HOW TO STAY INFORMED: MEDICARE UPDATES & REMINDERS FROM CGS
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1 HOW TO STAY INFORMED: MEDICARE UPDATES & REMINDERS FROM CGS NATIONAL ASSOCIATION FOR HOME CARE & HOSPICE 2014 ANNUAL MEETING & EXPOSITION PHOENIX, AZ OCTOBER 19-22, 2014 RECENT MEDICARE CHANGES Home Health September 2,
2 SPECIAL EDITION ARTICLE (SE) 1305 Full Implementation of Edits on the Ordering/Referring Providers in Medicare Home e e Health Agency Claims Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf Effective January 6, 2014, claims will be denied if claim fails ordering/referring edit home health claim (type of bill 329) home health adjustment t (type of bill 327) September 2, SPECIAL EDITION ARTICLE (SE) 1305 If appropriate, may appeal claim denials for ordering/referring edits Ex: NPI /name mis-keyed or PECOS file was incorrect and has been corrected To appeal, must submit: Reopening Request Form, pdf and Adjustment claim on hardcopy UB-04 See Ordering/Referring Denial Reopening on Reopenings webpage, September 2,
3 CHANGE REQUEST 8441 Home Health Agency Reporting Requirements for the Certifying Physician and the Physician Who Signs the Plan of Care Network-MLN/MLNMattersArticles/Downloads/MM8441.pdf Effective for episodes beginning on/after July 1, 2014 Requires NPI and name of physicians who: Signs the home health plan of care (POC) and Certifies/recertifies the patient s eligibility for home health services Note: Only when different than certifying physician September 2, CHANGE REQUEST 8441 Example #1: Certifying physician and POC physician are different ATT PHYS = Physician who signed POC REF PHYS = Physician who certified/recertified home health eligibility ESRD HOURS ADJUSTMENT REASON CODE REJECT CODE NONPAY CODE ATT PHYS NPI XXXXXXXXXX L SMITH F A M SC OPR PHYS NPI L F M SC OTH OPR NPI L F M SC REN PHYS NPI L F M SC REF PHYS NPI XXXXXXXXXX L JONES F B M SC Example #2: Certifying gphysician and POC physician are same ATT PHYS = Physician who certified HHA eligibility and signed POC ESRD HOURS ADJUSTMENT REASON CODE REJECT CODE NONPAY CODE ATT PHYS NPI XXXXXXXXXX L SMITH F A M SC OPR PHYS NPI L F M SC OTH OPR NPI L F M SC REN PHYS NPI L F M SC REF PHYS NPI L F M SC September 2,
4 CHANGE REQUEST 8699 Preventing Duplicate Payments When Overlapping Inpatient and Home Health (HH) Claims Are Received ed Out of Sequence Network-MLN/MLNMattersArticles/Downloads/MM8699.pdf Effective dates of service on/after January 1, 2015 Current edits reject a HH claim with service dates that overlap a posted inpatient stay CR 8699 will implement additional edits: To recoup HH PPS payment when inpatient stay billed after paid HH episode To include swing bed (type of bill 18X) as an inpatient claim September 2, CHANGE REQUEST 8699 To resolve issue, adjust HH claim to remove line item dates of service that overlap inpatient t stay See Top Claim Submission Errors C7080 webpage, Use beneficiary eligibility file to look for overlapping inpatient stays If overlapping dates cannot be determined, contact CGS Provider Contact Center (Option 1) September 2,
5 CHANGE REQUEST 8710 Preventing Payment on Requests for Anticipated Payment (RAPs) When Home Health Beneficiaries e es are Enrolled in Medicare e Advantage (MA) Plans Network-MLN/MLNMattersArticles/Downloads/MM8710.pdf Effective dates of service on/after January 1, 2015 Implements edits to prevent RAP payments when final claim not payable due to MA plan RAPs will reject when FROM date falls on/after start of MA plan enrollment FROM date falls before end of MA plan enrollment September 2, CHANGE REQUEST 8710 Reminders about home health and MA plans If a beneficiary is enrolled in MA plan, and OPT Code = C, claims must be submitted to MA plan; not CGS Exception: If beneficiary elects hospice, claims are submitted to CGS Additional guidance available on MA Plans Claim Filing Tips webpage, vantage_plans.html September 2,
6 CHANGE REQUEST 8813 Diagnosis Reporting on Home Health Claims and Network-MLN/MLNMattersArticles/Downloads/MM8813.pdf Effective for dates of service on/after January 1, 2015 Implements edits to prevent manifestation codes as primary diagnosis on home health claims Principal diagnosis on HH claim should be ICD-9 code most related to current HH plan of care (POC) RAPs and claims reporting a manifestation code as principal diagnosis will be returned to provider (RTPd) September 2, RECENT MEDICARE CHANGES Home Health & Hospice September 2,
7 MEDICARE SECONDARY PAYER (MSP) CHANGES Reminder: Change Request 6426 requires MSP claims to be submitted electronically, ect ca using format Guidance/Guidance/Transmittals/downloads/R70MSP.pdf For Group Health Plans (GHPs), must submit electronically, even when services were applied to deductible or benefits exhausted Claims submitted direct data entry (DDE) will be returned to provider (RTP) with reason code For Non-group Health Plans (NGHPs), if services are unrelated, claims may be submitted DDE with Medicare as primary if claim does not include any related diagnosis codes September 2, ICD-10-CM/PS ICD-10 compliance date is October 1, 2015 CGS ICD-10-CM/PCS CM/PCS webpage, CMS ICD-10 webpage, Medicare Fee-for-Service Provider Resources webpage, Service-Provider-Resources.html September 2,
8 ICD-10-CM/PS For Home Health: Special Edition article SE1410, /Out a ducat o / ed ca e g Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf RAPs - report ICD-9 or ICD-10 code based on TO date Claims report ICD-9 or ICD-10 code based on TO date HH claims cannot be split HH claims cannot report both ICD-9 and ICD-10 CMS states: HHAs will be allowed to use payment group code derived from ICD-9 codes on claims that span 10/1, but claims must report ICD-10 codes September 2, RECENT MEDICARE CHANGES Hospice September 2,
9 CHANGE REQUEST 8358 Additional Data Reporting Requirements for Hospice Claims, /out a educat o / ed ca e g et o mln/mlnmattersarticles/downloads/mm8358.pdf Effective for dates of service April 1, 2014 Additional hospice data to support hospice payment reform 1. Line item visit data for hospice staff provided under general inpatient care (GIP) in skilled nursing facilities or hospitals 2. National Provider Identifier (NPI) of facility where beneficiary resides 3. Post-mortem visits (on date of death) to capture visits and duration for hospice employed nurses, aides, social workers and therapist 4. Injectable and non-injectable prescription drugs 5. Infusion pumps and medication refills September 2, CHANGE REQUEST 8358 GIP visits Appropriate revenue and HCPCS code, units (15-min min. increments) when site of service is Q5004, Q5005, Q5007 or Q5008 Facility NPI Required with Q5003, Q5004, Q5005, Q5007, and Q5008 Required with Q5006 if different than billing hospice Post-mortem visits Appropriate revenue and HCPCS code, PM modifier, units (15-min. increments) Exception: PM visits under GIP in hospice inpatient facility (Q5006) cannot be reported September 2,
10 Injectable drugs Line item reporting per fill CHANGE REQUEST 8358 Revenue code 0636 and HCPCS, units (amount filled, according to HCPCS definition) Non-injectable prescriptions Line item reporting per fill Revenue code 0250 and National Drug Code (NDC), units Infusion pump Line item reporting per pump and per medication refill Revenue code 029X (equipment), 0294 (drug) and HCPCS September 2, Additional resources CHANGE REQUEST Table of Drugs (HCPCS), -Numeric-HCPCS-Items/2014-Drugs- Table.html?DLPage=1&DLSort=0&DLSortDir=descending NDC directory, Hospice Prescription Drug Reporting Table, presdrugreportingtable.pdf FAQs, (under Hospice Billing) September 2,
11 CR 8877 Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election ecto (NOE) and Termination ato or Revocation ocato of Election, ecto Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf Effective for dates of service on/after October 1, Prohibits use of Symptoms, Signs, and Ill-defined Conditions diagnosis codes as principal diagnosis 2. Mandates filing of Notice of Election (NOE) within 5 calendar days after hospice admission date 3. Must submit Notice of Termination/Revocation (NOTR) within 5 calendar days after effective date of live discharge/revocation 4. Clarification of Q5003 and Q5004 September 2, CR 8877 Codes prohibited as principal diagnosis and (Debility) (Adult failure to thrive) Multiple dementia codes See Attachment A for complete list Claims with prohibited codes will be returned to provider (RTPd) with reason code Note: Editing will be updated with implementation of ICD-10 September 2,
12 Timely filing of NOEs CR 8877 Defined as a NOE that is submitted to the Medicare contractor and accepted by the Medicare contractor within 5 calendar days after the hospice admission date Providers need to consider Staff availability to submit NOEs timely QA process to ensure accuracy of submission of NOE An NOE that is returned to provider (RTPs) does not constitute an accepted NOE When NOE is corrected (F9 d) out of RTP, it gets new receipt date; this will be receipt date used to determine timely filing of NOE Untimely NOEs will still process and post beneficiary s hospice election September 2, CR 8877 Example of timely/untimely NOE calculation Admission date = 10/10/14 Day 1 = 10/11/14 Day 2 = 10/12/14 Day 3 = 10/13/14 Day 4 = 10/14/14 Day 5 = 10/15/14 NOE due date If NOE received on/after 10/16/14, it is untimely Example: NOE received 10/16/14 OSC 77 reported with 10/10/14 10/15/14 September 2,
13 CR 8877 If the NOE is untimely, provider must submit claim with: An occurrence span code 77 with noncovered dates Noncovered dates = admission date / day before NOE received MAP1711 PAGE 01 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXXX SC INST CLAIM ENTRY C201433P HH:MM:SS HIC TOB 811 S/LOC S B0100 OSCAR SV: UB-FORM NPI TRANS HOSP PROV PROCESS NEW HIC PAT.CNTL#: TAX#/SUB: TAXO.CD: STMT DATES FROM TO DAYS COV N-C CO LTR LAST FIRST MI DOB ADDR CARR: 5 6 LOC: ZIP SEX MS ADMIT DATE HR TYPE SRC D HM STAT COND CODES OCC CDS/DATE SPAN CODES/DATES FAC.ZIP DCN September 2, CR 8877 Noncovered level of care days due to untimely NOE are reported on separate ate revenue e code line from covered ed days MAP1712 PAGE 02 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY SXB4699 SC INST CLAIM ENTRY C201433P HH:MM:SS REV CD PAGE 01 HIC TOB 811 S/LOC S B0100 PROVIDER TOT COV SERV RED CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND 0651 Q Q Q Noncovered discipline visits and drugs may be reported as noncovered, but not required September 2,
14 Four exceptional circumstances CR Fires, flood, earthquakes, or other unusual events that inflict extensive damage to hospice s ability to operate 2. An event that produces a data filing problem due to CMS or contractor system issues, beyond control of hospice 3. Newly Medicare-certified hospice that is notified of certification after Medicare certification date, or awaiting user ID from Medicare contractor; or 4. Other circumstances determined by Medicare contractor or CMS to be beyond hospice s control Examples provided in Section IV. Supporting Information section of CR See and September 2, CR 8877 To request an exception: Report KX modifier on earliest dated level of care line (0651, 0652, 0655, 0656) CGS will generate non-medical review Additional Development Request (non-mr ADR) Claim will move to S B6001 Edit code on FISS Page 08 will be ADR narrative will indicate need to submit documentation to support exceptional circumstance FISS Page 08 will provide mailing address to submit documentation esmd will be accepted Documentation must be submitted as soon as possible, but no later than day 30 days September 2,
15 CR 8877 CGS will review exceptional circumstance documentation If documentation supports exception CGS will remove non-covered days, and pay for days associated with late-filed NOE If documentation does not support exception CGS will process claim as billed (with noncovered days) September 2, CR 8877 Hospices required to submit Notice of Termination/Revocation (NOTR) within 5 calendar days after effective ect e date of discharge/revocation e o Unless final claim already filed Submit direct data entry (DDE) Use Claims option; instead of NOE option September 2,
16 Billing requirements for NOTR Similar to NOEs (8XA) except: CR 8877 Type of bill (TOB) = 81B or 82B From date = Start date of hospice benefit period in which termination/revocation is effective Through date = date of termination/revocation Admission Date = Effective date of hospice benefit period in which the discharge/revocation is effective Note: Not initial hospice admission date Patient status = appropriate patient status code September 2, Q5003 vs. Q5004 Q5004 used in 4 situations: CR Beneficiary receiving hospice care in solely-certified SNF 2. Beneficiary receiving general inpatient care in SNF 3. Beneficiary in SNF receiving SNF care under Medicare SNF benefit for condition unrelated to terminal illness/related conditions and under hospice routine home care (rare) 4. Beneficiary receiving inpatient respite care in SNF Q5003 used when beneficiary received care in nursing facility that doesn t meet criteria above September 2,
17 COMMON BILLING ERRORS & TOP DENIALS Home Health September 2, CGS CLAIMS DATA HOME HEALTH April 1, 2014 July 31, 2014 Number of Claims Submitted 844,984 Total # of Claim Submission Errors (CSEs) 98,763 Number of Claims Reviewed by Medical Review 1,957 Number of Claims Denials (Partial/Full) by Medical Review 1,646 September 2,
18 CGS BILLING ERRORS HOME HEALTH April 1, 2014 July 31, 2014 Reason Code Billing Error # of Errors FISS can t find matching RAP 30, , Duplicate RAP/claim same beneficiary/same dates of service/same billing provider 12,292 U538I Overlap another HHA s episode 68 6, Less than 60 days billed on home health claim and patient status code billed equals 30 3, HCPC Q5001, Q5002, or Q5009 not present 2,724 September 2, CGS BILLING ERRORS RESOURCES HOME HEALTH Top Claim Submission Errors (Reason Codes) and How to Resolve web page, September 2,
19 Denial Reason Code 5FFTF CGS MEDICAL REVIEW DATA HOME HEALTH April 1, 2014 July 31, 2014 Denial Reason # of Denials Face-to-face documentation missing/incomplete/untimely 5HMED Medical necessity not supported ADR information not received/timely 218 5HPLN Missing/incomplete/untimely plan of care 73 5HHBD Homebound status not supported 53 September 2, CGS MR DENIAL RESOURCES HOME HEALTH Home Health Denial Fact Sheets 5FFTF - Missing/incomplete/untimely FTF Encounter, TF_FactSheet.pdf 5HMED Medical necessity, MED_FactSheet.pdf 5HNOA No OASIS, a_factsheet.pdf September 2,
20 CGS MR DENIAL RESOURCES HOME HEALTH Home Health Denial Fact Sheets (cont.) 5HPLN/5HORD Missing plan of care or orders, LN-5HORD_FactSheet.pdf 5HHBD Homebound status, d_factsheet.pdf No response to ADR ADR Process webpage, Additional Development Request quick resource tool, T.pdf September 2, COMMON BILLING ERRORS & TOP DENIALS Hospice September 2,
21 CGS CLAIMS DATA HOSPICE April 1, 2014 July 31, 2014 Number of Claims Submitted 277,117 Total # of Claim Submission Errors (CSEs) 54,456 Number of Claims Reviewed by Medical Review 2,933 Number of Claims Denials (Partial/Full) by Medical Review 1,994 September 2, CGS BILLING ERRORS HOSPICE April 1, 2014 July 31, 2014 Reason Code Billing Error # of Errors Sequential billing no prior processed claim 6, Service facility NPI not reported 5,020 (May-Jul) Duplicate claim 4,114 U5150 No NOE on file for hospice election 3,316 U5106 NOE falls within current hospice election 2,944 September 2,
22 CGS BILLING ERRORS RESOURCES HOSPICE Top Claim Submission Errors (Reason Codes) and How to Resolve web page, September 2, CGS MEDICAL REVIEW DENIAL DATA HOSPICE April 1, 2014 July 31, 2014 Denial Reason Code Denial Reason # of Denials 5PTER Six-month terminal prognosis not supported PPOC POC does not meet requirements 252 5PCER Missing/incomplete/untimely certification/recertification No response to ADR 161 5PRLM Reduced level of care 97 September 2,
23 CGS MR DENIAL RESOURCES HOSPICE Hospice Denial Fact Sheets 5PTER Six-month prognosis not supported, 5PTER_FactSheet.pdf 5PPOC Plan of care does not meet requirements, 5ppoc_factsheet.pdf 5PCER Missing/incomplete/untimely certification/recertification, com/hhh/education/materials/pdf/hospice 5pcer_factsheet.pdf 5PRLM/5PRLT Reduced level of care, 5prlm_factsheet.pdf September 2, CGS MR DENIAL RESOURCES No response to ADR HOSPICE ADR Process webpage, Additional Development Request quick resource tool, T.pdf September 2,
24 CGS HH&H WEBSITE RESOURCES Home Health & Hospice September 2, CGS HH&H WEBSITE Join/Update ListServ Contact Us link Search engine September 2,
25 CGS HH&H WEBSITE Main navigation menu Click + for Quick Links Links to Hot Topics September 2, CGS HH&H WEBSITE: MYCGS PORTAL mycgs: Login, FAQs, User Manual, Help Desk September 2,
26 CGS HH&H WEBSITE: APPEALS Appeals: Overview, FAQs, Timeliness Calculator, Appropriate Requests, Reopenings, Redeterminations September 2, CGS HH&H WEBSITE: CLAIMS Claims: ADRs, Checking Claim Status, FAQs, FISS, MSP, Timely Filing, RTPs, Transfer Dispute September 2,
27 CGS HH&H WEBSITE: CUSTOMER SERVICE Customer Service: Contact Info, Site Map, Website Feedback, IVR User Guide September 2, CGS HH&H WEBSITE: EDUCATION & RESOURCES Education & Resources: CMS Educational Resources, Educational Materials, FAQs September 2,
28 CGS HH&H WEBSITE: EDUCATIONAL MATERIALS September 2, CGS HH&H WEBSITE: FINANCIAL Financial: Cost Reports, PS&R, Rates & Fee Schedules, RA/ERA September 2,
29 CGS HH&H WEBSITE: LCDS/COVERAGE LCDs/Coverage: Home Health Coverage, Hospice Coverage, OASIS September 2, CGS HH&H WEBSITE: MEDICAL REVIEW Medical Review: ADRs, esmd, CERT, Overview of MR, Reopenings September 2,
30 CGS HH&H WEBSITE: NEWS & PUBLICATIONS News & Publications: Recent News (listservs), CGS Bulletin, Join Listserv September 2, QUESTIONS? CGS Provider Contact t Center: (Option 1) CGS EDI Department: (Option 2) September 2,
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