Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part A claims billed on dates of service from July 1, 2022 through November 30, 2023. Below are the review results:

Background

In March 2020, CMS announced the Hospitals Without Walls program, which provides broad regulatory flexibility that allows hospitals to provide services in locations beyond their existing walls. The Acute Hospital Care at Home (AHCaH) program was developed to support models of at-home hospital care throughout the country.

The Acute Hospital Care at Home (AHCaH) program was developed to support models of at-home hospital care throughout the country. The AHCaH waiver initiation begun in November 2020 in response to the COVID-19 pandemic-related hospital capacity concerns. This initiative allowed individually approved hospitals to provide inpatient-level care for Medicare patients, leveraging telehealth, and waiving the requirement that a nurse be always present.

The Consolidated Appropriations Act (CAA), 2023 was passed by Congress on December 29, 2022, and extended the AHCaH initiative through December 2024. This legislation requires hospitals to provide data to the Secretary to monitor the quality of care and to undertake a study, which must be completed on or before September 30, 2024. As a requirement of this legislation, CMS will perform a study to analyze the quality of care and clinical conditions treated, costs incurred, quantity, mix, and intensity of services furnished at home, and socioeconomic information on beneficiaries treated, which are the same criteria used by hospitals.

More information can be found on the Acute Hospital Care at Home (AHCaH) webpage.

Reason for Review

The Consolidated Appropriations Act of 2023 (CAA, 2023) was signed into law on December 29, 2022, which included funding for disaster relief and extended several expiring waivers or flexibilities put in place during COVID-19. The extension of the AHCaH initiative is effective through December 31, 2024. As part of this extension, the SMRC conducted a DRG coding review to analyze AHCaH claims.

The SMRC was tasked with performing data analysis and conducted DRG coding reviews on claims billed with AHCaH DRG codes billed with dates of service July 1, 2022, through November 30, 2023.

The SMRC conducted DRG coding reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, sub-regulatory, and coding guidance.

Common Reasons for Denial

• No Response to ADR
  • Refer to Social Security Act 1833(e); 42 CFR 424.5(a)(6); Medicare Program Integrity Manual IOM 100-08, Chapter 3, Section 3.2.3.8C. No medical record documentation was received. The inpatient documentation was not submitted to support the claim, as requested by the additional documentation request (ADR).
• Diagnosis Code Not Supported
  • Refer to Internet-Only Manual, Pub 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4, 3.6.2.5, Pub 100-04, Medicare Claims Processing Manual, Chapter 23. The documentation does not support the diagnosis code billed or the documentation submitted supported a different admitting and/or principal diagnosis code from what was originally billed on the claim.
• Incomplete/Insufficient Information
  • Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, Social Security Act 1833(e), 42 CFR 424.5(a)(6). Incomplete/Insufficient information. Documentation received did not contain medical records.

References

Social Security Act (SSA) Title XI

• § 1135. Authority to Waive Requirements During National Emergencies.

Social Security Act (SSA), Title XVIII

• § 1812. Scope of Benefits.
• § 1815(a). Payment to Providers of Services.
• § 1861. Definitions of Services, Institutions, Etc.
• § 1862 (a)(1) (A). Exclusions from Coverage and Medicare as Secondary Payer.
• § 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1886(I)(i). Payment to Hospitals for Inpatient Hospital Services.
• § 1893(b). Medicare Integrity Program.

42 Code of Federal Regulations (CFR)

• § 411.15(k)(1). Particular Services Excluded from Coverage.
• § 412.1(a)(1). Scope of Part.
• § 412.2. Basis of payment.
• § 412.4(b) Discharges and Transfers.
• Subpart A, § 413.1. Introduction and General Rules.
• § 424.5 and 424.5(a)(6). Conditions for Medicare Payment – Basic Conditions, Sufficient Information.

Public Law

• H.R. 2617-117th Congress (2021-2022) Consolidated Appropriations Act, 2023. Retrieved from H.R.2617 – 117th Congress (2021-2022): Consolidated Appropriations Act, 2023 | Congress.gov | Library of Congress

Federal Register

• Interim Final Rule with Comments (IFC). Volume 85, Number 66. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. CMS-1744-IFC. Effective March 31, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC). Vol. 85, No. 90. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in response to the COVID–19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Effective May 8, 2020. Retrieved from https://www.cms.gov/files/document/covid-final-ifc.pdf
• Final Rule (FR). Vol. 85, No. 248. Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID–19; and Finalization of Certain Provisions from the March 31st, May 8th, and September 2nd Interim Final Rules in Response to the PHE for COVID–19. CMS-1734-F Effective January 1, 2021. Retrieved from 2020-26815.pdf (govinfo.gov)

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Chapter (Ch.) 1. Inpatient Hospital Services Covered Under Part A.
• Ch. 16. General Exclusion from Coverage.

Internet-Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 1. General Billing Requirements.
• Ch. 3. Inpatient Hospital Billing.
• Ch. 23, § 10.2. Inpatient Claim Diagnosis Reporting.

Internet-Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3. Verifying Potential Errors and Taking Corrective Actions.
• Ch. 6, §§ 6.5.1-6.5.4. Medical Review of Inpatient Hospital Claims for Part A Payment.

CMS Coding Policies

• CMS. New Occurrence Span Code and Revenue Code for Acute Hospital Care at Home. Change Request 12540 Effective July 1, 2022. Retrieved from r11191otn.pdf (cms.gov)

Other

• CMS. Acute Hospital Care at Home Individual Waiver Only (not a blanket waiver). Retrieved from Acute Hospital Care at Home (cms.gov)
• CMS. Acute Hospital Care at Home Program approved List of Hospitals as of 4/5/2021. April 9, 2021. Retrieved from Acute Hospital Care at Home Program Approved List of hospitals as of 4/5/2021 (cms.gov)

Last Updated Aug 28, 2024