Highmark Medicare Services Date: January 13, 2012

Transcription

1 Medicare Updates 2012 Highmark Medicare Services Date: January 13,

2 Disclaimer All Current Procedural Terminology (CPT) codes and descriptors used in this presentation are copyright by the American Medical Association. All rights reserved. The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Highmark Medicare Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. Highmark Medicare Services does not permit videotaping or audio recording of training events. 2 2

3 Highmark Medicare Services Education specific to providers in Medicare Administrative Contractor (MAC) Jurisdiction 12 include: Delaware, District of Columbia Metropolitan Area (DCMA), Maryland, New Jersey and Pennsylvania This education contains specific contractor guidance If you are not a provider in Jurisdiction 12, please contact your Medicare contractor for specific guidance 3 3

4 Agenda Comprehensive Error Rate Testing Recurring Medicare Updates Medicare Updates Medicare Initiatives Preventive Services Self Service Contractor Updates 4 4

5 Comprehensive Error Rate Testing (CERT) 5 5

6 Comprehensive Error Rate Testing (CERT) National Claim Paid Error Rate 7.9 % - Inpatient hospitals 4.4 % - Non-inpatient hospital facilities 9.2 % Physician/Lab/Ambulance Impacts all providers submitting Fee for Service claims Limited random claim sample Record requests must be received within 30 days from the initial CERT letter Right to Appeal? Yes 6 6

7 Common Errors Errors across entire spectrum of codes Most frequently on Evaluation and Management Services Incorrect coding Documentation did not support code billed One or more of the key components Insufficient Documentation Documentation did not contain a valid physician s signature Missing Records 7 7

8 CERT Scores Part B rate is at a good spot Part A rate is high due to medically unnecessary inpatient admissions Even though these bills are submitted by facilities under Part A, individual physicians write the order to admit An inpatient admission must be substantiated by the patient s: Severity of illness at the time of the order to admit and Intensity of treatments required 8 8

9 CERT Center Medical Record Requests Common Errors Articles and Frequently Asked Questions References and Contact Information Visit: 9 9

10 Recurring Medicare Updates 10 10

11 2012 Medicare Deductible and Coinsurance Inpatient hospital deductible = $1, Hospital coinsurance Days = $ Days = $ Skilled Nursing Facility Days = $ Part B deductible = $ Medicare Learning Network Matters Article, MM7567: Effective January 1, 2012:Implementation January 3,

12 January 2012 Annual / Quarterly Updates Hospital Outpatient Prospective Payment System (OPPS) OutpatientPPS/ Outpatient Code Editor (OCE) Influenza Vaccine Payment Allowances Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Medicare Remit Easy Print (MREP) and PC Print Update Correct Coding Initiative Edits, Version Average Sales Price Medicare Part B Drug Pricing Files

13 Outpatient Mental Health Treatment Limitation 5 Year Phase Out of 62.5% Limitation = 68.5% (55% Medicare/ 45% patient) 2012 = 75% (60%/ 40%) 2013 = 81.25% (65%/ 35%) 2014 = 100% (80%/ 20%) Medicare Learning Network Matters Article MM6686: Effective January 1, 2010;Implementation January 4,

14 Therapy Cap Values Therapy caps for 2012 $ physical therapy (including speech-language pathology) $ occupational therapy Medicare Learning Network Matters Article, MM7529: Effective January 1, 2012;Implementation January 3,

15 HCPCS Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Physicians and other providers/suppliers are advised that new code files have been posted to the Centers for Medicare and Medicaid Services SNF CB web page 2012 Carrier/A/B MAC Update Medicare Learning Network Matters Article, MM7552: Effective January 1, 2012;Implementation January 3,

16 2012 Medicare Participation Enrollment Period 11/14/2011 through 2/14/2012 Participation status change during extension remains 1/1/2012 What to do: Participating and wish to continue Do nothing Non-participating and wish to participate Complete participation agreement bursement/2012-announcement.html 16 16

17 2012 Fee Schedule Negative update for 2012 Medicare Physician Fee Schedule CMS instructs contractors to hold claims for 10 business days Minimal impact on providers due to current hold perimeters: 14 calendar electronic 29 calendar days for paper 17

18 Medicare Updates 18

19 Changes to the Laboratory National Coverage Determination (NCD) Edit Software Changes to the NCD code lists are described below and are effective for dates of service on and after January 1, 2012 Delete diagnosis codes and from the list of covered diagnoses for the Alpha-fetoprotein (190.25) NCD Add diagnosis codes and to the list of covered diagnoses for the Prothrombin Time (PT)(190.17) NCD International Classification of Diseases, 10 th Revision (ICD-10) codes, contractors will track to ensure edits are properly updated during the ICD-10 implementation , ICD-10 R , ICD-10 R07.2 Medicare Learning Network Matters Article, MM7621: Effective January 1, 2012;Implementation January 3,

20 New Waived Tests Medicare Learning Network Matters Article, MM7566:Effective January 1, 2012;Implementation January 3, Code Effective Date Description 81003QW February 14, 2011 Germaine Laboratories Inc. AimStrip Urine Analyzer G0434QW April 22, 2011 UCP Biosciences, Inc. UCP Drug Screening Test Cups G0434QW April 22, 2011 Diagnostic Test Group Clarity Multiple Drug Screen Test Cups 81003QW March 24, 2011 Mediwatch urinewatch Urine Analyzer G0434QW June 17, 2011 Insight Medical Drug of Abuse Urine Cassette Test G0434QW June 17, 2011 Insight Medical Drug of Abuse Urine Cup Test G0434QW June 17, 2011 Instant Technologies, Inc. iscreen Drug of Abuse Urine (Cassette) Test G0434QW June 17, 2011 Instant Technologies, Inc. iscreen Drug of Abuse Urine (Cup) Test G0434QW June 17, 2011 Jant Pharmacal Accutest Drug of Abuse Urine (Cassette) Test G0434QW June 17, 2011 Jant Pharmacal Accutest Drug of Abuse Urine (Cup) Test G0434QW June 17, 2011 Total Diagnostic Solutions Drug of Abuse Urine (Cassette) Test G0434QW June 17, 2011 Total Diagnostic Solutions Drug of Abuse Urine (Cup) Test G0434QW June 30, 2011 Diagnostic Test Group Clarity Simple Drug Screening Cups G0434QW June 30, 2011 Diagnostic Test Group Clarity Multi-Drug Test Cards 81003QW July 14, 2011 Stanbio Uri-Trak 120 Urine Analyzer G0434QW July 21, 2011 UCP Biosciences, Inc. U-Checker Drug Screening Test Cups 20 20

21 Therapy Code List Always Therapy Code 92618, Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) Medicare Learning Network Matters Article, MM7648: Effective January 1, 2012;Implementation January 3,

22 Expansion of Medicare Telehealth Services May bill codes and G0436 G0437 for smoking cessation services furnished as Medicare telehealth services Initial inpatient telehealth consultation code descriptors (G0425- G0427) revised to allow practitioners to report services furnished to emergency department patients Accept and pay these codes when submitted with: GQ modifier (Via asynchronous telecommunications system) or GT modifier (Via interactive audio and video telecommunications system); Medicare Learning Network Matters Article, MM7504: Effective January 1, 2012; Implementation January 3,

23 Independent Laboratory Billing of Automated Multi-Channel Chemistry (AMCC) Organ Disease Panel Laboratory Tests for Beneficiaries not Receiving Dialysis for End Stage Renal Disease (ESRD) Effective for services on or after January 1, 2012, the requirement for independent laboratories to bill separately for each individual AMCC laboratory test included in organ disease panel codes for ESRD eligible beneficiaries has been eliminated Organ disease panels will be paid under the Clinical Laboratory Fee Schedule and will not be subject to the 50/50 rule payment calculation when billed by independent laboratories Medicare Learning Network Matters Article, MM7497: Effective January 1, 2012;Implemention January 3,

24 Accreditation for Physicians and Non-Physician Practitioners Supplying the Technical Component (TC) of Advanced Diagnostic Imaging (ADI) Services In order to furnish the TC of ADI services for Medicare beneficiaries, suppliers must be accredited by January 1, Provider s claims for the TC for ADI services will be denied: If the provider is not enrolled or accredited by a designated Centers for Medicare/Medicaid Services accreditation organization (Denial code N290: Missing/incomplete/invalid rendering provider primary identifier. ); or If the code submitted is not listed on the provider s eligibility file (claim adjustment reason code185: The rendering provider is not eligible to perform the service billed. )

25 Accreditation for Physicians and Non-Physician Practitioners Supplying the Technical Component (TC) of Advanced Diagnostic Imaging (ADI) Services Centers for Medicare & Medicaid Services (CMS) approved three national accreditation organizations (AOs) to provide accreditation services for suppliers of the technical component (TC) of advanced diagnostic imaging procedures: The American College of Radiology, The Intersocietal Accreditation Commission, The Joint Commission Medicare Learning Network Matters Article, MM7176: Effective January 1, 2012/Implementation July 5, Medicare Learning Network Matters Article, MM7177: Effective/Implementation June 12,

26 Enrollment Revalidation All providers and suppliers who enrolled in the Medicare program prior to March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria Revalidation notices will be sent through March of 2015 Provider Enrollment Chain and Ownership System (PECOS) In PECOS revalidation letter sent to the special payments and correspondence addresses simultaneously; if same -it will also be mailed to the primary practice address Not in PECOS revalidation letter sent to the special payments or primary practice address Do not submit an enrollment form until you receive a request to revalidate 26 26

27 List of Providers sent a Revalidation Request The Centers for Medicare and Medicaid Services (CMS) posted a list of providers who have been sent a request to revalidate their Medicare enrollment information The list contains the name and national provider identifier (NPI) of each provider sent a letter, as well as the date the letter was sent To see the listing, click on Revalidation Phase 1 Listing in the Downloads section of the Medicare Provider Supplier Enrollment Revalidation Page. If you are listed, and have not received the request, please contact Highmark Medicare Services. For more information on revalidation of Medicare provider enrollment, see Medicare Learning Network Matters Article, MM1126 Further Details on the Revalidation of Provider Enrollment Information

28 Payments to be made by Electronic Funds Transfer Existing regulations at 42 CFR (e)(1)(2) require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). Section 1104 of the Affordable Care Act of 2010 (ACA) further expands Section 1862 (a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means. As part of the Centers for Medicare and Medicaid Services' (CMS) revalidation efforts, all suppliers and providers who are not currently receiving EFT payments will be identified, and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application

29 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures MPPR applies when multiple diagnostic imaging services are furnished by the same physician to the same patient on the same day. Previously, applied only to the technical component (TC) Full payment is made for service with highest TC payment under the Medicare Physician Fee Schedule (MPFS). Payment is made at 50% for the TC of subsequent services Expanding the MPPR to professional component (PC) Full payment is made for each PC and TC service with highest payment under MPFS. Payment is made at 75% for subsequent PC services. Payment is made at 50% for subsequent TC services Effective 1/1/2012, Implementation 1/3/2012 MLN Matters Article MM

30 3-Day Payment Window Policy Services rendered on or after January 1, 2012 Patient seen in a wholly owned or wholly operated physician practice and is admitted as an inpatient within 3-days (or 1-day for non-ipps hospital) 3-day payment window will apply to diagnostic and non-diagnostic services that are clinically related to the reason for the inpatient admission regardless of the diagnosis New payment modifier PD MLN Matters Article MM

31 Medicare Initiatives 31 31

32 ICD-10 Medical Coding Compliance Deadline: October 1, Suggestions: Identify current systems using ICD-9 codes Clinical Documentation Encounter Forms/Superbills Practice Management System Electronic Health Record System Contracts Public Health and Quality Reporting Protocols Talk with practice management system vendor about version 5010 and ICD-10 codes Discuss implementation plans with your clearinghouses, billing services, and payers to ensure a smooth transition Assess staff training needs Conduct test transactions using version 5010/ICD-10 codes with payers and clearinghouses Keep Up To Date: Visit the CMS website at to receive timely information about the upcoming version 5010 and ICD-10 transitions 32 32

33 2012 ICD-10 CM Code Updates CMS has posted the 2012 ICD-10 codes updates 2012 ICD-10 CM Index and Tabular Code Titles Addendum General Equivalence Mappings Reimbursement mapping files _and_gems.asp. 33

34 Health Professional Shortage Area (HPSA) Bonus Payments HPSA bonus payment file for 2012 are posted at Review this file each year to determine whether to add the AQ modifier to receive the bonus payment, or to see if the ZIP code area in which services are rendered services will automatically receive the HPSA bonus payment Medicare Learning Network Matters Article, MM7517: Effective January 1, 2012;Implementation January 3,

35 Fraud Prevention Initiative Aims to ensure correct payments are made to legitimate providers for covered appropriate and reasonable services in all federal health care programs Expanded federal government effort to reduce fraud and other improper payments health care programs to help ensure long-term viability Federal government recovered $4 billion last year Fraud prevention efforts focus on a more proactive prevention and detection model that will help prevent fraud and abuse before payment is made. This information is available in the Fraud Prevention Toolkit on the web at:

36 Recovery Auditor (RA) RAs detect and correct past improper payments so that Centers for Medicare/Medicaid Services (CMS) and Carriers, Fiscal Intermediaries (FIs) and Medicare Administrative Contractors (MACs) can implement actions that will prevent future improper payments. RA for Jurisdiction 12 is Diversified Collection Services (DCS)

37 Recovery Auditor (RA) Demonstration High-Risk Vulnerabilities for Physicians Medicare Learning Network Special Edition (SE) Article SE1036 Fourth in a series of articles that will disseminate information on Recovery Auditor (RA) demonstration high dollar improper payment vulnerabilities Two high risk vulnerabilities for physician claims: Other Services with Excessive Units Units billed exceeded the number of units per day based on the Current Procedural Terminology (CPT) code descriptor, reporting instructions in the CPT book, and/or other local or national policy Duplicate Claims Physician billed and was paid for two claims for the same beneficiary, for the same date of service, same CPT code, and same physician

38 Recovery Auditor Effective January 3, 2012, the Centers for Medicare and Medicaid Services transfers responsibility for issuing demand letters from the Recovery Auditor to the claims processing contractors When a Recovery Auditor finds improper payments, they will submit claim adjustments to your Medicare contractor Medicare contractor will establish receivables and issue automated demand letters and follow the same process as is used to recover any other overpayment from you Medicare Learning Network Matters Article, MM7436: Effective January 1, 2012/Implementation January 3,

39 2012 Physician Quality Reporting System (PQRS) Program The Center for Medicare and Medicaid Services (CMS) Posted to PQRS Website: 2012 Measures Codes 2012 Reporting Mechanisms 2012 Analysis and Payment 2012 Payment is 0.5%

40 2012 Electronic Prescribing (erx) Incentive Program The Centers for Medicare and Medicaid Services (CMS) posted 2012 to erx Website: erx Incentive Program Adjustment Feedback Report CMS has received a high volume of hardship exemption requests Providers receiving the adjustment will see an LE on their remittance advice (RA). RA will also have the following Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) CARC = 237 RARC = N545 CMS National Call on PQRS and erx January 17, 2012, 1:30-3pm

41 Preventive Services 41 41

42 CMS Medicare Learning Network (MLN) Products for Preventive Services Help Keep Your Medicare Patients Healthy In the 2012! Ensure your patients take advantage of Medicare-covered preventive services. Medicare covers a wide array of preventive services for eligible beneficiaries, including cancer screenings, certain immunizations, among others. The Medicare Learning Network (MLN) Preventive Services Educational Products Web Page provides descriptions and ordering information for MLN preventive services educational products and resources for health care professionals and their staff. Preventive Services Educational Resources for Health Care Professionals can be found in MLN Matters Article SE

43 New for Screening Preventive Services Screening for Depression in Adults Effective October 14, 2011; Implementation April 2, Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse Effective October 14, 2011; Implementation April 2, Intensive Behavioral Therapy for Cardiovascular Disease Effective November 8, 2011; Implementation July 2,

44 Screening for Depression in Adults Effective 10/14/2011, Implementation 4/2/2012 Medicare covers annual screening for adults for depression in primary care setting Staff assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up HCPCS code G0444; annual depression screening, 15 minutes MLN Matters Article MM

45 Screening and Behavioral Counseling Interventions to Reduce Alcohol Misuse Effective 10/14/2011, Implementation 4/2/2012 Cover annual alcohol screening, for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year Two codes: G0442 Annual Alcohol Misuse Screening, 15 minutes G0443 Brief face-to-face counseling for Alcohol Misuse, 15 minutes MLN Matters Article MM

46 Intensive Behavior Therapy (IBT) for Cardiovascular Disease (CVD) Effective 11/08/2011, Implementation 7/2/2012 Covers one face-to-face CVD risk reduction visit annually for competent beneficiaries, furnished by a qualified primary care practitioner in a primary care setting HCPCS G0446; Annual, face-to-face IBT for CVD, individual, 15 minutes MLN Matters Article MM

47 Influenza Vaccine Payment Allowances Annual Update for Season Payment is based on 95 percent of the Average Wholesale Price (AWP) Medicare Learning Network Matters Article, MM7575: Effective September 1, 2011;Implementation January 27, We have a page dedicated to Flu Vaccine Reimbursement and Administration fees

48 Local Coverage Determination (LCD)/Billing & Coding Article 48 48

49 Local Coverage Determination (LCD)/Billing & Coding Article The following Local Coverage Determination (LCD) will become effective January 23, 2012: Radiation Therapy Services (L27515) LCD Revision Magnetic Resonance Angiography (L31399) Chiropractic (L27480) Wound Care (L27547) Article Revision Sleep Disorder Testing (A50380) 49 49

50 Claim Rejections and Denials 50 50

51 Denial vs. Rejections Denial not medically necessary, not covered under Medicare, etc. Rejection incomplete or invalid information Rejection code on Standard Paper Remittance (SPR) is MA

52 Claim Rejections/Denials Beneficiary eligibility Is Medicare primary or secondary Does the beneficiary have a Medicare Advantage plan Duplicate Name and address of facility where service took place Rendering physicians National Provider Identifier (NPI) Invalid procedure code or not otherwise classified code without a narrative or description Bundled services 52 52

53 Remittance Advice Remark Code and Claim Adjustment Reason Code Stay current with codes Updates made every 4 months Understanding the Remittance Advice Guide

54 Self Service Options 54 54

55 Version 5010 Transaction Electronic transactions will transition to Version 5010 on December 31, 2011 UPDATE Will not be enforced until April 1, 2012 Software vendors, billing services and clearinghouses need to update and test their software Providers should obtain the updated software before December 31, 2011 Part B providers can bill production 5010 as of April 29, 2011 Part A providers can bill production 5010 as of July 25, 2011 Transaction news is available at

56 Version 5010 Upgrade Basics Page Find the following information: Background Information and Timeline Find Out if You need to Test 5010 and Steps Needed to Migrate to Production Test Version 5010 Mpower Provider Portal Testing Certification Tool X12N Testing Tops for Vendors Migration to Version 5010 Electronic Remittance Advice (ERA) Part B Only Technical Support Connecting to SmartXfr Telecommunications Server Guide, which includes the new SmartXfr telecommunications server telephone number and login/password information needed to connect for 5010 claim submission Resources Billing Guides and Publications Electronic Report Training Modules EDI Enrollment Approved Vendor list Washington Publishing Company (WPC) Web Site CMS 5010 Resources

57 Medicare Insights Weekly Podcast Weekly podcast covering important Medicare news and events Automatically delivered Easy to subscribe, just copy the link to your podcast software. Visit:

58 Mailing List Subscribe to our Lists Available mailing lists Part B General Education (Receives All Updates, except EDI) Part B Electronic Billers (EDI) Part A & B PC-ACE Pro32 Users (EDI) 58 58

59 Medicare Part B Center Our website offers a wide variety of valuable resources including: A/B Reference Manual Appeals Electronic Billing (EDI) News and Bulletins Self-Service Tools For additional resources visit:

60 Top Provider Inquiries For the Top Provider Inquiries and other Frequently Asked Questions (FAQs), please visit : ex.html 60 60

61 Evaluation and Management (E/M) Center Valuable information in one convenient location Evaluation and Management (E/M) Center Offers an array of educational resources which will assist you in coding E/M services The E/M Center allows you to access information from one convenient location Visit: html 61 61

62 Calendar of Events Our Training and Events Center offers a wide variety of education Join us for Workshops, Teleconferences, and Webinars To view the most current calendar of events, visit:

63 Centers for Medicare & Medicaid Services (CMS) The CMS website offers a wide variety of valuable resources including: CMS Internet Only Manuals (IOMs) Medicare Learning Network (MLN) Matters Articles Open Door Forum For additional resources visit:

64 Beneficiary Contact Information Patient / Medicare Beneficiary MEDICARE ( )

65 Contractor Initiatives 65

66 Mpower Provider Portal Mpower Provider Portal is the preferred method for all Highmark Medicare Services 5010 testing because it offer the following benefits: Avoid dial-up costs and connection issues by submitting 837I (Part A) and 837P (Part B) electronic claim test files and viewing response reports through the Internet. Receive testing response reports immediately. Receive approval status without viewing the detailed response reports and manually calculating the acceptance rate. Mpower Provider Portal will verify the 837 test files, meet all mandated testing requirements and update your status automatically. Migrate to production I and 837P electronic claim submission automatically. This will allow you to submit production 5010 claims in three business days of being approved. Step-by-step instructions are available on our Website s Mpower Provider Portal section to walk you through the use of this new product and the successful completion of your version 5010 testing at:

67 Provider Telephone Consolidation Project Telephone consolidation became effective on December 1, 2011 One toll free telephone number for all Highmark Medicare Services (HMS) telephone inquires Consolidate the following toll free telephone lines General inquires (i.e., Customer Contact Center, Interactive Voice Response (IVR) ) Provider Enrollment (PE) Electronic Data Interchange (EDI) Telephone Reopenings (Part B only) Prior toll free telephone numbers will become inactive on May 1,

68 Provider Telephone Consolidation Project Benefits Prompts will route providers to either: Part A or B Interactive Voice Response (IVR) Part A or B Electronic Data Interchange (EDI) Part A or B Provider Enrollment (PE) Part B Telephone Reopenings Benefits of telephone consolidation Fewer numbers Decrease wait times Reduce busy signals 68 68

69 Provider Outreach & Education Staff in Pittsburgh, Camp Hill and Hunt Valley The Medicare Experts Provide educational sessions and materials: Conferences, Seminars, Podcast, CBT Modules, Lunchtime Teleconferences, etc. Website and webinars heavily utilized by provider community Built upon a foundation of internal and external collaboration Provider-Focused approach Relationship building has been key 69 69

70 Social Media We are moving forward with social media Our first social media will be Twitter We expect to implement Twitter soon We are currently exploring the use of Web Chat to assist providers in navigating the web site 70 70

71 Thank You!!! Questions? 71