Monmouth Ocean NJ AAPC Local Chapter: Medicare Part B Updates

Transcription

1 Monmouth Ocean NJ AAPC Local Chapter: Medicare Part B Updates January 5, 2017 Disclaimer All Current Procedural Terminology (CPT) only are copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 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. Novitas Solutions 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. Novitas Solutions does not permit videotaping or audio recording of training events. 1

2 Novitas Solutions Education This education contains specific contractor guidance for providers in Medicare Administrative Contractor (MAC): Jurisdiction H (JH) includes: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas Jurisdiction L (JL) includes: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania Acronym List Acronym CERT CMS CR EDI HIPAA LCD MBI MLN NCD NPI PHI SSNRI Definition Comprehensive Error Rate Testing Centers for Medicare & Medicaid Services Change Request Electronic Data Interchange Health Insurance Portability and Accountability Act Local Coverage Determination Medicare Beneficiary Identifier Medicare Learning Network National Coverage Determination National Provider Identifier Personal Health Information Social Security Number Removal Initiative 2

3 Today s Presentation Agenda: Quarterly Updates Novitas Initiatives Website Features Preventive Services Important Reminders Comprehensive Error Rate Testing (CERT) Program Self-Service Options Objectives: Identify and understand the current Medicare changes Learn how to apply the new guidelines Identify and utilize the educational resources and information Quarterly Updates 3

4 What is a CR? Change Request (CR)- guidelines from CMS How Do I Know if a New CR Has Been Released? Make sure you are signed up for electronic mailing list CRs will be listed on Novitas website: Home page/top News/All News: JL Part B Providers: 4

5 So What is a MLN? Medicare Learning Network (MLN)- are national articles designed to inform health care professionals about the latest changes to CMS programs Where to Find MLN Articles On our website we list MLN Articles: Publication/MLN Articles: JL Providers: CMS website: Outreach and Education-MLN articles: MLN/MLNMattersArticles/index.html 5

6 Social Security Number Removal Initiative The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019 Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards: 11-characters in length Made up only of numbers and uppercase letters (no special characters) Transition period: Will begin no earlier than April 1, 2018 and run through December 31, 2019: Either the HICN or the MBI can be used Use the MBI or the HICN to check Medicare eligibility, after transition period ends use only the MBI Use the beneficiary identifier (MBI or HICN) you used to submit the claim that s under appeal, even after the transition period What Providers Need to Know on The Social Security Number Removal Initiative How will providers get MBIs?: During the transition period, the MBI will be on the remittance advice when you submit a claim using your patient s HICN In the message field on the eligibility transaction responses it will let you know when a new Medicare card has been mailed to each person with Medicare Your systems must be ready to accept the MBI by April 2018: No earlier than April 2018 Medicare cards will be sent, people new to Medicare will only be assigned an MBI Claim forms: Not changing: During the transition period, you can use either the HICN or the MBI Once the transition period ends, you must use the MBI Get more information about the SSNRI: 6

7 MBI Characteristics The Medicare Beneficiary Identifier will have the following characteristics: The same number of characters as the current HICN (11), but will be visibly distinguishable from the HICN Contain uppercase alphabetic and numeric characters throughout the 11 digit identifier Occupy the same field as the HICN on transactions Be unique to each beneficiary (e.g. husband and wife will have their own MBI) Be easy to read and limit the possibility of letters being interpreted as numbers (e.g. Alphabetic characters are upper case only and will exclude S, L, O, I, B, Z) Not contain any embedded intelligence or special characters Not contain inappropriate combinations of numbers or strings that may be offensive HICN and MBI Number Health Insurance Claim Number (HICN): Primary Beneficiary Account Holder Social Security Number (SSN) plus Beneficiary Identification Code (BIC) 9-byte SSN plus 1 or 2-byte BIC Key positions 1-9 are numeric Medicare Beneficiary Identifier (MBI): New Non-Intelligent Unique Identifier 11 bytes Key positions 2, 5, 8, and 9 will always be alphabetic 16.pptx 7

8 Clarifications Regarding the Processing of Form CMS-855R Applications Change Request # 9552: Effective: December 19, 2016 Implementation: December 19, 2016 Key Points: CMS-855R application to be completed for individuals: Reassigning their benefits to an eligible entity or individual Terminating an existing reassignment Updating the primary practice location listed on the 855R Effective date of enrollment and reassignment Companion CMS-855R applications to CMS-855I applications or stand-alone loose 855R applications shall be consistent with the 30-day rule: The later of the date of filing or the date the reassignor first began furnishing services at the new location More On Clarifications Regarding the Processing of Form CMS-855R Applications Key Points: The Form CMS-855R application is not to be used to: Report employment arrangements of physician assistants (PAs); employment arrangements for PAs must be reported on the Form CMS-855I Revalidate reassignments; the individual practitioner should only use the Form CMS-855I and list their active reassignment information in Section 4B Update Contact Person for the provider s file; this must be completed on the Form CMS-855I application Payments based on Medicare effective date: Retro-active billing privileges will not be granted prior to the effective date Regardless of the 30 day rule: the effective date of reassignment will never be prior to the individual s license/certification date or the reassigning group/organization s Medicare effective date Reference: Network-MLN/MLNMattersArticles/Downloads/MM9552.pdf 8

9 Timely Reporting of Provider Enrollment Information Changes Special Edition Article SE1617 Key Points: All physician and non-physician practitioners and physician and nonphysician organizations must report the following changes within 30 days: A change of ownership An adverse legal action A change in practice location All other changes must be reported to your MAC within 90 days of the change Changes can be reported via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or the CMS 855 paper enrollment application Reference: MLN/MLNMattersArticles/Downloads/SE1617.pdf Provider Enrollment Revalidation Cycle 2 Special Edition Article SE1605 Key Points: Requires all providers/suppliers to resubmit and recertify the accuracy of their enrollment information All providers/suppliers must be revalidated under the new enrollment screening criteria Revalidation Cycle 2 expectations: CMS and MACs to streamline the process More standardized process across all MACs Reduce provider/supplier burden Reference: Network-MLN/MLNMattersArticles/Downloads/SE1605.pdf 9

10 CMS Look Up Tool for Provider Enrollment Revalidation Cycle 2 Due Dates are posted to CMS look up tool: Lookup tool will display all currently enrolled providers/suppliers by either: Due Date TBD (To be determined) Posted up to 6 months before revalidation due date MACs will continue to issue revalidation notices in addition to the CMS posted list Avoid Deactivation: Submit a complete application to Novitas and include all active practice locations and reassignments by the requested due date Reference: New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy Change Request # 9726: Effective- January 1, 2017 Implementation- January 3, 2017 Key Points: New POS code 02- for use by the physician or practitioner furnishing telehealth services from a distant site The list of Medicare Telehealth services which can be billed with POS 02 is found on the CMS web site at: Remember to use modifiers: GT (via interactive audio and video telecommunications systems) GQ (via an asynchronous telecommunications system) Reference: Network-MLN/MLNMattersArticles/Downloads/MM9726.pdf 10

11 New Physician Specialty Code for Hospitalist Change Request # 9716 Effective- April 1, 2017 Implementation- April 3, 2017 Key Points: The new specialty code for Hospitalist is C6 Recognize the new code as a valid specialty for the following edits: Ordering/certifying Part B clinical laboratory and imaging, durable medical equipment (DME), and Part A home health agency (HHA) claims Critical Access Hospital (CAH) Method II Attending and Rendering claims Attending, operating, or other physician or non-physician practitioner listed on CAH claims Reference: Network-MLN/MLNMattersArticles/Downloads/MM9716.pdf Nurse Practitioner (NP) Supporting Documentation Best Practice! Novitas Provider Enrollment Services is seeing an increase in development for Nurse Practitioner National Certifying Certification and Master s Degrees As a Best Practice please, send in a copy of the NP s Certification and Master s Degree and/or transcripts with the form CMS-855I: This can be attached to the paper CMS-855I application submission; Or uploaded within the Provider Enrollment, Chain and Ownership System (Internet-based PECOS) Necessary measure for Provider Enrollment Services to meet your enrollment needs quickly without having to develop: Websites are not available to confirm the details for all NP National Certifying Bodies Not all school/university websites can verify a student s master s degree or Doctor of Nursing Practice (DNP) This is any easy practice that will allow for your NPs to be enrolled without delay or burden 11

12 Enrollment Terms and Roles Commonly Used in Medicare Enrollment Do you find the roles and terminology used in the Medicare enrollment process confusing? How about those application roles and I&A associations? If so, this article will provide a clear and concise breakdown for you: Enrollment Center Information available: Tips and tutorials for enrolling in the Medicare program Enrollment forms Check enrollment status Revalidation Medicare Part D enrollment CMS links JL Providers: 12

13 Update to Medicare Deductible, Coinsurance and Premium Rates for 2017 Change Request # 9902: Effective: January 1, 2017 Implementation: January 3, 2017 Part B Deductible: $ per calendar year Part B Co-insurance: 20% of the Medicare allowed amount / fee schedule For more information: Amounts in Controversy Appeal Level Time Limit for Filing Appeal Amount in Controversy Redetermination 120 days $0.00 Reconsideration 180 days $0.00 Administrative Law Judge (ALJ) Hearing Medicare Appeals Council of the Departmental Appeals Board (DAB) Judicial Review in Federal District Court 60 days $ for 2016 $ for days $ days $1, for 2016 $1, for

14 Coding Revisions to National Coverage Determinations (NCDs) Change Request # 9631: Effective: October 1, 2016 Implementation: October 3, 2016 Key Points: Many NCDs will be updated with revisions to ICD-10 coding: 20.4 Implantable Automatic Defibrillators 20.7 Percutaneous Transluminal Angioplasty (PTA) 20.9 Artificial Hearts Hyperbaric Oxygen Therapy Reference: Network-MLN/MLNMattersArticles/Downloads/MM9631.pdf Coding Revisions to NCDs Change Request # 9681: Effective: October 1, 2016 Implementation: January 20, 2016 Key Points: Many NCDs will be updated with revisions to ICD-10-CM coding: Bariatric Surgery 40.1 Diabetes Outpatient Self-Management Training Colorectal Cancer Screening Mammograms Reference: Guidance/Guidance/Transmittals/Downloads/R1755OTN.pdf 14

15 Ninth Maintenance Update of ICD- 10 Conversions For NCDs Change Request # 9751: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Ninth maintenance update of ICD-10 conversions Edits to ICD-10 and other coding updates specific to NCD s will be included in subsequent quarterly releases Policy related changes to NCD s continue to be implemented via the current long standing NCD process Reference: Network-MLN/MLNMattersArticles/Downloads/MM9751.pdf Interest Rate for Overpayments and Underpayments- 1st Quarter FY 2017 Change Request # 9863: Effective: October 18, 2016 Implementation: October 18, 2016 Key Point: Interest rate of 9.625% for Medicare overpayments and underpayments Reference: Guidance/Guidance/Transmittals/Downloads/R273FM.pdf 15

16 2017 Annual Update to the Therapy Code List Change Request # 9782: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: The 2017 updates to the therapy code list are adding eight always therapy codes ( ) for physical therapy (PT) and occupational therapy (OT) evaluative procedures This update will delete the four codes currently used to report these services ( ) Reference: Network-MLN/MLNMattersArticles/Downloads/MM9865.pdf Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. Therapy Cap Values for Calendar Year (CY) 2017 Change Request # 9865: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Outpatient therapy limits for: Physical Therapy (PT) and Speech-Language Pathology (SLP) combined is $1,980 Occupational Therapy (OT) is $1,980 Reference: Network-MLN/MLNMattersArticles/Downloads/MM9865.pdf 16

17 Influenza (Flu) Resources for Health Care Professionals Special Edition Article SE1622 Key Point Reminders: Annual Part B deductible and coinsurance amounts do not apply All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine Fee schedule: JL Providers: More information on SE1622: MLN/MLNMattersArticles/Downloads/SE1622.pdf Updates for Code New code for influenza vaccine Flucelvax: Effective August 1, 2016 Medicare claims processing systems will not be able to accept the new code until January 1, 2017 Institutional claims will be implemented on February 20, 2017 Providers should hold their claims until this time For more information: Education/Outreach/FFSProvPartProg/Provider-Partnership- - Archive-Items/ eNews.html Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. 17

18 Quality Payment Program MACRA- Medicare Access & CHIP Reauthorization Act of 2015: A new approach to paying clinicians for the value and quality of care they provide The Quality Payment Program has two tracks you can choose from: APM- Advanced Alternative Payment Models: A payment approach, developed in partnership with the clinician community, that provides added incentives to clinicians to provide high-quality and costefficient care MIPS- Merit-based Incentive Payment System: A new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program Resources for Quality Payment Program Read or find answers to many questions about the MACRA Request for Information Attend new webinars and can also replay past webinars: Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA- MIPS-and-APMs.html Fact Sheet: 18

19 JW Modifier: Drug Amount Discarded/Not Administered to Any Patient Change Request # 9603: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Use of the JW modifier is required to identify unused drugs or biologicals that are appropriately discarded Providers are required to document the discarded drug or biological in the patient's medical record Reference: Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf New Waived Tests Change Request # 9797: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: List of forty (40) newly approved tests by the Food and Drug Administration (FDA) as waived tests under the Clinical Laboratory Improvement Amendments (CLIA) List of tests that require the QW modifier to be recognized as waived test List of tests that do not require a QW modifier 19

20 Guidance to Laboratories for Collecting and Reporting Data for the Private Payor Rate-Based Payment System Special Edition Article SE1619: Implementation date of new Clinical Lab Fee Schedule (CLFS): January 1, 2018 Key Points: New requirements for the CLFS Clarification on applicable laboratory Entity responsible for reporting applicable information to CMS Data collection and reporting periods Schedule for implementing the new CLFS References: Network-MLN/MLNMattersArticles/Downloads/SE1619.pdf Payment/ClinicalLabFeeSched/PAMA-Regulations.html Clinical Laboratory Fee Schedule (CLFS) Data Reporting Template Special Edition Article SE1620 Key Points: Guidance for the Fee-For-Service Data Collection System (FFSDCS) CLFS data reporting template Quick user guide CLFS inquiries mailbox Links to: CLFS final rule Related press release Fact sheet Frequently asked questions CLFS Power Point slide presentation Reference: 370/SE1620.pdf 20

21 Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of Certain Diagnostic Imaging Procedures Change Request # 9647: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Revised the Multiple Procedure Payment Reduction (MPPR) for the Professional Component (PC): Second and subsequent procedures from 25 percent to 5 percent of the physician fee schedule amount Reduction applies to: PC only services PC portion of global services Procedures with a multiple surgery value of 4 in the Medicare Fee Schedule Database Reference: Network-MLN/MLNMattersArticles/Downloads/MM9647.pdf Payment Reduction for X-Rays Taken Using Film Change Request # 9727: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Reduction in the TC (technical component) of X-ray imaging services provided using film: Including the TC portion of a global service Payment amounts under the PFS (Physician Fee Schedule) reduced by 20 percent for the TC Claims for X-rays using film must include modifier FX Reference: Network-MLN/MLNMattersArticles/Downloads/MM9727.pdf 21

22 2017 Annual Update of HCPCS for SNF Consolidated Billing Change Request # 9735 Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Annual updates of HCPCS Codes for SNF Consolidated Billing available the first week in December 2016: New code files for Part B processing New excel and PDF files for Part A processing Available at Reference: Network-MLN/MLNMattersArticles/Downloads/MM9735.pdf Medicare Outpatient Observation Notice (MOON) MOON is a standardized notice to inform beneficiaries they are: An outpatient receiving observation services Not an inpatient of the hospital or critical access hospital (CAH) Federal Notice of Observation Treatment and Implication for Care Eligibility ACT (NOTICE Act) passed August 6, 2015: NOTICE Act requires all hospitals and CAHs to provide written and oral notification under specified guidelines Form and instructions are located under the downloads section at: Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing- Items/CMS html All hospitals and CAHs are required to provide the MOON beginning no later than March 8,

23 Part B Quarterly Updates Summary of Policies in the Calendar Year (CY) 2017 Medicare Physician Fee Schedule (MPFS) Final Rule Network-MLN/MLNMattersArticles/Downloads/MM9844.pdf Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 23.0, Effective January 1, 2017: Network-MLN/MLNMattersArticles/Downloads/MM9847.pdf Annual Clotting Factor Furnishing Fee Update 2017: Network-MLN/MLNMattersArticles/Downloads/MM9759.pdf More Quarterly Updates Healthcare Provider Taxonomy Codes October 2016 Code Set Update: Network-MLN/MLNMattersArticles/Downloads/MM9659.pdf Claim Status Category and Claim Status Codes Update: Network-MLN/MLNMattersArticles/Downloads/MM9769.pdf January 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files: Network-MLN/MLNMattersArticles/Downloads/MM9843.pdf Influenza Vaccine Payment Allowances - Annual Update for Season: Network-MLN/MLNMattersArticles/Downloads/MM9299.pdf 23

24 Novitas Initiatives Novitas Medicare Learning Center Features: Create an individualized education account Register for webinars, teleconferences, and workshops Download your Continuing Education Unit (CEU) Certificates Be placed on a waitlist if the educational event you register for is closed Benefits: Centralized location for all educational materials Track all of the educational events you ve attended Access Medicare education 24 hours a day, 7 days a week with webbased training modules JL Providers: =

25 Novitasphere Free Web-based portal Part A Access to Eligibility, Medical Review Record Submission,, Claim Submission with File Status, and Audit and Reimbursement Cost Reports Submission Part B - Access to Eligibility, Claim Information and Remittance Advice, Claim Submission with File Status, Electronic Remittance Advice (ERA), Claim Correction, Secure Messaging and a MailBox Live Chat feature Dedicated Help Desk For demonstrations and more information: JL Providers: Novitasphere Claim Correction Feature Common clerical errors can be corrected on finalized claims: Number of services or units Diagnosis code (Primary) Eligible modifiers Procedure code Date of service Place of service Billed amount JL Novitasphere Claims Correction Guide: od=latestreleased&ddocname= &allowinterrupt=1 25

26 Automated Claim Correction Using the IVR New feature for all Part B providers allowing an unlimited number of claims to be corrected using the IVR: Adding, changing or deleting a modifier Changing a primary diagnosis code Changing an ordering/referring provider Changing a procedure code (and billed amount) Changing the quantity billed (and billed amount) Changing a date of service Completing a history correction Correct claims within one year of finalized date using the IVR Claims billed in error must be corrected using: Return of Monies to Medicare Form Part B Redetermination and Clerical Error Reopening Request Form Claim corrections not accepted via IVR may use: Novitasphere Part B Redetermination and Clerical Error Reopening Request Form Automated Claim Correction Using the IVR Resources User Guide JL Providers: Frequently Asked Questions: JL Providers: 26

27 Website Features Website Satisfaction Surveys 27

28 Join Our List Today Stay current with Medicare by receiving s twice a week Available lists (not all-inclusive): Jurisdiction L Jurisdiction H Part B Electronic Billing Novitasphere Portal ABILITY PC-ACE Medicare Remit Easy Print (MREP) Users JL Providers join using: Part B Publications Latest Part B News and Web Site Updates News Bulletins and Articles Novitas e-news Medicare Reports: Medicare medical policy Reimbursement updates Specialty billing information Claim reporting tips and more Published online at: JL Providers: 28

29 On-Demand Education Frequently Asked Questions Podcasts Educational Videos and Tutorials: Watch and learn about the Medicare program and our website's features JL Providers: Provider Specialties / Services One stop shop to direct access to consolidate information for certain provider specialties and other specific services: Anesthesia Ambulance Ambulatory Surgical Center Behavioral Health Chiropractor Global Surgery Hematology and Oncology Incident-To Independent Diagnostic Testing Facility (IDTF) Influenza Billing And many more 29

30 Incident To Interactive Tool The purpose of the "Incident to" self-service tool is to assist providers with understanding the CMS Part B "incident-to" requirements and to apply the rules to their individual given patient/provider circumstances and to understand documentation requirements: JL Providers: E/M Interactive Score Sheet This interactive score sheet was created as a tool to assist providers in selecting a code and is not intended as a replacement for the 1995 and 1997 E/M documentation guidelines published by the Centers for Medicare & Medicaid Services (CMS): JL Providers: 30

31 Over Coding? Under Coding? RIGHT Coding! Recently, there is an increasing trend of under coding in evaluation and management (E/M) services The goal of CMS and Novitas is to pay claims that meet Medicare s requirements and pay them at the proper level of service When there is an underpayment due to under coding, the claim is not paid correctly and it is counted as an improper payment error Under coding misrepresents the true level care that is provided to Medicare beneficiaries Read more from an article posted on our website: JL Providers: Policy Search Application Updated customized Policy Search Application : Current, retired or draft policies ICD-9 LCDs and Articles ICD-10 LCDs and Articles National Coverage Determinations (NCDs) Gives more search power, more accurate results, the new options allows for search by date of service Search results only return policies based on search criteria entered JL Policy Search: 31

32 JL Retired LCDs Looking for retired LCDs or retired Local Coverage Articles: Links to the retired LCDs and retired Articles have been added to our Medical Policy Center home page If you are looking for an LCD or Article that was retired on September 30, 2015 or after please follow the links below If you are looking for an LCD or Article that was retired prior to September 30, 2015 please visit the MCD Archive Site: LCDs and Coverage Articles Local Cover Determinations became effective December 1, 2016: Biomarkers for Oncology (L35396) Biomarkers Overview (L35062) BRCA1 and BRCA2 Genetic Testing (L36715) Corus CAD Test (L36713) Intensity Modulated Radiation Therapy (IMRT) (L36711) Non-Invasive Cerebrovascular Arterial Studies (L35397) Non-Invasive Peripheral Venous Studies (L35451) Local Coverage Article with code updates revised and published as of December 1, 2016 Biomarkers for Oncology (A52986) Non-Invasive Cerebrovascular Arterial Studies (A52992) Non-Invasive Peripheral Venous Studies (A52993) 32

33 Preventive Services Medicare Learning Network (MLN) Products for Preventive Services Help Keep Your Medicare Patients Healthy In 2016! 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: Network-MLN/MLNProducts/PreventiveServices.html 33

34 Preventive Services and Screenings Covered by Medicare Abdominal Aortic Aneurysm Screening Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care Annual Wellness Visit (Including Personalized Prevention Plan Services) Bone Mass Measurements Cancer Screenings Breast Cancer (mammograms and clinical breast exam) Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam]) Colorectal Cancer Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Barium Enema Prostate (Prostate Specific Antigen blood test and Digital Rectal Exam) Lung Cancer Cardiovascular Disease Screening Depression Screening in Adults Diabetes Screening Diabetes Self-Management Training Glaucoma Screening Hepatitis C Human Immunodeficiency Virus (HIV) Screening Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B) Initial Preventive Physical Examination (IPPE) (also commonly referred to as the Welcome to Medicare Preventive Visit) Intensive Behavioral Therapy for Cardiovascular Disease Intensive Behavioral Therapy for Obesity Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease) Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs Tobacco-Use Cessation Counseling Screening for the Human Immunodeficiency Virus (HIV) Infection Change Request # 9403: Effective: April 13, 2015 Implementation: January 3, 2017 Key Points: Screening of HIV infection for all individuals between the ages of years Individuals entitled to Part A or enrolled in Part B Must meet coverage criteria listed in National Coverage Determination HCPCS code: G0475 Reference: Network-MLN/MLNMattersArticles/Downloads/MM9403.pdf Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. 34

35 Screening for Cervical Cancer With Human Papillomavirus (HPV) Testing Change Request # 9434: Effective: July 9, 2015 Implementation: January 3, 2017 Key Points: For individuals entitled to benefits under Medicare Part A and Medicare Part B Adding HPV testing under specified conditions: Reasonable and necessary for the prevention or early detection of cervical cancer Testing allowed once every five years as an additional preventive service Applies to beneficiaries aged 30 to 65 years in conjunction with the Pap smear test Reference: Network-MLN/MLNMattersArticles/Downloads/MM9434.pdf HCPCS Code Update for Preventive Services Change Request: Effective: January 1, 2017 Implementation: January 3, 2017 Key Points: Allows for only one ultrasound screening test for an abdominal aortic aneurysm by Medicare CPT code for abdominal aortic aneurysm replaces HCPCS code G0389 Reference: Network-MLN/MLNMattersArticles/Downloads/MM9888.pdf 35

36 Preventive Services Resources Quick Reference Chart for Medicare Preventive Services: /MPS_QuickReferenceChart_1.pdf Improve Your Patients Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV): Network-MLN/MLNMattersArticles/downloads/SE1338.pdf Important Updates and Reminders 36

37 Sequestration Update Mandatory Payment Reduction of 2% continues until further notice for the Medicare Fee For Service Program For more information: Education/Outreach/FFSProvPartProg/Provider-Partnership- - Archive-Items/ Enews.html Frequently Asked Questions: JL Providers: 60 Medically Unlikely Edits Tips CMS developed the MUE program to reduce the paid claims error rate for certain services Review these important points: The MUE for a procedure code is the maximum units of service a provider would report for a single patient on a single date of service MUEs do not exist for all HCPCS/CPT codes When requested, the records should explain why the patient required more than the approved MUE for any service While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUE values because of fraud and abuse concerns For more tips: JL providers: 37

38 Proper Use of Modifier 59 Overwhelming amount of claims reporting modifier 59 on multiple lines for the same procedure code without a narrative or documentation to support the additional lines Editing to reject claims reporting more than one line with modifier 59 appended to the same procedure code, without a narrative and/or documentation to support the additional lines Claims will receive rejection code 969/standard code 16 (Claim/service lacks information or has submission/billing error(s), needed for adjudication): JL Providers: Centers for Medicare & Medicaid Services (CMS) CMS Internet Only Manuals (IOMs): Offers day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives Medicare Learning Network (MLN) Matters Articles: Your destination for health care professional education products Open Door Forums: Provides an opportunity for live dialogue between CMS and the stakeholder community at large Quarterly Provider Updates: Published quarterly for providers, suppliers, and the general public 38

39 Comprehensive Error Rate Testing (CERT) Program CERT Program Program developed by CMS to monitor the accuracy of claims processing Designed to protect the Medicare trust fund and determine error rates nationally and regionally Random audits conducted on a monthly basis: AdvanceMed request medical records for claims selected as part of the monthly random sample Medical record documentation supporting claim must be returned in designated time frame JL CERT page: 39

40 New CERT Documentation Contractor AdvanceMed, the current Comprehensive Error Rate Testing (CERT) Review Contactor, will also be operating the CERT Documentation Center All CERT inquires and medical records should be sent to AdvanceMed More Information: Education/Outreach/FFSProvPartProg/Provider-Partnership- - Archive-Items/ eNews.html CERT Identification Online Tool Provides status information for sampled claims using the Claim Identification Number (CID) where a decision has been made by the CERT contractor: Claim in Error- CERT error was assessed or not Status Date- last date that CERT updated/reviewed the case Status Decision- where the claim is with the CERT Review Contractor Appealed- if an appeal was initiated and the appeal status Error Code- errors assessed 40

41 Trending Errors- Part B Insufficient documentation: Procedure/service billed Missing or illegible documentation and/or physician signature No valid physician s order No physical therapy certified plan of care/treatment plan Incorrect coding errors: Evaluation and Management (E/M) codes Critical care, discharge day management, physical therapy Units of medication/infusion services Laboratory services Medical Record Signature Reminders Categorized as Insufficient Documentation errors: Missing signatures Illegible handwritten signatures Electronic signatures not dated Attestation statements do not match the date of service Records must be signed and dated Include signature logs to determine handwritten signatures Complete attestation statements when records are not signed Do not add late signatures CMS Complying with Medicare Signature Requirements: Network- MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_I CN pdf 41

42 Evaluation and Management Subsequent hospital care: Missing documentation: Documentation does not support a face to face interaction between the patient and the physician Documentation received: Documentation is a review of a lab study and possible plans to discharge the next day Submitted an authenticated hospital visit progress note for the billed DOS but does not support a face to face CERT error: Insufficient documentation Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. Lab Test Comprehensive metabolic panel: Missing Documentation: The order for the billed lab work or the intent to order the billed comprehensive metabolic panel, complete blood count with differential Documentation received: Results Progress notes that support the necessity No specific orders CERT Error: Insufficient documentation Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. 42

43 Venipuncture Venipuncture: Missing Documentation: Medical record documentation supporting the medical necessity for billed service Received Documentation: Unauthenticated note documenting intent/plan to order labs Lab results as a result of services which are not covered under Medicare Medication record CERT Error: Medically Unnecessary Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved. Summary Gave key points and references to the latest quarterly updates Stay up to date with the latest Medicare changes by visiting the Novitas Solutions website Be aware of CERT documentation request and respond appropriately Take advantage of the various self service options available to the provider community 43

44 Self-Service Options JL Customer Contact Information Providers are required to use the IVR unit to obtain: Claim Status Patient Eligibility Check/Earning Remittance inquiries Customer Contact Center Provider Teletypewriter JL Self-Service Tools: solutions.com/webcenter/portal/customerservicecenter_jl/self- Service+Tools Patient / Medicare Beneficiary: MEDICARE ( ) 44

45 Important Contacts Denise Church Manager Provider Outreach and Education Gregory Hart Supervisor Provider Outreach and Education Thank you 45