Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), has conducted post-payment coding review of claims for Medicare Part A billed on dates of service from March 1, 2020, through December 31, 2021. Below are the review results:

Background

A nationwide Public Health Emergency (PHE) was declared on January 31, 2020. In response, Secretary Alex Azar of the Department of Health and Human Services (HHS) authorized waivers and modifications on March 13, 2020, retroactive to March 1, 2020, under Section 1135 of the Social Security Act (SSA), which outlines the authority to waive requirements during national emergencies.

Waivers under Section 1135 of the SSA included several modifications related to hospital transfers during the PHE which allowed acute care facilities to accommodate the potential increased patient load due to COVID-19 and facilitate patient quarantine during the PHE. In June 2022, Noridian completed research and performed data analysis on inpatient facility claims for transfers with overlapping dates of service (DOS) and identified a potential area of vulnerability.

Reason for Review

The SMRC was tasked to perform data analysis and conduct coding reviews for inpatient facility transfers with overlapping DOS from March 1, 2020, through December 31, 2021.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• No response to the documentation request
  • Internet-Only Manuals (IOM), Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter (Ch.) 3, Section 3.2.3.8 states “During post-payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary.” Providers are required to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted, or not submitted timely, therefore the claim was denied.
• Insufficient documentation
  • Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, “If the MAC, CERT, RAC, SMRC, or UPIC requests additional documentation to verify compliance with a benefit category requirement, and the submitted documentation lacks evidence that the benefit category requirements were met, the reviewer shall issue a benefit category denial.” The documentation submitted did not contain enough information to support the admission dates and/or discharge dates to determine coverage for payment.

References

Social Security Act (SSA), Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

SSA, Title XVIII

• § 1812 Scope of Benefits
• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1861 Definitions of Services, Institutions, Etc.
• § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1877(g) Limitation on Certain Physician Referrals
• § 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) and (f) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• § 411.15(k)(1) Particular Services Excluded from Coverage
• § 412 Subpart A – General Provisions
• § 413.1 Subpart A – Introduction and General Rules

Federal Register

• Final Rule Volume 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)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC
• IFC Volume 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. May 8, 2020. Retrieved from 2020-09608.pdf (govinfo.gov)

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

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

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

• Ch. 1 General Billing Requirements
• Ch. 3 § 20.1.2.4 Transfers
• Ch. 3 § 40.2.4 IPPS Transfers Between Hospitals
• Ch. 3 § 150 Long Term Care Hospitals
• Ch. 6 Inpatient Part A Billing and SNF Consolidated Billing
• Ch. 25 Completing and Processing the Form CMS-1450 Data Set

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

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions

Other

• 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs). March 2022. Retrieved from 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs) (cms.gov)
• Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver. March 15, 2019. Retrieved from Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver (cms.gov)
• COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. Updated May 24, 2022. Retrieved from COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (cms.gov)
• COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Updated February 28, 2022. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (cms.gov)
• Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers. Updated June 1, 2022. Retrieved from Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers (cms.gov)
• Medicare Telemedicine Health Care Provider Fact Sheet. March 17, 2020. Retrieved from  MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET | CMS
• Medicare Learning Network (MLN) SE1411, Clarification of Patient Discharge Status Codes and Hospital Transfer Policies. November 17, 2015. Retrieved from SE1411 (cms.gov)
• MLN SE20011, Medicare FFS Response to the PHE on COVID-19. Release Date September 8, 2021. Retrieved from SE20011 (cms.gov)
• Office of Inspector General (OIG) Work Plan Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies. Report Number W-00-20-35832. 2022. Retrieved from Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies (hhs.gov)

Last Updated Jul 18, 2023