Medicare Part B Quarterly Updates, Changes and Reminders September, 2015

Transcription

1 You are connected to the Part B September Quarterly Updates Webcast. We will begin shortly. Medicare Part B Quarterly Updates, Changes and Reminders September, 2015 Are you logged into the correct Webcast for your provider type? Part A EventID=9Y9LNN6277 Home Health and Hospice EventID=9YFNXE8582 9/10/ Using On24 Widgets Use your mouse to point, click, and open a widget. 9/10/

2 Disclaimer The information provided in this presentation was current as of 9/8/2015. Any changes or new information superseding the information in this presentation is provided in articles with publication dates after 9/8/2015, posted on our website at: CPT only copyright 2015 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2015 American Dental Association (ADA). All rights reserved. 9/10/ Agenda Medicare Updates and Changes CERT Medical Review Spotlight Hot Topics and Reminders News to Use and Resources 9/10/

3 Updates and Changes 9/10/ August 27, 2015 Successful implementation of the new Jurisdiction M (JM) contract Impact to providers was minimal Website now reflects JM instead of J11 You may occasionally still see an older article or publication that reflects the J11 contract Information is still applicable to JM Jurisdiction M 9/10/

4 How to Access MLN Matters Details Full details for CMS MLN Matters Articles located on the CMS Website Education/Medicare-Learning-Network- MLN/MLNMattersArticles/2014-MLN-Matters- Articles.html 9/10/ National Site Visit Verification (NSV) Initiative CMS implemented a site visit verification program using a National Site Visit Contractor (NSVC) Screening mechanism to prevent questionable providers and suppliers from enrolling or maintaining enrollment in the Medicare program Conducted by MSM Security Services, LLC and its subcontractors, Computer Evidence Specialists, LLC (CES) and Health Integrity, LLC (HI) Unannounced site visits for Medicare Part A/B providers and suppliers Observational site visit or a detailed review SE1520 9/10/

5 Alemtuzumab Effective for dates of service on or after October 1, 2015 New HCPCS code Q9979 for Injection, Alemtuzumab 1mg payable by Medicare MM9273 9/10/ National Provider Identifier (NPI) Reported for Anti-Markup and Reference Laboratory Claims Effective October 1, 2015 Medicare Administrative Contractors (MACs) to return reference laboratory and anti-markup claims as unprocessable when the billing and service location NPIs match CR 8806 initially implemented a new policy indicating that providers would no longer be permitted to submit their own National Provider Identifier (NPI) in Item 32a of the CMS-1500 claim form for anti-markup and reference laboratory claims when the performing physician or supplier is located in another jurisdiction MM9150 9/10/

6 Remittance Advice Remark and Claims Adjustment Reason Code Effective Date: October 1, 2015 Implementation Date: October 5, 2015 Announces updates to the Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) lists and also instructs Medicare system maintainers to update Medicare Remit Easy Print (MREP) and PC Print software used by some providers. Washington Publishing Company MM9278 9/10/ Quarterly Update in the Medicare Physician Fee Schedule Database (MPFSDB) October CY 2015 Update Effective with dates of services on or after January 1, 2015 Implementation date: October 5, 2015 CMS updates to the 2015 Medicare Physician Fee Schedule Data Base (MPFSDB) Key changes include updates to the Malpractice Relative Value Units (RVU) of several codes Contractors may adjust claims brought to their attention MM9266 9/10/

7 Notice of New Interest Rate for Medicare Effective date: July 20, 2015 Implementation date: July 20, th Quarter Notification of Interest Rate for FY 2015 Overpayments and Underpayments of 9.75 percent for Medicare overpayments and underpayments MM9288 9/10/ IRS Tax Levy Effective October 16, 2015 If a provider owes back taxes to the IRS and those taxes are eligible to be withheld from payments due from Medicare, the withhold rate will increase from the current 30 percent to 100 percent MM9285 9/10/

8 October Drug Pricing File CMS released the October 2015 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files Medicare contractors will adjust claims brought to their attention MM9248 9/10/ National Coverage Determination (NCD) for Screening for Colorectal Cancer Effective Date: October 9, 2014 Implementation Date: January 4, 2016 NCD for Screening for Colorectal Cancer Using Cologuard - A Multitarget Stool DNA Test New HCPCS code G0464 (colorectal cancer screening; stool-based DNA and fecal occult hemoglobin) as a covered service Contractors may adjust claims that are brought to their attention MM9115 9/10/

9 Influenza Vaccine Payment Allowances Effective date: 8/1/2015-7/31/2016 Implementation Date: No later than November 24, 2015 Annual flu payment allowances are pending Payment allowances will be posted in the influenza vaccine pricing webpage Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html MM9299 9/10/ Fingerprint-Based Background Requirement Required for all individuals with a five percent or greater ownership interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or has submitted an initial enrollment application Affected providers will receive a letter indicating requirement Given 30 days from the date of the letter to comply Failure to comply could result in denial of enrollment application or revocation of Medicare billing privileges SE1427 9/10/

10 Healthcare Provider Taxonomy Codes October 2015 Code Set Update Taxonomy codes are not required but if used, they must be valid Valid HPTCs are those that the NUCC has approved for current use MM9260 9/10/ National Coverage Determination (NCD) Update - Speech Generating Device CMS revises scope of benefit NCD for Speech Generating Devices (SGDs) covered under the Medicare benefit category for Durable Medical Equipment (DME) Please make sure that your billing staff are aware of these changes MM9281 9/10/

11 New CLIA Waived Tests New Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration (FDA) CLIA regulations require a facility to be appropriately certified for each test it performs CPT codes that CMS considers to be laboratory tests under CLIA (and thus requiring certification) change each year Guidance/Legislation/CLIA/downloads/waivetbl.pdf MM9261 9/10/ Medicare Remit Easy Print (MREP) Upgrade Effective Date: January 1, 2016 Implementation Date: January 4, 2016 MREP software is available free of charge from the CMS website and now offers a number of special reports that users can view and download in addition to the remittance advice MM9203 9/10/

12 Place of Service Codes (POS) for Outpatient Hospitals Effective Date: January 1, 2016 Implementation Date: January 4, 2016 Place of service 19 Off-Campus-Outpatient Hospital A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization Place of service 22 On-Campus-Outpatient Hospital A portion of a hospital s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization MM9231 9/10/ Dialysis Monthly Capitation Payment (MCP) The Monthly Capitation Payment (MCP) physician or practitioner should bill for the age appropriate home dialysis MCP service, as described by HCPCS codes through 90966, for the home dialysis (less than a full month) scenario if the MCP practitioner furnishes a complete monthly assessment of the ESRD beneficiary and at least one face-to-face patient visit during the month MM9265 9/10/

13 NCCI and SNF Consolidated Billing Updates MM9111 National Correct Coding Initiative (NCCI) Version 21.3 Effective Date: October 1, /10/ DMEPOS MM9244 MM9279 October 2015 Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) October 2015 Quarterly Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 9/10/

14 Comprehensive Error Rate Testing (CERT) A Partnership 9/10/ CERT Part B Error Rates Rise 9/10/

15 Actions to Reduce Projected Financial Impact Part B Type of Service National Improper Payment Rate Palmetto GBA Projected Error Rate Palmetto GBA Projected Improper Payment Overall Part B 12.1% 13.9% $1,029,043,347 Error Rate Reduction Plan (ERRP) Strategy Analysis Report (SAR) Medical Review Strategy (MRS) Contractor Problem List 9/10/ Active Medical Reviews Part B CPT E/M Part B CPT 99283, 99284, Emergency Department E/M Part B CPT Outpatient Surgical Debridement in POS 22 Part B HCPCS Ambulance A0425, A0428 Services, Non- Emergent Part B HCPCS J2778 Ranibizumab 9/10/

16 Drugs & Biologicals Due the high cost of biologicals and the increasing utilization trends, several drugs were identified for review during the upcoming option year. All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report. They are the top drugs based on dollars at risk and CERT error rates. Some of the top drugs have been excluded due to MAU edits already in place. 9/10/ Drugs and Biologicals Reviews J2778 Ranibizumab (Lucentis ) Inj. 1 mg J0178 Aflibercept (Eylea ) Inj. 1 mg J0897 Denosumab (Prolia ) Inj. 1 mg J9041 Bortezomib (Velcade ) Inj. 1 mg 9/10/

17 HCPCS Code J2778, Ranibizumab (Lucentis ), 0.1mg Based on internal data analysis and prioritization, as well as past experience, this code has been identified as a major risk service Probe edits set to select 100 claims from each state State Charge Denial Rate Total Dollars Denied South Carolina 67.2 $131, West Virginia 61.1 $109, Virginia 40.8 $83, North Carolina 40.2 $80, /10/ Drug and Biologicals Self-Audit Tips Check documentation for: Patient s name is the document being submitted for the correct beneficiary? Date(s) of service Is there documentation for the specific dates of service billed? Order or intent to order needed Signed medical records documenting the physician s order/intent to order the drug, including drug name, dosage amount, method of administration and frequency of the drug to be administered? Is there a physician certified diagnosis documented to substantiate the medical need for the drug? 9/10/

18 Continued Documentation of actual service: Is each date of service noted in the record? Is documentation present for the method (how) the drug was administration for the specific date of service? Does documentation include the name of the drug administered? Does the documentation include the amount of drug administered and why? Do the units billed correspond with the vials used in documentation submitted for review? 9/10/ Self-Audit! Identify area for improved documentation Educate staff including practitioners Repeat self-audits and education as necessary until documentation is sufficient to support each service Sign up for the Palmetto GBA Updates to receive updates of upcoming probe reviews Assess and audit the chain of communication between delivery of mail and distribution 9/10/

19 Health Information Supply Chain Step 1 Medicare beneficiary & provider encounter Step 2 Coding and billing of claim Step 3 Processing of claim by Palmetto GBA & use of information by CMS 9/10/ CERT Tips Review your denials Review and use Palmetto GBA CERT Tips Submit missing documentation directly to CERT if denial is not a medical necessity denial Appeal medical necessity denials CERT Redetermination Request Form Designate a CERT Point of Contact (POC) 9/10/

20 CERT Help and Task Force 9/10/ Medical Review Resources 9/10/

21 Hot Topics and Reminders 9/10/ Use for all services performed on/after October 1, ocscathome/icd-10 ex.html?redirect=/icd10 SE1408 9/10/

22 CMS ICD-10 Resources ICD10/index.html 9/10/ This is an AAPC Tool! 9/10/

23 Palmetto GBA ICD-10 Resources 9/10/ ICD-10 Testing CMS conducted two successful acknowledgement testing weeks Providers can still complete ICD-10 acknowledgement testing Make certain to label your file as a test file ISA15 segment of the claim file 9/10/

24 ICD-10 Reminders ICD-10 use based on date of service Do not combine ICD-9 and ICD-10 codes on same claim CMS released guidance that allows for additional flexibility in the claims auditing and quality reporting processes For 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a code from the right family. However, a valid ICD-10 code will be required on all claims with dates of service on or after October 1, /10/ ICD-10 Reminders (Cont.) Coverage outlined in NCDs and LCDs regarding ICD- 10 codes to support medical necessity will be applied 9/10/

25 ICD-10 Family of Codes CMS states a Family of codes is the same as the ICD-10 three-character category Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. Example: category H25 (Age-related cataract) contains a number of specific codes that further define the condition and capture information on the type of cataract as well as information on the eye involved. Examples include: H (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters 9/10/ ICD-10 Reminders (Cont.) CMS will: Set up a communication and collaboration center for monitoring the implementation of ICD-I0 Name an ICD-10 Ombudsman to help receive and triage physician and provider ICD-10 issues 9/10/

26 ICD-10 Reminders (Cont.) Paper CMS 1500 claim form submitters must complete the ICD indicator or ICD IND' field in block 21 Enter an indicator of: Nine to indicate the diagnosis codes on the given claim are ICD-9 codes Enter a zero if the codes used are ICD-10 codes. Electronic submitters complete the equivalent electronic field Prior to October 1, 2015, Palmetto GBA will stop auto populating that field with a 9 Failure to complete this field or incorrectly completing this field will result in claim rejection 9/10/ ICD-10 Reminders (Cont.) Insert ICD-10 without the periods as you did with ICD-9 Part B providers billing services on the CMS 1500 form or electronic equivalent will bill using ICD-10CM codes. ICD- 10PCS codes are intended for use by facilities billing Part A inpatient facility charges to Medicare Continue to use modifiers (50, RT, LT etc ) There is no change to coding for the services performed CPT and HCPCS codes will continue to be submitted to represent the service provided 9/10/

27 Land Ambulance: Physician Certification Statement (PCS) Requirements Reminder There are specific requirements for a written order from the beneficiary s attending physician certifying that medical necessity requirements are met for: Nonemergency, unscheduled ambulance services and nonemergency, scheduled, repetitive and nonrepetitive ambulance services Providers should carefully review all documentation requirements and time frames for the physician certification statement Cat/JM-Part-B~8A5KUC2727 9/10/ General Ambulance Coverage Medicare covers ambulance transportation only when transportation by any other means would endanger the patient s health A patient whose medical condition permits transport in any type of vehicle other than an ambulance does not qualify for ambulance coverage Details regarding the encounter should paint a picture of the patient s condition at the time of transport JM-Part-B~8EEMJQ2707 9/10/

28 Ambulance Prior Authorization Demonstration Began December 1, 2014 Requires a prior authorization process for repetitive scheduled non-emergent ambulance transports for independently enrolled ambulance suppliers Garaged in South Carolina Does not create new documentation requirements for physicians/practitioners or suppliers it simply requires the documentation to be submitted earlier in the claims process Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Prior-Authorization- Initiatives/Downloads/AmbulancePriorAuth_Physician- Letter_ pdf 9/10/ Ambulance Prior Authorization Demonstration (Continued) CMS announced that the demonstration is expected to be expanded to additional states Sign up for the Palmetto GBA -Updates to stay up to date on announcements 9/10/

29 Dentists to Take Action: New CMS Initiative New policy requires all prescribers of Part D drugs to submit a Medicare enrollment applications or opt-out affidavits by June 1, 2015 Required to avoid patient s Part D drug claims from being denied by their Part D plans beginning 1/1/ /10/ Home Health Certifications Require documentation of a face-to-face encounter Certifying physician is required to certify (attest) that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility Documentation must be in the certifying physician s medical records and/or the acute/postacute care facility s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of patient eligibility MM9119 9/10/

30 PQRS Payment Adjustments Beginning in 2015 eligible professionals who did not satisfactorily report data on quality measures for covered professional services are receiving a payment adjustment under PQRS 2016 and subsequent years - 2.0% Instruments/PQRS/Payment-Adjustment-Information.html 9/10/ Reminder - Electronic Health Records (EHR) Applicable payment adjustments began in 2015 EHR Details, Requirements and Background Guidance/Legislation/EHRIncentivePrograms/index.html EHR Payment Adjustments Background Guidance/Legislation/EHRIncentivePrograms/Do wnloads/paymentadj_hardshipexceptipsheetfor EP.pdf 9/10/

31 Invalid/Untimely Dismissed Appeals 1,200 1, May-15 Jun-15 Jul-15 0 Cases Dismissed as Untimely Incomplete Appeal Requests No Initial Determination (Rejected Claims) 9/10/ Appeals Before appealing verify you have appeal rights Send all documentation necessary to support your appeal Provide all necessary information Use the right form Send it to the right address or fax number Use the free, fast, efficient Online Provider Service (OPS) method for first level appeal and reopening requests! 9/10/

32 Top Denial/Rejection Reasons Reason Code Description CO-50 - Non-covered services because deemed not a medical necessity' by the payer. PR Service/equipment/drug not covered under patient's current benefit plan. Medicare does not pay for item or service. CO-B15 - Service/procedure requires a qualifying service/procedure be received and covered. Qualifying other service/procedure has not been received/adjudicated. CO-B7 Provider not certified/eligible to be paid for this procedure/service on date of service. CO-16 - Claim/service lacks information or has submission/billing error(s) needed for adjudication. Remarks Code Description N115 - Decision based on Local Coverage Determination (LCD). N/A N20 - Service not payable with other service rendered on same date. N570 - Missing/incomplete/invalid credentialing data. M79 - Missing/incomplete/invalid charge. 9/10/ Top Provider Contact Center Inquiries August /10/

33 Top Written Provider Inquiries August /10/ News to Use and Resources 9/10/

34 GBD Blog and Twitter Palmetto GBA is using the Going Beyond Diagnosis (GBD) blog and Twitter account to help facilitate communication on error rate reduction 9/10/ Self Service Tools 9/10/

35 Online Provider Services esuite of Services edelivery - Receive Paperless Additional Documentation and messages via your OPS Message Inbox einquiry Submission of general inquiries using a secure form eappeals Submission of first level appeals and reopening requests eoffset and echeck Request an automatic offset or make a payment with an echeck to satisfy an overpayment 9/10/ Online Provider Services (OPS) 9/10/

36 Benefits of eappeals Greater control over documents throughout the process Reduces the possibility of keying errors Allows documents to enter the appropriate process work step much more quickly Receive notification of receipt and check the status No busy signal that can occur when faxing Documentation can be submitted as a child document, reducing the risk of documentation being separated from the request Increases the probability of acceptance of a valid request by preventing submissions without required information Receive Medicare Redetermination Notice electronically Also use for reopening requests! 9/10/ Palmetto GBA Advanced Clinical Editing (P-ACE) No cost to all direct submitters and those transmitting claims through a clearinghouse/billing service Smart edits appear on claim rejection reports (277CA) Claims failing pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted No software to download 9/10/

37 Medicare Learning Network (MLN) Official CMS Medicare Fee-For-Service provider educational information MLN Matters national provider education articles Educational products (including Web-based training courses, hard copy and downloadable publications, and CD-ROMs) Physician Center Web page MLN National Provider Calls Network-MLN/MLNGenInfo/index.html?redirect=/MLNGenInfo 9/10/ CMS National and Open Door Calls and E- News National Provider Calls and Events Education/Outreach/NPC/National-Provider-Callsand-Events.html Open Door Forums Education/Outreach/OpenDoorForums/index.html CMS E-News Education/Outreach/FFSProvPartProg/Provider-Partnership- -Archive.html 9/10/

38 Claim Processing Issue Log (CPIL) 9/10/ Educational Opportunities Coming Soon Fall Working October /10/

39 JM Part B Video Education 9/10/ Palmetto GBA J11 Part B Home Page Palmetto GBA E- Mail Updates Provider Enrollment Resources Contact Us By Self Service Tools Resources Contacts Select UPDATES Click on Browse By Topic then Provider Enrollment JM.PartB@PalmettoGBA.com (center of home page) Provider Contact Center /10/

40 Social Networking 9/10/ Thank You for Attending Please take a moment to complete the short evaluation as we being to review your submitted questions Q&A widget Resource widget Survey Widget Once the session ends you will not have the ability to complete the evaluation. 9/10/