Third Party Newsletter

Transcription

1 NEBRASKA OPTOMETRIC ASSOCIATION Third Party Newsletter October 2006 Volume 6 Issue 10 YOUR NOA 3RD PARTY RESOURCE Two Presentations on Coding and Billing at Kearney Convention Both Courses Open to ODs and Paras Dr. Quack will be presenting two 2-hour sessions on 3rd Party topics in Kearney this year. The first will deal with basic 3rd party matters, and is a must for new licensees and new insurance personnel. The second course will provide more advanced 3rd party information, including coding and billing issues. Both courses are open to ODs as well as Paras. A brief description of each course follows. Coding & Billing Basics ~ This session is tailored to those who wish to learn the fundamentals of insurance, coding & billing, including: The types of 3rd parties encountered Deciding whether to be a provider Essentials of diagnosis coding Essentials of services coding codes codes Use of Modifiers Resources available for future reference. Handouts will include forms and other useful resources. Coding & Billing Updates, Intermediate Level ~ This presentation is designed for those at least somewhat familiar with coding and billing. It will Inside this issue: address: Recent and upcoming changes in Medicare, DME MAC (formerly DMERC), Medicaid, etc. The requirements for billing the 99000, the 92000, and the S-codes. The advantages and limitations of the 92000, 99000, and S-codes. How to self-assess one s coding of the and codes. Forms will be provided and explained. Examples will be worked on in class as time permits. How to find and use 3rd party resources on the Web. Handouts will consist of a number of forms, including customized ABNs for Medicare B and for DMERC, NEMBs, DMERC Standards, Hx and Exam forms, Orders for special testing, self-audit forms for the and codes, and more. Additional Requirements Necessary To Implement The Revised Health Insurance Claim Form CMS-1500 to Accommodate the NPI Where to Go for CMS Directions on What Data to Put in Which Box Of the New CMS Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals a new publication needed in every OD s office. Dave McBride Receives National Award as Executive Director of the Year 5 More Information on Whether to Obtain a Separate NPI for you Optical Dispensary. 5 Midlands Choice Announces Common Address for Paper Claims 6 The Ten Most Frequently Asked Questions of Our Medicare Carrier 7 2 4

2 Additional Requirements Necessary To Implement The Revised Health Insurance Claim Form CMS-1500 to Accommodate the NPI From MLN Matters Number: MM5060 Physicians and suppliers who bill Medicare carriers including durable medical equipment regional carriers (DMERCs) for their services using the Form CMS need to be aware of the following changes. Key Points The Centers for Medicare & Medicaid Services (CMS) is implementing the revised Form CMS- 1500, which accommodates the reporting of the National Provider Identifier (NPI). The Form CMS-1500 (08-05) version will be effective January 1, 2007, but will not be mandated for use until April 2, During this transition time there will be a dual acceptability period of the current and the revised forms. A major difference between Form CMS-1500 (08-05) and the prior form CMS-1500 is the split provider identifier fields. The split fields will enable NPI reporting in the fields labeled as NPI, and corresponding legacy number reporting in the unlabeled block above each NPI field. There will be a period of time where both versions of the CMS-1500 will be accepted (08-05 and versions). The dual acceptability timeline period for Form CMS-1500 is as follows: January 2, 2007 March 30, 2007 Providers can use either the current Form CMS-1500 (12-90) version or the revised Form CMS-1500 (08-05) version. Note: Health plans, clearinghouses, and other information support vendors should be able to handle and accept the revised Form CMS-1500 (08-05) by January 2, April 2, 2007 The current Form CMS-1500 (12-90) version of the claim form is discontinued; only the revised Form CMS-1500 (08-05) is to be used. Note: All rebilling of claims should use the revised Form CMS-1500 (08-05) from this date forward, even though earlier submissions may have been on the current Form CMS-1500 (12-90). Background Form CMS-1500 is one of the basic forms prescribed by CMS for the Medicare program. It is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law (ASCA), and the implementing regulation at 42 CFR The CMS-1500 form is being revised to accommodate the reporting of the National Provider Identifier (NPI). Note that a provision in the HIPAA legislation allows for an additional year for small health plans to comply with NPI guidelines. Thus, small plans may need to receive legacy provider numbers on coordination of benefits (COB) transactions through May 23, CMS will issue requirements for reporting legacy numbers in COB transactions after May 22, In a related Change Request, CR4023, CMS required submitters of the Form CMS-1500 (12-90 version) to continue to report Provider Identification Numbers (PINs) and Unique Physician Identification Numbers (UPINs) as applicable. There were no fields on that version of the form for reporting of NPIs in addition to those legacy identifiers. Change Request 4293 provided guidance for implementing the revised Form CMS-1500 (08-05). This article, based on CR 5060, provides additional Form CMS-1500 (08-05) information for Medicare carriers and DMERCs, related to validation edits and requirements. Billing Guidelines When the NPI number is effective and required (May 23, 2007, although it can be reported starting January 1, 2007), claims will be rejected (in most cases with reason code 16 claim/service lacks information that is needed for adjudication ) in tandem with the appropriate remark code that specifies the (Continued on page 3) THIRD PARTY NEWSLETTER PAGE 22

3 (Continued from page 2) missing information, if The NPI of the billing provider or group is not entered on Form CMS-1500 (08-05) in items: 24J (replacing item 24K, Form CMS-1500 (12-90)); 17B (replacing item 17 or 17A, Form CMS (12-90)); 32a (replacing item 32, Form CMS-1500 (12-90)); and 33a (replacing item 33, Form CMS-1500 (12-90)). Additional Information When the NPI Number is Effective and Required (May 23, 2007) To enable proper processing of Form CMS-1500 (08-05) claims and to avoid claim rejections, please be sure to enter the correct identifying information for any numbers entered on the claim. Legacy identifiers are pre-npi provider identifiers such as: PINs (Provider Identification Numbers) UPINs (Unique Physician Identification Numbers) OSCARs (Online Survey Certification & Reporting System numbers) NSCs (National Supplier Clearinghouse numbers) for DMERC claims. Additional NPI-Related Information Additional NPI-related information can be found at on the CMS web site. CMS The change log which lists the various changes made to the Form CMS-1500 (08-05) version can be viewed at the NUCC Web site at MLN Matters article MM4320, Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions via Direct Data Entry Screen, or Paper Claim Forms, can be found on the CMS web site at CR4293, Transmittal Number 899, Revised Health Insurance Claim Form CMS-1500, provides contractor guidance for implementing the revised Form CMS-1500 (08-05). It can be found on the CMS web site at MLN Matters article MM4023, Stage 2 Requirements for Use and Editing of National Provider Identifier (NPI) Numbers Received in Electronic Data Interchange (EDI) Transactions, via Direct Data Entry (DDE) Screens, or Paper Claim Forms, can be found on the CMS web site at More on NPI and Optical Dispensaries.See Page 5. Where to Go for the Exact CMS Directions on What Data to Put in Which Box Of the New CMS-1500 (08-05) The official instructions on what data to put in which item or box can be found in CR5060. CR5060 is the official instruction issued to our carrier or DMERC regarding changes mentioned in the article above. CR5060 can be located on the CMS web site at: This document is 28 pages long, and the specific instructions for completing claims on the new CMS-1500 start on page 10. THIRD PARTY NEWSLETTER PAGE 33

4 Medicare Physician s Guide NEW FOR 2006!! The Basics You Need to Know About Medicare There are times when providers and staff have basic questions about Medicare, and despite their best efforts, are unable to find the information they need. In April of this year Medicare came out with the Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals. This reference offers general information about the Medicare Program, becoming a Medicare provider or supplier, Medicare payment policies, Medicare reimbursement, evaluation and management documentation, protecting the Medicare Trust Fund, inquiries, overpayments, and appeals. It can be downloaded from the following web site: FILTERTYPE=NONE&FILTERBYDID=- 99&SORTBYDID=1&SORTORDER=ASCENDING&ITEMID=CMS It also is available, at no charge, on CD-ROM, or in print, from the same source. Dr. Quack strongly recommends that every office obtain at least one up-to-date copy of this resource. To give you a flavor of the vast information it contains, Dr. Quack has printed its Table of Contents below. Chapter 1 Introduction to the Medicare Program o The Medicare Program o Medicare Eligibility o Identifying Medicare Beneficiaries o Organizations That Impact the Medicare Program o Recent Laws That Impact the Medicare Program Chapter 2 Becoming a Medicare Provider or Supplier o Medicare Providers and Suppliers o Enrolling in the Medicare Program o Protecting Your Practice o Promoting Cultural Competency and Enhancing Quality in Your Practice Chapter 3 Medicare Reimbursement o Medicare Claims o Deductibles, Coinsurance, and Copayments o Coordination of Benefits o Incentive and Bonus Payments o Medicare Notices o Other Health Insurance Plans o Documentation Dr. Quack strongly recommends that every office obtain at least one up-to-date copy of this resource. o National Correct Coding Initiative o Comprehensive Error Rate Testing Chapter 4 Medicare Payment Policies o Services That Medicare DOES Pay For o Commonly Furnished Services o Services That Medicare Does NOT Pay For Chapter 5 Evaluation and Management Documentation o Guidelines for Residents and Teaching Physicians o Evaluation and Management Background o Reference I Documentation Guidelines for Evaluation and Management Services o Reference II Documentation Guidelines for Evaluation and Management Services Chapter 6 Protecting the Medicare Trust Fund o Data Analysis o Medical Review o Coverage Determinations o Fraud and Abuse o Significant Medicare Fraud and Abuse Provisions o Potential Legal Actions o Incentive Reward Program o Whistle Blower Provision o How to Report Suspected Fraud or Abuse Chapter 7 Inquiries, Overpayments, and Appeals o Inquiries o Overpayments o Fee-for-Service Appeals Reference Section o Reference A Glossary o Reference B Acronyms o Reference C Helpful Websites o Reference D Reference Materials PAGE 4 THIRD PARTY NEWSLETTER

5 More Information on Whether to Obtain a Separate NPI for your Optical Dispensary. The following CMS article (see italics) addresses obtaining NPIs for providers who bill two different types of Medicare contractors (e.g., Medicare B and DMERC). Depending on how one interprets this article, its direction may differ somewhat from the BCBS article Dr. Quack previously quoted regarding NPIs and sub-parts. CMS: Enrolled organization health care providers or subparts who bill more than one type of Medicare contractor Generally, the type of service being reported on a Medicare claim determines the type of Medicare contractor who processes the claim. Medicare will expect an enrolled organization health care provider or subpart to use a single (the same) NPI when billing more than one type (fiscal intermediary, carrier, RHHI, DMERC) of Medicare contractor. However, in certain situations, Medicare requires that the organization health care provider (or possibly even a subpart) enroll in Medicare as more than one type of provider. For example, an ambulatory surgical center enrolls in Medicare as a Certified Supplier and bills a carrier. If the ambulatory surgical center also sells durable medical equipment, it must also enroll in Medicare as a Supplier of DME and bill a DMERC. This ambulatory surgical center would obtain a single NPI and use it to bill the fiscal intermediary and the DMERC. Medicare expects that this ambulatory surgical center would report two different Taxonomies when it applies for its NPI: (1) that of Ambulatory Health Care Facility-Clinic/Center--Ambulatory Surgical (261QA1903X) and (2) that of Suppliers-Durable Medical Equipment & Medical Supplies (332B00000X) or the appropriate sub-specialization under the 332B00000X specialization. So, considering the article, do you really need a separate NPI for your optical, or should you have just one NPI with multiple taxonomy codes (i.e., one for optometry, one for optical Is there a penalty for not having an NPI if one is needed? It could delay or prevent proper reimbursement if business names, or addresses, or tax ID numbers, etc., don t match up correctly with the NPI used on the claim. supply) as described? Dr. Quack thinks you should consider the following when pondering this question: Does your optical dispensary have a name other than that of the provider; that is, does your dispensary go by Dr. William Smith, Optometrist or is it named separately, like Billy s Optical? Does your optical have a separate address or PO Box? Does the optical dispensary advertise independently, presenting itself separately from the ODs that practice there? Is the bookkeeping for the optical portion of the practice separate from the clinic portion? If the answer is yes to any of these questions, a separate NPI might be the way to go, in Dr. Quack s opinion. And, if the optical dispensary is organized as a separate company with a separate tax ID number, then a separate NPI is definitely called for. Otherwise, a single NPI with multiple taxonomy codes may be appropriate, as described in the article in italics. Is there a penalty for having a separate NPI for your optical if it really isn t needed? Dr. Quack doesn t know the answer to that question. Is there a penalty for not having an NPI if one is needed? It could delay or prevent proper reimbursement if business names, or addresses, or tax ID numbers, etc., don t match up correctly with the NPI used on the claim. Dave McBride Receives National Award Dr. Quack passes kudos to Dave McBride, NOA s executive director, who recently returned from San Francisco where he received the national "C. Carney Smith Award", from National Association of Insurance and Financial Advisors (NAIFA), for being the Executive Director of the Year. Founded in 1890 as the National Association of Life Underwriters, NAIFA comprises 800+ state and local associations representing the business interests of 225,000 members and their employees nationwide. Members focus their practices on one or more of the following: life insurance and annuities, health insurance and employee benefits, multiline, and financial advising and investments. NAIFA's mission is to advocate for a positive legislative and regulatory environment, enhance business and professional skills, and promote the ethical conduct of its members. NAIFA is also a founding member of and contributor to the Life and Health Insurance Foundation for Education. Congratulations, Dave! THIRD PARTY NEWSLETTER PAGE 55

6 Midlands Choice Announces Common Address for Paper Claims Midlands Choice network providers soon will be able to mail all paper claims whether original, corrected or secondary to a single destination. The new address, effective Sept. 25, 2006, is: Midlands Choice PO BOX 5809 TROY, MI All other aspects of submitting non-electronic claims remain the same, including the process providers should follow to submit claims directly to delegated re-pricer payers. Currently, the delegated payers are Aetna, CIGNA, Principal and HDM. In addition, the location of the Midlands Choice home office remains Omaha, NE. Upon receipt of claims at the post office box, they will be scanned and forwarded electronically to Midlands Choice for re-pricing. To give providers and payers time to implement the new address, mail received at the old address will continue to be forwarded during a transitional phase. However, we strongly encourage providers to implement this change by Sept. 25 to avoid any delays involved in the mail forwarding process. Midlands Choice payers are being asked to update this mailing address on their member ID cards during group renewal periods over the next 12 months. If you have questions about this change, please contact the provider relations manager assigned to your region: Nebraska: Melissa Goeden, mgoeden@midlandschoice.com or The Nebraska Diabetes Consensus Guidelines Be Sure to Use a Diabetes Eye Exam Report Form... Adapted from Recently all optometrists in Nebraska received a copy of the latest edition of the Nebraska Diabetes Consensus Guidelines from the Nebraska Health and Human Services System (HHSS). HHSS has developed and distributed the Nebraska Diabetes Consensus Guidelines of Diabetes Care for both adult and pediatric patients to health professionals throughout the State since These guidelines were developed in conjunction with multiple primary and specialty care physicians, diabetes educators, and representatives of the major managed care plans in the State of Nebraska and were based on the American Diabetes Association s (ADA) Standards of Care. Katrina Thompson OD represented the Nebraska Optometric Association in this latest endeavor. After implementation of the guidelines by physicians, diabetes educators and insurance plans, some revisions were indicated; also, the ADA Guidelines have been updated annually (latest changes were published in Diabetes Care, Volume 28, Supplement 1, 2005) which changes some of the indicator goals. These changes have been incorporated in the revised Nebraska Diabetes Consensus Guidelines, which are attached. The guidelines have been placed in several formats as flow sheets that can be used in patient charts for documenting results. All of these may be copied as they are or revised to better serve patient and provider needs. The goals of developing the consensus guidelines and the flow sheets are: to reach agreement on a consistent set of guidelines suggested for use in the management of diabetes in Nebraska; and to increase awareness that good blood glucose control can lead to decreased complications, decreased hospitalizations, and improved quantity and quality of life for people with diabetes. Included in the mailing is a form entitled Diabetes Eye Exam Report. This form is to be used by ODs and OMDs to forward DFE results to the diabetic patient s primary care physician. Be sure to use this form (or one of the similar forms previously printed in this newsletter) each time a DFE is performed on a diabetic. The guidelines will be placed on the Nebraska Diabetes Prevention and Control Program's website in the near future at: If you have any questions or concerns, or would like information on other diabetes materials that are available, contact the Nebraska Diabetes Prevention and Control Program of the Department of Health and Human Services at and ask for the Diabetes Section or JOYCE.POPE@HHSS.STATE.NE.US VOLUME 6 PAGE 6

7 Dr. Quentin Quack s Queries and Questionable Quotes ~~~~~~~~~~~~~~~~~~~~~~~~~~ Third Party Questions from NOA Doctors and Staff ~~~~~~~~~~~~~~~~~~~~~~~~~~ Dr. Quentin Quack Our Medicare s Carrier s Most Frequently Asked Questions The following are Nebraska Medicare s 10 most frequently asked questions, recently published in the Fall Communiqué. 1. I need help verifying what beneficiary/claim a recoupment (FCN) was adjusted on. Answer: If you are receiving your remittance advices electronically, then this information will be printed on the last page of your remittance advice. If you have additional questions, then you may contact the Medicare Customer Service department at , or to speak to a Customer Service Representative. 2. Can you give me the status of my claim? Answer: You may contact the Medicare Customer Service department at , or and check this using the automated system (IVR). 3. My claim has denied as unprocessable (MA130). How do I correct the claim? Answer: You will need to refile your claim electronically with the required missing and/or invalid information. 4. Can you verify Part B eligibility for a patient? Answer: You may contact the Medicare Customer Service department at , or and check this using the automated system (IVR). 5. I need a copy of a Remittance Advice, how can I get one? Answer: You may download the free MREP software from our website which allows you to obtain a copy of the remittance advice from your own desktop. You may also check with your vendor if they are set up to receive remittance advices electronically for a copy. However, if you have submitted the Request to Deactivate Electronic Remittance from then you will receive copies of remittance advices dated June 1, 2006 through the date of your request. 6. Can you explain this denial? Answer: If you are not sure why your claim was denied, you may contact the Medicare Customer Service department at , or and check this using the automated system (IVR). If you still have questions, you may opt to speak to a Customer Service Representative. 7. My claim was denied because of Medicare claims processing or system issues, how do I correct this? Answer: You may contact the Medicare Customer Service department at , or and speak to a Customer Service Representative to research your claim to determine if it was a claims processing error or system error. 8. I m notifying you that a refund is due to Medicare. Answer: You may contact the Medicare Customer Service department at , or and speak to a Customer Service Representative to complete a refund request or you may send in a voluntary refund. 9. Claim information change. Answer: You may refile your claim electronically. 10. We received an Automated Development System (ADS) letter requesting additional information. The letter stated that if the information was not returned to Medicare within 45 days the claim would be denied. I do not think I can get the information returned in time. What should I do? Answer: If you cannot or do not return this information within the specified time frame, then you may refile your claim with the additional or requested information. VOLUME 6 PAGE 7

8 NEBRASKA OPTOMETRIC ASSOCIATION 201 N. 8TH Street, Suite 400 P.O. Box Lincoln, NE ABSTRACTS OF THIS MONTH S ISSUE TWO KEARNEY PRESENTATIONS ON CODING AND BILLING Dr. Quack will be presenting two 2-hour sessions on 3rd Party topics in Kearney this year. The first will deal with basic 3rd party matters, and is a must for new licensees and new insurance personnel. The second course will provide more advanced 3rd party information, including coding and billing issues. Both are open to Paras and ODs as well. Pg. 1. ADDITIONAL REQUIREMENTS FOR NEW CMS-1500 Physicians and suppliers who bill Medicare carriers, including durable medical equipment regional carriers (DMERCs), for their services using the Form CMS-1500 need to be aware of the changes found on pages 2 &3. CMS DIRECTIONS ON WHAT DATA TO PUT IN WHICH BOX OF THE NEW CMS-1500 The official instructions on what data to put in which item or box can be found in CR5060. CR5060 is the official instruction issued to our carrier or DMERC regarding changes mentioned on page 2. Pg. 3. NEW FOR 2006: MEDICARE PHYSICIAN GUIDE This reference offers general information about the Medicare Program, becoming a Medicare provider or supplier, Medicare payment policies, Medicare reimbursement, evaluation and management documentation, protecting the Medicare Trust Fund, inquiries, overpayments, and appeals. Pg. 4. MORE ON OBTAINING SEPARATE NPI FOR DISPENSARY. Is there a penalty for having a separate NPI for your optical if it really isn t needed? Dr. Quack doesn t know the answer to that question. Is there a penalty for not having an NPI if one is needed? It could delay or prevent proper reimbursement if business names, or addresses, or tax ID numbers, etc., don t match up correctly with the NPI used on the claim. See more on Pg. 5. DAVE MCBRIDE RECEIVES NATIONAL AWARD Dr. Quack passes kudos to Dave McBride, NOA s executive director, who recently returned from San Francisco where he received the national "C. Carney Smith Award", from National Association of Insurance and Financial Advisors (NAIFA), for being the Executive Director of the Year. Pg. 5. MIDLANDS CHOICE COMMON ADDRESS FOR PAPER CLAIMS Midlands Choice network providers soon will be able to mail all paper claims whether original, corrected or secondary to a single destination. Pg. 6. THE NEBRASKA DIABETES CONSENSUS GUIDELINES The Diabetes Eye Exam Report form is to be used by ODs and OMDs to forward DFE results to the diabetic patient s primary care physician. Be sure to use this form (or one of the similar forms previously printed in this newsletter) each time a DFE is performed on a diabetic. Pg. 6. OUR MEDICARE S CARRIER S MOST FREQUENTLY ASKED QUESTIONS Nebraska Medicare s 10 most frequently asked questions, and their responses, are found on page 7. O ccasionally Dr. Quack s fax machine or contains a question or story that is interesting, but may not pertain directly to third party care. Dr. Quack feels that he should share some of these humorous thoughts. D for a few moments, and then said, Well, I suggest that you go to a spa and take a mud bath on a daily basis. With this treatment is there any hope for a cure? asked the man. No, said the doctor, but it will help you get used to dirt. A man wasn t feeling very well at all, so he decided to see his physician. The doctor did the usual blood tests, and then X-rays, and then an MRI. He told the man to return in a week for the results of the tests. When the man returned the physician told him, I m sorry, but I have very bad news. You have an incurable disease. There is nothing that I can do for you. The man was devastated, and beseeched the doctor to suggest anything he might do to improve his condition. The doctor thought The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed Schneider, O.D., Third Party Consultant. To reach Ed (aka Dr. Quack): > (BEST): SchneiderEd@msn.com (HIPAA Compliant) > Ed s mobile phone is Voic available. > Fax number is Call Ed before faxing. To reach the NOA: Nebraska Optometric Association 201 North Eighth Street, Suite 400 P.O. Box (68501) Lincoln, Nebraska Phone: Fax: VOLUME 6 PAGE 88