Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Education Bulletin December 2010 To: All Medicare Advantage (MA) Physicians & Practitioners, Hospitals & Facilities* *Contracting physicians & practitioners, hospitals & facilities should follow their contracts for all billing guidelines Medicare Advantage 2011 Product Information Empire Blue Cross and Blue Shield (Empire) would like to share with the physicians and practitioners who treat our members the upcoming changes to our Medicare Advantage (MA) products. This quick reference article will give you the highlights of the plans being offered in 2011 as well as the major contrasts to the 2010 products. to click on is the Click here for Important Medicare Advantage Updates at the top of the page ESRD Changes Effective January 1, 2011, CMS has announced a new End Stage Renal Disease (ESRD) bundled prospective payment system (PPS). The ESRD PPS will provide a single payment to ESRD facilities, i.e., hospital-based providers of services and renal dialysis facilities, that will cover all the resources used in providing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis in the ESRD facility or at a patient s home, drugs, biologicals, laboratory tests, training, and support services. The ESRD PPS provides ESRD facilities a 4-year phase-in (transition) period under which they would receive a blend of the current payment methodology and the new ESRD PPS payment. In 2014, the payments will be based 100 percent on the ESRD PPS payment. 2011: 75 percent of the old payment methodology, and 25 percent of the new PPS payment. 2012: 50 percent of the old payment methodology, and 50 percent of the new PPS payment. 2013: 25 percent of the old payment methodology, and 75 percent of the new PPS payment. 2014: 100 percent of the PPS payment. Providers wishing to opt out of the phase in process should have faxed their request to CMS by November 1st, The new ESRD PPS provides for three categories of chronic comorbid conditions and three categories for acute comorbid conditions. New comorbid condition codes are MA, MB, MC, MD, ME and MF. A single adjustment will be made to claims containing one or more of the comorbid conditions. The highest comorbid adjustment applicable will be applied to the claim. The acute comorbid adjustment may be paid no greater than four consecutive months for any reported acute comorbid condition unless there is a reoccurrence of the condition. The three chronic comorbid categories eligible for a payment adjustment are: New Condition code ME - Hereditary hemolytic and sickle cell anemia, New Condition code MF - Monoclonal gammopathy (in the absence of multiple myeloma) and New Condition code MD - Myelodysplastic syndrome.

2 The three acute comorbid categories eligible for a payment adjustment are: New Condition code MB - Bacterial Pneumonia, New Condition code MA - Gastrointestinal Bleeding, and New Condition code MC - Pericarditis. Medicare Contractors will accept the new condition codes H3, H4 and H5 when reported on the 72x bill type effective January 1, Effective January 1, 2011 renal dialysis facilities must report the appropriate diagnosis code(s) for comorbidity conditions in the other diagnosis fields. The ESRD PRICER shall not apply comorbid adjustments when the onset of dialysis adjustment is applicable. New Condition code H3 reoccurrence of MA category New Condition code H4 reoccurrence of MB category New Condition code H5 - reoccurrence of MC category Services not included in the PPS that remain separately payable include blood and blood processing, preventive vaccines, and Telehealth services that are not considered outlier services. Blood and blood processing Preventive vaccines Telehealth services Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, CMS has made significant changes in policy as a result of the law and many of these changes apply to Medicare Advantage programs. Empire Blue Cross and Blue Shield recognizes that these changes affect the physicians and practitioners who treat our members. On each of Empire's MA product pages within there is a link titled Patient Protection and Affordable Care Act. Within that link Empire has posted, and will continue to post going forward, CMS published material with a forward explaining Empire s role and responsibility in regards to the updated PPACA regulation. to click on is the Patient Protection and Affordable Care Act Information under the Additional Information section at the bottom of the page. The PPACA articles from CMS with Forwards by Empire can be found here. For complete details of CMS s timeline and implementation of PPACA regulations please visit Instructions for Reporting Assessment Dates under the Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF), and Swing Bed (SB) Prospective Payment Systems (PPSs) The assessment date data element has been removed from the new version of the 8371 electronic format. Therefore, effective for dates of service on or after January 1, 2011, CMS requires an occurrence code 50 for reporting assessment dates for IRF, SNF, and SB PPS providers. Providers should no longer report this date in the service date field on the UB-04 and the 8371 electronic version for dates of service on or after January 1, Occurrence code 50 must be reported on all IRF PPS 11X bill types. If occurrence code 50 is not included on the claim, the claim will be rejected as a billing error.

3 New Statutory Provision Pertaining to Medicare 3-Day Payment Window Policy On June 25, 2010, President Obama signed into law the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of Section 102 of the law pertains to Medicare s policy for payment of outpatient services provided on either the date of a beneficiary s admission or during the three calendar days immediately preceding the date of a beneficiary s inpatient admission to a hospital subject to the inpatient prospective payment system (IPPS). This policy is known as the 3-day or 1-day payment window. A hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the beneficiary s inpatient claim the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services that are furnished to the beneficiary during the 3-day (or 1-day) payment window. The new law makes the policy pertaining to admission-related outpatient nondiagnostic services more consistent with common hospital billing practices. Section 102 of Pub. L is effective for services furnished on or after the date of enactment, which is June 25, Critical Access Hospital (CAH) Method II-Removal of Annual Election Effective October 1, 2010, CAH s election of the optional or Method II payment method for outpatient services will remain in place until the CAH terminates it. Prior to October 1, 2010, it was required that your Method II status had to be renewed every 12 months in order to remain a Method II provider Changes to Present on Admission (POA) Indicator 1 Effective with the implementation of 5010 Inpatient Prospective Payment System (IPPS), January 1, 2011 hospitals will no longer be required to report the Present on Admission (POA) indicator of 1. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are exempt from the POA reporting requirement should be left blank instead of populating a 1. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

4 Medicare Advantage Outreach and Education Bulletin December 2010 To: All Medicare Advantage (MA) Physicians & Practitioners, Hospitals & Facilities* *Contracting physicians & practitioners, hospitals & facilities should follow their contracts for all billing guidelines Medicare Advantage 2011 Product Information Empire Blue Cross (Empire) would like to share with the physicians and practitioners who treat our members the upcoming changes to our Medicare Advantage (MA) products. This quick reference article will give you the highlights of the plans being offered in 2011 as well as the major contrasts to the 2010 products. to click on is the Click here for Important Medicare Advantage Updates at the top of the page ESRD Changes Effective January 1, 2011, CMS has announced a new End Stage Renal Disease (ESRD) bundled prospective payment system (PPS). The ESRD PPS will provide a single payment to ESRD facilities, i.e., hospital-based providers of services and renal dialysis facilities, that will cover all the resources used in providing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis in the ESRD facility or at a patient s home, drugs, biologicals, laboratory tests, training, and support services. The ESRD PPS provides ESRD facilities a 4-year phase-in (transition) period under which they would receive a blend of the current payment methodology and the new ESRD PPS payment. In 2014, the payments will be based 100 percent on the ESRD PPS payment. 2011: 75 percent of the old payment methodology, and 25 percent of the new PPS payment. 2012: 50 percent of the old payment methodology, and 50 percent of the new PPS payment. 2013: 25 percent of the old payment methodology, and 75 percent of the new PPS payment. 2014: 100 percent of the PPS payment. Providers wishing to opt out of the phase in process should have faxed their request to CMS by November 1st, The new ESRD PPS provides for three categories of chronic comorbid conditions and three categories for acute comorbid conditions. New comorbid condition codes are MA, MB, MC, MD, ME and MF. A single adjustment will be made to claims containing one or more of the comorbid conditions. The highest comorbid adjustment applicable will be applied to the claim. The acute comorbid adjustment may be paid no greater than four consecutive months for any reported acute comorbid condition unless there is a reoccurrence of the condition. The three chronic comorbid categories eligible for a payment adjustment are: New Condition code ME - Hereditary hemolytic and sickle cell anemia, New Condition code MF - Monoclonal gammopathy (in the absence of multiple myeloma) and New Condition code MD - Myelodysplastic syndrome. The three acute comorbid categories eligible for a payment adjustment are:

5 New Condition code MB - Bacterial Pneumonia, New Condition code MA - Gastrointestinal Bleeding, and New Condition code MC - Pericarditis. Medicare Contractors will accept the new condition codes H3, H4 and H5 when reported on the 72x bill type effective January 1, Effective January 1, 2011 renal dialysis facilities must report the appropriate diagnosis code(s) for comorbidity conditions in the other diagnosis fields. The ESRD PRICER shall not apply comorbid adjustments when the onset of dialysis adjustment is applicable. New Condition code H3 reoccurrence of MA category New Condition code H4 reoccurrence of MB category New Condition code H5 - reoccurrence of MC category Services not included in the PPS that remain separately payable include blood and blood processing, preventive vaccines, and Telehealth services that are not considered outlier services. Blood and blood processing Preventive vaccines Telehealth services Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, CMS has made significant changes in policy as a result of the law and many of these changes apply to Medicare Advantage programs. Empire Blue Cross recognizes that these changes affect the physicians and practitioners who treat our members. On each of Empire's MA product pages within there is a link titled Patient Protection and Affordable Care Act. Within that link Empire has posted, and will continue to post going forward, CMS published material with a forward explaining Empire s role and responsibility in regards to the updated PPACA regulation. to click on is the Patient Protection and Affordable Care Act Information under the Additional Information section at the bottom of the page. The PPACA articles from CMS with Forwards by Empire can be found here. For complete details of CMS s timeline and implementation of PPACA regulations please visit Instructions for Reporting Assessment Dates under the Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF), and Swing Bed (SB) Prospective Payment Systems (PPSs) The assessment date data element has been removed from the new version of the 8371 electronic format. Therefore, effective for dates of service on or after January 1, 2011, CMS requires an occurrence code 50 for reporting assessment dates for IRF, SNF, and SB PPS providers. Providers should no longer report this date in the service date field on the UB-04 and the 8371 electronic version for dates of service on or after January 1, Occurrence code 50 must be reported on all IRF PPS 11X bill types. If occurrence code 50 is not included on the claim, the claim will be rejected as a billing error.

6 New Statutory Provision Pertaining to Medicare 3-Day Payment Window Policy On June 25, 2010, President Obama signed into law the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of Section 102 of the law pertains to Medicare s policy for payment of outpatient services provided on either the date of a beneficiary s admission or during the three calendar days immediately preceding the date of a beneficiary s inpatient admission to a hospital subject to the inpatient prospective payment system (IPPS). This policy is known as the 3-day or 1-day payment window. A hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the beneficiary s inpatient claim the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services that are furnished to the beneficiary during the 3-day (or 1-day) payment window. The new law makes the policy pertaining to admission-related outpatient nondiagnostic services more consistent with common hospital billing practices. Section 102 of Pub. L is effective for services furnished on or after the date of enactment, which is June 25, Critical Access Hospital (CAH) Method II-Removal of Annual Election Effective October 1,2010, CAH s election of the optional or Method II payment method for outpatient services will remain in place until the CAH terminates it. Prior to October 1,2010, it was required that your Method II status had to be renewed every 12 months in order to remain a Method II provider Changes to Present on Admission (POA) Indicator 1 Effective with the implementation of 5010 Inpatient Prospective Payment System (IPPS), January 1, 2011 hospitals will no longer be required to report the Present on Admission (POA) indicator of 1. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are exempt from the POA reporting requirement should be left blank instead of populating a 1. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross Association, an association of independent Blue Cross plans. The Blue Cross names and symbols are registered marks of the Blue Cross Association.