Local Coverage Determination (LCD)

One Day Stays for Chest Pain

L34551

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34551
Original ICD-9 LCD ID
Not Applicable
LCD Title
One Day Stays for Chest Pain
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 05/05/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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Issue

Issue Description

The LCD L34551 (One Day Stays for Chest Pain) provides coverage guidance for one-day acute inpatient hospital admissions (one-day stays) for chest pain. The goal of this policy is to decrease the frequency of denials and improper Medicare payments. This goal will be accomplished by utilizing the concepts contained in the American College of Cardiology Foundation/ American Heart Association (ACC/AHA) guidelines for unstable angina/non-ST elevation myocardial infarction (NSTEMI) as a framework to communicate reasonable and necessary acute inpatient admissions for chest pain.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, §10 Covered Inpatient Hospital Services Covered Under Part A

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Background and Rationale:

The goal of this policy is to decrease the frequency of denials and improper Medicare payments for one-day acute inpatient hospital admissions (one-day stays) for chest pain. This goal will be accomplished by utilizing the concepts contained in the American College of Cardiology Foundation/American Heart Association (ACC/AHA) guidelines for unstable angina/non-ST elevation myocardial infarction (NSTEMI) as a framework to communicate reasonable and necessary acute inpatient admissions for chest pain. The ACC/AHA evaluation & management algorithm of patients suspected of having acute coronary syndrome (ACS) algorithm provides a reliable, evidence-based structure for documenting the complex decision-making process required of hospitals submitting claims for one-day stays.

The patient’s history, physical examination, diagnostic test results, together with observed changes over time (including responsiveness/non-responsiveness to treatment) are used by physicians to synthesize the clinical rationale for an acute inpatient admission. This cognitive process, however, is often incompletely transcribed into the healthcare record to support the resultant acute inpatient admission for chest pain. This incomplete transcription often results in Medicare one-day stay denials for failing to meet the “reasonable and necessary” standards established in the Medicare Benefit Policy Manual.

While the Medicare coverage requirements for acute inpatient admissions have been in effect and disseminated by the Centers for Medicare & Medicaid Services (CMS) for many years, they have not been consistently adopted and implemented by acute care hospitals. This variation led to pre-payment record reviews by this A/B MAC and post-payment record reviews by the Comprehensive Error-Rate Testing Contractor (CERT) and the Recovery Audit Contractors (RACs). These record reviews have identified many instances of improper payments for one-day stays for chest pain.

Relevant Concepts:

The ACS algorithm contains evidence-based clinical diagnostic pathways that are also aligned with existing Medicare coverage and reimbursement policy. According to the ACC/AHA guidelines, a patient’s history, physical examination, 12-lead ECG and initial cardiac biomarker tests should be used to select the most appropriate evidenced-based treatment and setting, acute inpatient admission, outpatient observation or outpatient follow-up.

Proposed Solution:

The ACC/AHA guidelines for unstable angina and NSTEMI provide a documentation framework for successfully communicating the complex decision-making processes required of physicians and hospitals caring for patients presenting with signs and symptoms of ACS. The resultant structured information could be used to improve both clinical and administrative communication. The adoption and implementation of these evidence-based guidelines for ACS will require a collaborative effort among physicians, nurses, hospitals and healthcare payers.

The communication of patient-specific information via the health record should be the goal of both physicians and hospitals. Hospitals experiencing one-day stays for chest pain are encouraged to use the ACC/AHA evidence-based workflows to help improve their clinical documentation processes and strengthen the healthcare records supporting one-day stays for chest pain. This approach will improve communication between hospitals and this A/B MAC and thus decrease Medicare denials and improper payments for one-day stays for chest pain.

This A/B MAC proposes to use the ACC/AHA framework in its reviews of one-day stays for chest pain in an effort to improve its communication with acute care hospitals experiencing denials for such claims. Education will be provided within the context of the ACS algorithm to help communicate opportunities for process improvements in documentation.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

Sources of Information
N/A
Bibliography

Centers for Medicare and Medicaid Services. Guidance on Hospital Inpatient Admission Decisions. Updated 7/31/12. Accessed 3/24/22.

Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2013;61(23):e179-347.

Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA focused update of the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2011;57(19):1920-1959.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
05/05/2022 R10

Under CMS National Coverage Policy added the regulation "Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim." Under Coverage Indications, Limitations and/or Medical Necessity replaced the verbiage ‘Palmetto GBA’ with ‘this A/B MAC’. Under Bibliography changes were made to citations to reflect AMA citation guidelines and the broken hyperlink was fixed for reference #1. Formatting, punctuation, and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
02/20/2020 R9

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Citations that are no longer available were deleted. Access date updated for the last reference. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/31/2019 R8

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD.

  • Provider Education/Guidance
10/03/2019 R7

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
05/24/2018 R6

Punctuation was corrected and words were capitalized or changed to lower case as appropriate throughout the policy. Under CMS National Coverage Policy deleted CMS Internet-Only Manual, Pub 100-08, Chapter 6, section 6.5. Under Coverage Indications, Limitations and/or Medical Necessity – Background and Rationale deleted the word “segment” from the second sentence of the first paragraph. Under Coverage Indications, Limitations and/or Medical Necessity – Proposed Solution deleted the words “Non ST-segment Elevation Myocardial Infarction” and removed the parentheses around the acronym NSTEMI in the first paragraph. Information under Sources of Information was moved to the Bibliography section. Under Bibliography changes were made to citations to reflect AMA citation guidelines. The title was corrected in the second reference, the verbiage “Updated July 31, 2012” was added to the third reference, and the access dates were changed to May 14, 2018 for the last four references.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Typographical Error
01/29/2018 R5 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
06/03/2016 R4 Annual Validation
  • Provider Education/Guidance
06/03/2016 R3 Under Sources of Information and Basis for Decision corrected author’s name “Jneid H” and title of the article “2012 ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;61(23):e179-347 and deleted a duplicate source entry.
  • Provider Education/Guidance
  • Typographical Error
10/01/2015 R2 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R1 Throughout the policy changed all numeral “1’s” to the word “one”, and made grammatical/punctuation corrections.
Under Coverage Indications, Limitations and/or Medical Necessity in the second sentence removed the word “and” and corrected to reference ACC/AHA Guidelines for Unstable Angina/Non-ST Segment Elevation Myocardial Infarction. In the second paragraph, corrected the grammar of the second sentence. In the last paragraph, re-worded the first sentence to read ….”framework in its reviews of One-Day Stays for Chest Pain in an effort to improve its communication with acute”…. Removed “in order” from the second sentence.
Under Sources of Information and Basis for Decision corrected all sources to meet AMA formatting, removed the second reference to 2011 ACC/AHA Focused Update and updated it with the 2013 version, added reference to ACC/AHA 2013 Guidelines for the Management of Patients with Unstable Angina.
  • Provider Education/Guidance
  • Other (Annual validation)
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
04/25/2022 05/05/2022 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Chest Pain

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