01-006 Inpatient Bone Marrow and Stem Cell Transplant Procedures Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Part A services billed on dates of service from January 1, 2017, through December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Office of Inspector General (OIG), under report A-09-14-02037, dated February 2016, found that Medicare paid hospitals $185.9 million for inpatient claims related to bone marrow and stem cell transplant procedures (collectively referred to as “stem cell transplants”). The OIG identified Medicare overpayments to two hospitals that did not always comply with Medicare billing requirements for inpatient claims for stem cell transplants. This resulted in overpayments of approximately $4 million. The lengths of stay for the claims reviewed were one to two days, but generally the lengths of stay for claims for these procedures range from 10 to 21 days. Because claims with these disparities are at risk for billing errors, the OIG reviewed $7.3 million in Medicare payments nationwide for 143 selected inpatient claims for stem cell transplants, from January 2010 through September 2013.

It was found that 133 of the 143 selected inpatient claims did not comply with Medicare billing requirements; the lengths of stay were one to two days. For 120 of those claims, the hospitals incorrectly billed Medicare Part A for beneficiary stays that should have been billed as outpatient, or outpatient with observation services. These claims did not have clinical evidence supporting that an inpatient level of care was required before, during or after the transplant procedure was performed. On the remaining 13 claims, the hospitals billed incorrect Medicare Severity-Diagnosis Related Group (MS-DRGs).

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review.  Noridian will complete medical record review to determine if providers billed in accordance with statutory, regulatory and subregulatory guidance.

Claim Sample Detail

 

Revenue Code MS-DRG
0001
  • 009: Bone marrow transplant
  • 014: Allogenic bone marrow transplant
  • 016: Autologous bone marrow transplant with a complication or comorbidity (CC)
  • 017: Autologous bone marrow transplant without a CC or major CC

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Documentation to support the beneficiary was expected to require an inpatient level of care for at least 2-Midnights
  2. Documentation to support an inpatient level of care was expected and provided. Documentation should include, but is not limited to: Medication Administration Records (MAR), History & Physical, Physician Progress Notes, Nursing Notes, Discharge Summary, Procedure Notes
  3. Inpatient admission order from attending physician
  4. Physician or Non-Physician Practitioner (NPP) order for the stem cell transplant for the dates of service
  5. Medical documentation that supports the beneficiary met criteria for one of the following covered services:
    1. Allogenic Hematopoietic Stem Cell Transplantation (HSCT)
    2. Autologous Stem Cell Transplantation (AuSCT)
  6. Documentation to support enrollment in an approved Clinical Research Study, if applicable
  7. Full detailed itemization of services, including diagnosis codes
  8. Legible handwritten physician and/or clinician signatures
    1. Signature logs and Signature Attestation Statement should be submitted when physician and/or clinician signatures are illegible
  9. Valid electronic physician and/or clinician signatures
  10. Advance Beneficiary Notice of Noncoverage (ABN), if applicable

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare As Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Code of Federal Regulations Title 42, Chapter 4, Section 412.3. Prospective Payment Systems for Inpatient Hospital Services
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 1. Inpatient Hospital Services Covered Under Part A
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 3. Duration of Covered Inpatient Services
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.3-6.5.9. Medical Review of Inpatient Hospital Claims for Part A Payment
  • CMS IOM, Publication 100-03 National Coverage Determination (NCD) Manual, Chapter 1, Section 110.23. Stem Cell Transplantation. Effective 01/27/2016
  • Office of Inspector General, Report A-09-14-02037, Medicare Did Not Pay Selected Inpatient Claims for Bone Marrow and Stem Cell Transplant Procedures In Accordance With Medicare Requirements

Last Updated Jan 17, 2019