Keys to Submitting Complete and Compliant Claims

Transcription

1 Keys to Submitting Complete and Compliant Claims Sponsored by: Oncology State Society Network at the Association of Community Cancer Centers for Legacy, J5 and J8 Providers Presented by: Mary E. Muchow WPS Medicare Provider Outreach & Education May 8, 2013 Agenda Drug Wastage WPS Medicare Policy Drugs & Biologicals Coverage Requirements Drug Pricing Drug Shortages High Dollar Claim Review Medicare Claim Review Programs: Common Billing, Coding, and Documentation Errors for Oncology Services Incident-to Reopenings/Appeals Updates 2 1

2 Drug Wastage Single-use vial WPS Medicare does not require the use of the JW modifier Report combined amount of drug administered/drug wasted on one claim line Documentation must support information reported on claim 3 CMS Billing Example Single Dose- Vial Drug Wastage and JW Modifier Although not required for WPS Medicare providers, those wishing to do so may report drug wastage (single-use vial) with JW Modifier Medicare payment will equal reimbursement for 100mg Documentation must support information reported on claim 4 2

3 CMS Billing Example Single Dose- Vial Drug Wastage and JW Modifier Example Drug packaged in 100mg vial and HCPCS code JXXXX specifies 1 mg units Provider administers 95 mg to patient and wastes 5 mgs Claim Line 1 JXXXX; 95 units Claim Line 2 JXXXX; JW modifier, 5 units 5 Consideration for Rounding Units for Single-Dose Vial Wasted Drugs If rounded up amount includes entire amount of the drug to be billed (including administered and wasted amounts), no additional billing for wasted amount should be made Medicare payment will equal reimbursement for 10mg Documentation must support information reported on claim 6 3

4 Consideration for Rounding Units for Single-Dose Vial Wasted Drugs Example Drug packed in a 10mg vial and HCPCS code JXXXXX specifies 10 mg Provider administers 7 mg to patient and wastes 3 mg Claim Line 1 JXXXX; 1 unit 7 Documentation for Drug Wastage Include Date Time Amount wasted Reason for wastage 8 4

5 Multi-Use Vials Not subject to payment for discarded amounts Medicare reimbursement will equal 150 mg 9 Multi-Use Vials Example Example Provider administered 150 milligrams (mg) of JXXXX from a multi-use vial containing 440mg of JXXXX Based on HCPCS description (JXXXX, 10mg), the number of units reported is calculated as follows: 150 mg divided by 10mg, to equal 15 units of JXXXX The unused portion is equal to 290mg of JXXXX (440mg less 150mg) Claim Line 1 JXXXX; 15 units 10 5

6 Using Drugs/Biologicals Most Efficiently In a Clinically Appropriate Manner Per CMS Internet-Only Manual (IOM), Publication , Chapter 17, Section 40: Physicians, hospitals, and other providers should make good faith efforts to minimize the unused portion of a drug/biological product by ordering, scheduling, and storing in a manner in which the provider can use drugs/biologicals most efficiently in a clinically appropriate manner 11 WPS Medicare Policy Web Pages Include List of Active/Final coverage determinations that pertain to WPS Medicare providers Local Coverage Determinations (LCDs) housed on CMS website Search will vary Crosswalk to CPT/HCPCS codes appearing in associated coverage determinations Information on open meetings Drafts Final comments LCD Reconsideration process More 12 6

7 WPS Medicare LCD - Chemotherapy Drugs and their Adjuncts (L28576) Limited to WPS Medicare contracts Does not describe drug and biological coverage under Medicare Part D benefits LCD in its entirety is housed on CMS website Link available WPS Medicare LCD web page 13 Drugs and Biologicals Coverage Requirements Medicare Benefit Policy Manual, Publication , Chapter 15, Section 50 Guidance/Guidance/Manuals/Download s/bp102c15.pdf 14 7

8 Definition of Drug or Biological Publication , Chapter 15, Section 50.1 Lists drug compendia Payment considered by Medicare when the drug/biological is included in listed references 15 Approved Use of Drug Publication , Chapter 15, Section Use of drug/biological must be safe and effective and otherwise reasonable and necessary Includes drugs/biologicals approved for marketing by the Food and Drug Administration (FDA) 16 8

9 FDA Approval Acceptable Evidence Includes: Copy of the FDA s letter to the drug s manufacturer approving the New Drug Application (NDA) Listing of the drug or biological in the FDA s Approved Drug Products or FDA Drug and Device Product Approvals Copy of the manufacturer s package insert approved by the FDA as part of the labeling of the drug, containing its recommended uses and dosage as well as possible adverse reactions and recommended precautions in using it; or Information from the FDA s website 17 Examples of Not Reasonable and Necessary Publication , Chapter 15, Section Not for Particular Illness 2. Injection Method Not Indicated 3. Excessive Medications 18 9

10 Off-Label Use of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen Publication , Chapter 15, Section Unlabeled Use of Anti-Cancer Drugs Definition: Use of a drug not indicated on the drug's officially approved Food and Drug Administration (FDA) label May be covered under Medicare if the contractor determines the use to be medically accepted 20 10

11 Unlabeled Use The contractor considers The major drug compendia; Authoritative medical literature; and/or Accepted standards of medical practice 21 Use Identified By Compendium to Establish Coverage In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium, or Class I, Class IIa, or Class IIb in Thomson Micromedex Drug Dex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive 22 11

12 Use Not Medically Accepted By A Compendium A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacology is not supportive 23 Use of Compendia - Absence of Narrative Text The complete absence of narrative text on a use is considered neither supportive nor non-supportive 24 12

13 Clinical Research - Peer-Reviewed Medical Literature Section C states contractors may also allow payment for offlabel uses identified and supported by clinical research List of considerations and relevant supporting literature included in IOM Include relevant supporting literature, if requested 25 Requests For Off-Label Chemotherapy Drug Coverage Consideration Submit to WPS Medicare via LCD Reconsideration process OR Submit a request with a copy of the compendia documenting the medically accepted category or narrative and or peer reviewed literature that is published in a CMS accepted journal supporting use to policycomments@wpsic.com 26 13

14 Drug Pricing Files Average Sales Price (ASP) and Not Otherwise Classified (NOC) o ASP and not otherwise classified (NOC) drug pricing files for Medicare Part B drugs are supplied by CMS to contractors on a quarterly basis ASP methodology based on quarterly data submitted to CMS by manufacturers *2013 ASP and NOC drug pricing *Prior year pricing also available on CMS website 27 Non-ASP New Drugs and NOC Drugs WPS Medicare will calculate pricing only after a valid claim is received Medical staff determines if that claim can be paid Guidelines in CMS IOM, Publication , Chapter 17, Section

15 Determining Payment Limit Payment for FDA approved new drugs not included in the ASP Pricing File or NOC Pricing File will be based on the published Wholesale Acquisition Cost (WAC) or invoice pricing if the WAC is not published Contractors use methodology described in the IOM Payment limit is 106 percent of the lesser of the lowest-priced brand or median generic WAC 29 No WAC Pricing Available in CMS Approved Published Compendia Submit invoice Medicare will allow: The invoice cost for the amount of the drug that is billed on the claim A prorated amount for shipping and handling Any applicable sales tax CMS does not grant an additional 6 percent when pricing by invoice Dispensing and compounding fees not allowed 30 15

16 Process to Obtain Payment Limits from CMS Contractors may contact CMS to obtain payment limits for drugs not included in the quarterly ASP or NOC files or otherwise made available by CMS on CMS website If payment limit is available, contractors will substitute CMS provided payment limits for pricing based on WAC or invoice pricing 31 Contractor Discretion to Determine Which Published Drug Compendia to Use as a Source for Drug Pricing Several CMS approved sources are available WPS Medicare currently uses Micromedex Red Book Online Pricing information submitted by outside sources are not considered published drug compendia 32 16

17 Review of Developed WAC Allowances Reviewed every three months in conjunction with the ASP quarterly update to determine if any changes have been made to the WAC or if any new pricing sources have been added for a given drug Pricing is recalculated and added to pricing database when necessary 33 Effective Date for Pricing Once Established by CMS Effective date for pricing is the quarter that corresponds to the ASP NOC file(s) that CMS has published Dates of service prior to the CMS decision will continue to be paid based on allowance developed by the contractor prior to the CMS decision or by invoice 34 17

18 Article How Does WPS Medicare Price Non-ASP New Drugs and NOC Drugs? Found on WPS Medicare website Refer to handout 35 Drug Shortages CMS will notify WPS Medicare regarding drug shortage issues WPS Medicare will notify providers Example Medicare Learning Network (MLN) Matters Number MM7841- News Flash Shortage of Doxil, new codes provided by CMS; CMS to release Change Request with additional instructions 36 18

19 High Dollar Claim Review Implemented based on Office of Inspector General (OIG) recommendations 37 Multi-Carrier System Edits for High Dollar Claims Additional Documentation Request (ADR) letter is sent when approved to pay amount on any claim line is $7,500 or more Documentation needed for review will vary, depending on billed item/service 38 19

20 Expedite High Dollar Review Process Avoid waiting for the ADR letter Obtain the claim Internal Control Number (ICN) Interactive Voice Response (IVR) telephone system Centers for Medicare & Medicaid Services (CMS) Secure Net Access Portal (C-SNAP) Use Development Resolution Fax Form (state specific) to submit requested documentation Available on Forms web page Check box to indicate High Dollar Development Resolution 39 Moving Forward Providers should develop internal processes that enable them to respond effectively and efficiently to high dollar claim edits WPS Medicare continues to accumulate, review, analyze and educate on current high dollar data to evaluate edit effectiveness 40 20

21 Medicare Claim Review Programs Performed by a variety of contractors Affiliated Contractor (AC) Medicare Administrative Contractor (MAC) Program Safeguard Contractor (PSC) Zone Program Integrity Contractor (ZPIC) Comprehensive Error Rate Testing (CERT) Contractor Recovery Audit (RA) 41 Medicare Prepayment and Postpayment Review Programs Prepayment Claim Review Programs Postpayment Claim Review Programs National Correct Coding Initiatives (NCCI) Edits Comprehensive Error Rate Testing Program Medically Unlikely Edits (MUEs) Recovery Audit (RA) Program AC/MAC Medical Review (MR) AC/MAC Medical Review (MR) 42 21

22 CERT Identified Errors by Provider Specialty Found on WPS Medicare website Refer to handout 43 CERT Errors by Denial Reason for Medical Oncology (Specialty 90)* Legacy B Insufficient documentation (100%) J5 MAC B No errors for this reporting period J8 MAC B Service incorrectly coded (99.24%) Insufficient documentation (.76%) For CMS November 2012 CERT Reporting Period 44 22

23 CERT Quarterly Error Finding Reports Found on WPS Medicare website Refer to handout 45 Example Insufficient Documentation Medical Oncology (Specialty 90) Billed CPT and Missing the physician order or documentation of intent of ordering the billed complete blood count (CBC) and automated differential and comprehensive metabolic panel (CMP) 46 23

24 CERT Error Example Insufficient Documentation Billed CPT J Missing documentation that Aranesp injection was administered on billed date of service Received flow sheet documenting the drug as being given on multiple dates except date billed on this claim For the date reported on claim: Drug dosage and frequency is documented; however, no indication it was administered No site of administration documented No initials of person administering the drug documented 47 CERT Error Example Not Medically Necessary Service or Treatment Billed CPT Billed venipuncture is related to the noncovered CBC and CMP level denied as insufficient documentation to support medically necessity on same claim - therefore the related venipuncture is denied 48 24

25 CMS Guidance to Address Billing CERT and RA Errors Quarterly provider compliance newsletter CERT and Recovery Audit findings Identifies provider types affected Provides guidance on avoiding errors Includes resources 49 Quarterly Provider Compliance Newsletter Archive 50 25

26 Where can I find more CMS Medicare Learning Network (MLN) products? 51 Common Billing Error Neulasta HCPCS code J2505 Claims submitted erroneously using the total number of milligrams administered instead of units 1 unit = 6 mg 52 26

27 Documentation Requirements Specific documentation may be required per the LCD Previous treatment regimens Lab values 53 Valid Order Documentation must support the intent to initiate the treatment regimen A prescription order from the initiating physician covering the cycle of infusions which includes the billed date of service OR A progress note from the prescribing physician documenting the intent for treatment which covers the billed date of service. Must include date, valid physician signature, drug dosage and treatment cycle that includes the billed date of service 54 27

28 Signature Requirements Physician s Order or Progress Notes Found in CMS IOM, Publication , Chapter 3, Section Electronic signature must validate provider has authenticated the record Stamped signatures or unsecured scanned signature not valid Attestation statements do not replace a missing or unsigned order but may be used to authenticate progress notes Attestation statements do not replace a missing or unsigned order but may be used to authenticate progress notes 55 Signature Guidelines for Medical Review Purposes CMS MLN Matters Number MM

29 Chemotherapy Infusion/Administration Record Documentation Must include: Clear indication of patient name, date of birth, and date of service(s) Name and dosage of drug administered Signed physician order for the drug(s) administered, dosage, frequency, route of infusion, and duration of treatment Time of infusion Signature/credentials of person doing the infusion Documentation must support the drug was administered according to the order 57 Drug Package Inserts and Drug Substitutions Drug package inserts not required Submit questions regarding chemotherapy drugs substitutions, if necessary, to: wpsic.com 58 29

30 Article Medical Documentation Required When Submitting Oncology Drug Services Found on WPS Medicare website Refer to handout 59 Bundled Services If performed to facilitate chemo infusion or injection, the following are included and are not separately billable: Use of local anesthesia IV access Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes and supplies Preparation of the chemotherapy agent(s) 60 30

31 Know if you are submitting claims with improper payments Conduct an internal assessment to identify if you are in compliance with Medicare rules Identify corrective actions to promote compliance Appeal when necessary Learn from past experiences 61 Incident-to Provision of Medicare Services are submitted by the billing/supervising physician/npp but are rendered by someone else Certain criteria must be met 62 31

32 Incident-to Criteria The service must be An integral part of the physician s professional services Commonly furnished in the physician s office or clinic Commonly provided without charge or included in the physician s bill Limited to situations in which there is direct physician supervision Without their own benefit category 63 Who may render services incident-to a physician? Auxiliary personnel Registered Nurses, Technicians, Medical Assistants, Licensed Practical or Vocational Nurses, or other qualified personnel Non-physician practitioners (NPPs) Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, Certified Nurse Mid Wife, Clinical Psychologists, or other NPPs as defined by CMS 64 32

33 Who can supervise incident-to services? Physician defined as physician or other practitioner (PA, NP, NS, CNMW, etc) authorized by the Act to receive payment for services incident-to his or her own services 65 Supervision in Group Practices Who can supervise incident to services? Any qualified physician in the same group who is in the clinic or office suite and is immediately available to furnish assistance or direction if needed, but only when all other incident to criteria is met Not necessarily the physician who performed the initial patient visit Not necessarily the patient s primary care physician Not necessarily the same specialty as the primary physician 66 33

34 Billing Incident-to Sole Proprietor Referring physician/npp s name must be identified in Item 17 and NPI in 17b Physician/NPP s billing information must be identified in Item 33 and NPI in Item 33a 67 Billing Incident-to Incorporated/LLC/Group/Clinic Ordering physician/npp s name must be identified in Item 17 and NPI in 17b Supervising physician/npp s NPI must be in Item 24J Billing entity information must be identified in Item 33 and NPI in Item 33a 68 34

35 Documentation Considerations Incident-to Documentation should include A clearly stated reason for the visit A means of relating this visit to the initial service and/or ongoing service provided by the physician Patient s progress notes, response to, and changes/revision in the care plan Information as required by LCD Date the service was provided Signature of person rendering the service 69 Reopenings Via phone or in writing to correct minor errors, clerical errors, or omissions May be requested up to one year from the receipt of the initial Remittance Advice (RA) Calculator available on WPS Medicare website 70 35

36 Article How to Request a Reopening Found on WPS Medicare website Refer to handout 71 Appeals Based on CMS guidance Five levels of appeal Different timeframes and amounts in controversy, depending on level of appeal First level appeal, the Redetermination, is performed by WPS Medicare 120 days from date of RA receipt to file request for Redetermination Calculator available on WPS Medicare website Contractors has up to 60 days to render decision 72 36

37 Appeals Web Page Found on WPS Medicare website Refer to handout 73 Article - How to Appeal a Claim Determination Found on WPS Medicare website Refer to handout 74 37

38 Other Important Items CMS Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) Handout Medicare Updates 75 Self Service Technology enews Sign up today! On Demand Training Interactive Voice Response (IVR) CMS Secure Net Access Portal (C- SNAP) New Feature Help Center 76 38

39 ICD-10 Compliance date is October 1, Disclaimer The information presented and responses to the questions posed are not intended to serve as coding or legal advice. Many variables affect coding decisions and any response to the limited information provided in a question is intended only to provide general information that might be considered in resolving coding issues. All coding must be considered on a case-by-case basis and must be supported by appropriate documentation in the medical record. The CPT codes that are utilized in coding claims are produced and copyrighted by the American Medical Association (AMA). Specific questions regarding the use of CPT codes may be directed to the AMA