislation:

  • CMS published MAC performance information on its website in the summer of 2015. You can see the results on the CMS website.
  • CMS conducted market research to gather industry feedback on performance information and various contract issues, including contract length and performance incentives.
  • On Aug. 5, 2016, CMS published a Request for Information (RFI) to provide industry with a draft Request for Proposal (RFP) for use in future MAC procurements.

Future MAC Procurements

CMS plans to execute the next round of MAC procurements based on a “first-in, first-out” timeline.

Read the full text of the MACRA legislation at Public Law No: 114-10.

Infusion Drug Payment Amounts to Change with April Update

By Renee Dustman
Jan 16th, 2017

The 21st Century Cures Act, signed into law Dec. 13, 2016, changed the way certain Medicare Part B drugs infused through durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items will be paid beginning in April.

Curing Improper Payments

Section 5004 sets payment amounts for Part B drugs infused through DMEPOS items using the Average Sales Price (ASP) plus 6 percent—the same methodology used for most physician-administered drugs. Previously, payment amounts were based on manufacturer sticker prices that were in effect in 2003. The Office of Inspector General found this methodology was overpaying some drugs while underpaying others.

Medicare will use the April 2017 ASP drug pricing files and, if released, the revised January 2017, October 2016, July 2016, and April 2016 ASP drug pricing files to determine the payment limit for claims of separately payable Medicare Part B drugs processed or reprocessed on or after April 3, 2017.

Quarterly payment files will be applied as follows:

Files Effective Dates of Service
April 2017 ASP and ASP NOC April 1, 2017, through June 30, 2017
January 2017 ASP and ASP NOC Jan. 1, 2017, through March 31, 2017
October 2016 ASP and ASP NOC Oct. 1, 2016, through Dec. 31, 2016
July 2016 ASP and ASP NOC July 1, 2016, through Sept.30, 2016
April 2016 ASP and ASP NOC April 1, 2016, through June 30, 2016

Payment for DME infusion drugs that do not appear on the ASP Drug Pricing Files will be determined by the Medicare administrative contractors in accordance with the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3.

Payment allowance limits under the Outpatient Prospective Payment System are incorporated into the Outpatient Code Editor through separate instructions in Chapter 4, Section 50 of the Medicare Claims Processing Manual.

Source: MLN Matters Article MM9945, release date Dec. 13, 2017


Adding Credentials Brings Both Short and Long-Term Benefits

By Chandra Stephenson
Jan 13th, 2017

Are you thinking about adding to your current credentials? Are you unsure which one to go for, next?

The answer to that question isn’t the same for everyone. Ask yourself a few questions and do your research. The questions below can help most individuals quickly narrow down their list of potentials. (Side note: Did you know AAPC offers over 30 different credentials?)

• What areas are you experienced in?
• What are your goals?
• Why do you want to add another credential?
• How much time and money do you have to invest?

If you have experience in an area and enjoy working in that specialty (i.e., orthopedic surgery, evaluation and management), consider getting a specialty certification to demonstrate proficiency in all the nuances of that area.

Your short-term and long-term goals may seem incongruous, but they may just need a step in between them. For example, let’s say you are a certified coder (CPC) with the following goals:

• Short-term goals: Add another credential; continue to move up in the organization in which you work.
• Long-term goal: Manage a practice.

You probably aren’t yet ready to jump right to preparing for and taking the practice management certification (CPPM). You know as a practice manager you’ll need to understand many aspects of the practice including oversight of coding and compliance impacts. The auditing (CPMA) or compliance (CPCO) credential may be a stepping-stone for you.

If you just want to add another credential or you don’t have a lot of time and money to spend, look for which credentials are most similar to the ones you currently have or cover areas in which you feel proficient. For example, if you’re a CPC and want to add another credential for on-going education but don’t have much time to spend you might consider the COC. It is very similar in content to the CPC with primarily one new area (~20 questions) all about payment methodologies.

With a little reflection and research, choosing the next credential for you can be easy.

CMS Updates eCQM Specs for 2017

By Renee Dustman
Jan 13th, 2017

An addendum to the 2016 Electronic Clinical Measure (eCQM) specifications updates ICD-10-CM and ICD-10-PCS value sets for the 2017 performance year. This update applies to eCQMs for the 2017 performance period of the Merit-based Incentive Payment System (MIPS).

Go here to access the following:

  • eCQMs for Eligible Clinicians Table January 2017
  • eCQM Specifications for Eligible Clinicians January 2017
  • eCQM Technical Release Notes Update January 2017
  • eCQM Technical release Notes Update January 2017 (ICD-10 Updates only)


Three Tidbits for Better MRSA Dx Reporting

By Sheri Poe Bernard
Jan 12th, 2017

Prevent the spread of misguided MRSA claims with these tips for precise ICD-10-CM coding.

Although the precision of code descriptions makes it harder to miscode an infection in ICD-10-CM, there are three tricks to coding Methicillin-resistant Staphylococcus aureus (MRSA) to prevent claims denials or questions.

1. Make Notes in ICD-10-CM About Four MRSA Codes

The two main codes for MRSA infections are:

  • A49.02 Methicillin resistant Staphylococcus aureus infection, unspecified site

The infection site has not been determined, yet.

  • B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere

The infection site is known, and reported secondarily (e.g., skin of the groin).

One of these two codes usually is the first-listed code when a patient is treated for an MRSA infection.

Exceptions include a patient with MRSA sepsis or MRSA pneumonia, which have specific codes:

  • A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus

Only one code is needed for sepsis; additional codes are reported to capture severe sepsis and accompanying organ failure.

  • J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureusNote: No other code is needed to capture the pneumonia

Other sequencing exceptions include MRSA in obstetrical or neonatal coding, for which you are instructed to report the source of infection as an additional code.

2. Never Report Z16.11 with the Four MRSA Codes 

To do so would be redundant.

  • Z16.11 Resistance to penicillins [Methicillin is a form of penicillin.]

Many conditions require you to report MRSA with B95.62, and a second code to identify the site/type of infection, such as the skin site or specific heart valve. The drug resistance is inherent in the MRSA code, and ICD-10-CM guidelines tell you to leave Z16.11 out.

There are instances, however, when  Z16.11 for staph infections is appropriate. When a newborn or neonate has MRSA pneumonia or MRSA sepsis, for example, the P code captures the staphylococcal infection, but not the penicillin resistance.

  • P36.39 Sepsis of newborn due to other staphylococci

Report P36.39 for all staph sepsis in a child 28 days or younger, and report Z16.11 to capture the drug resistance.

  • P23.2 Congenital pneumonia due to staphylococcus

Report P23.2 for all staph pneumonia in a child 28 days or younger, and report Z16.11 to capture the drug resistance.

ICD-10-CM guidelines state, “If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should not be assigned.”

Because P36.39 describes the causal agent, you can capture the penicillin resistance with Z16.11. The same logic holds true for P23, although you’re not so instructed.

3. Report Colonization History, Testing, and Results 

MRSA lurks on the skin and in the nasal cavities of many people, increasing the risk of infection for the colonized persons and those around them. A person who has been “colonized” has MRSA present, without necessarily having an active MRSA infection. Patients undergoing hospitalization or outpatient elective surgery usually are tested for colonization using a nasal swab. The cost of this test is bundled into the Medicare Severity-Diagnosis Related Groups payment, but the preventive value of the test makes it financially advantageous for facilities.

In some cases, provider offices test high-risk patients for MRSA. These patients may have a history of MRSA or immunodeficiency. If MRSA is found, documentation may read “MRSA screen positive” or “MRSA swab positive.” ICD-10-CM has developed codes that allow you to capture these situations.

  • Z22.322 Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
  • Z86.14 Personal history of Methicillin resistant Staphylococcus aureus infection

A patient may have MRSA colonization and an active MRSA infection, in which case, code both conditions.

There are two CPT® codes for reporting MRSA screening or testing:

  • 87081 Culture, presumptive, pathogenic organisms, screening only

Report this code anytime a true screening is performed, as for hospital admission or when a skin or other accessible infection site is suspect.

Report Z22.322 to show the reason for the test, whether as a true screening or to screen for a symptomatic pathogen. The test’s focus is to determine if the infective agent will colonize a slide.

  • 87641 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique

A polymerase chain reaction technique is employed to test nasal swab specimens. Fluorescent dyes bind with the MRSA deoxyribonucleic acid (DNA) and software reports whether MRSA is present or absent in the sample. It should be clear from the documentation which of the diagnostic codes is appropriate to report with this test.

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About Has 6 Posts

Sheri Poe Bernard, CPC, COC, CPC-I, CCS-P, has developed education, training, and referential medical coding and reimbursement products for 20 years. She is the author of the AMA's 2015 publication, Netter's Atlas of Surgical Anatomy for CPT Coding. Her areas of expertise include CPT, ICD-9-CM, ICD-10-CM, and risk adjustment coding.