Medicare 2018 What's on the Horizon. Part A/B Provider Outreach and Education April 2018

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1 Medicare 2018 What's on the Horizon Part A/B Provider Outreach and Education April 2018

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2018 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. April

3 2018 CMS initiatives Part A/B Agenda Medicare Review Contractors Noridian Updates Resources Educational Information April

4 Acronyms Acronyms CMS CPT CR CY DME EOB FQHC HCPCS HICN Description Center for Medicare & Medicaid Service Current Procedural Terminology Change Request Calendar Year Durable Medical Equipment Explanation of Benefits Federally Qualified Health Center Healthcare Common Procedural Coding System Health Insurance Claim Number April

5 Acronyms MAC MBI MDDP MLN MSP NCD PECOS QMB RARC SPR Acronyms2 Description Medicare Administrative Contractor Medicare Beneficiary Identifier Medicare Diabetes Development Plan Medicare Learning Network Medicare Secondary Payer National Coverage Determination Provider Enrollment, Chain & Ownership Systems Qualified Medicare Beneficiary Remittance Advice Remark Code Standard Paper Remit April

6 CMS Initiatives April

7 Review Medicare Programs Patients Over Paperwork This is the second issue of our recurring newsletter about Patients over Paperwork, our effort to reduce administrative burden and improve the customer experience while putting patients first. In this edition, we reflect on 2017 and update you on how we have been working to reduce burdensome regulations, streamline requirements and improve the clarity of our programmatic guidance. This work is in accordance with our agency s strategic goals: 1. Empower patients and clinicians to make decisions about their health care. 2. Usher in a new era of state flexibility and local leadership. 3. Support innovative approaches to improve quality, accessibility, and affordability. 4. Improve the CMS customer experience. Stay Connected Click HERE to learn more about Patients over Paperwork. To ensure that you receive this newsletter and any other Patients over Paperwork updates, be sure to join our listserv. You may also review past newsletter editions HERE. Tweet about Patients over Paperwork by using the hashtag #patientsoverpaperwork and #regreform February

8 Patients Over Paperwork (2) Quality Measures You Said: CMS quality programs have too many quality measures that are not meaningful to patients or providers. Reporting on these measures takes valuable time away from patient care. We Heard You: Across our rules, CMS is adopting policies that balance the meaningfulness of quality measurement data with efforts to limit provider burden and improve the doctor-patient relationship. In 2017, CMS took initial steps to reduce the number of quality measures in our programs, and will continue to make progress on this initiative in Hospital Outpatient Quality Reporting Program CMS finalized the removal of six measures, resulting in an estimated burden reduction of 457,490 hours and $16.7 million reduction in associated stakeholder costs for the 2020 payment determination. April

9 Patients Over Paperwork (3) Ambulatory Surgical Center (ASC) Quality Reporting Program CMS finalized the removal of three measures. Removing these measures will alleviate maintenance costs and administrative burdens to the ASCs, resulting in reducing burden by an estimated 1,314 hours and $48,066 for the 2019 payment determination. CMS also delayed implementation of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) under the ASCQR Program beginning with the 2018 data collection. April

10 New Medicare Card Mailing - Insert Recommended provider action Sign up Noridian list serv bi-weekly s Visit CMS Website/ Attend Their Events Medicare/New-Medicare-Card/index.html Inform Beneficiaries/ Obtain new MBIs Prepare and Test Systems

11 New Railroad Retirement Board Medicare Card Claims processed through Medicare Administrative Contractor (MAC) Palmetto GBA not Noridian What is the difference? Symbol Red Banner Railroad Retirement Board All other information is the same as the Standard Medicare Card February

12 MBI State Mailing Schedule Zone 2 (April June 2018) Alaska, American Samoa, California, Guam, Hawaii, Northern Mariana Islands, Oregon Zone 3 (After June 2018) Arkansas, Illinois, Indiana, Iowa, Kansas, Minnesota, Nebraska, North Dakota, Oklahoma, South Dakota, Wisconsin Zone 6 (After June 2018) Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Texas, Utah, Washington, Wyoming April

13 Medicare Diabetes Prevention Program (MDPP) Pilot to prevent onset of Type II Diabetes Separate enrollment for MDPP coach/provider Special PECOS Enrollment Form CMS Codes include G G9889 Allow between $25 - $160 Services available after 4/01/18 dprp-standards.pdf February

14 MDPP Overview e/fact-sheets/2016-fact-sheets-items/ html February

15 MDPP Enrollment Prospective MDPP suppliers began enrolling on January 1, 2018 Policies related to furnishing and billing MDPP services effective April 1, 2018 I.E. beneficiary eligibility, MDPP set of services, payment, beneficiary engagement incentives April

16 MDDP Enrollment Form Separate CMS Enroll using PECOS CMS website Medicare/Provider- Enrollment-and- Certification/MedicareP rovidersupenroll/enroll mentapplications.html February

17 Inquiry Reduction initiative April

Noridian Self-Service Required2 CMS requires providers use self-service options CMS Internet Only Manual (IOM), Publication 100-09, Chapter 6, Section 50.

18 Noridian Self-Service Required2 CMS requires providers use self-service options CMS Internet Only Manual (IOM), Publication , Chapter 6, Section 50.1 Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR or portal... Process change allows our CSRs to assist callers with more complex inquiries which cannot be answered through self-service tools February

Self-Service Requirements Effective February 5, 2018 Noridian Medicare Portal (NMP) and/or Interactive Voice Response (IVR) Part A/B patient eligibility and deductible Claim

19 Self-Service Requirements Effective February 5, 2018 Noridian Medicare Portal (NMP) and/or Interactive Voice Response (IVR) Part A/B patient eligibility and deductible Claim status-remittance Advice (RA) Electronic Funds Transfer (EFT)/check #/amount/date Self Service Reopenings (NMP only) Enrollment Application Status Search Enrollment application status April

Noridian Medicare Portal (NMP) New quick link Keep up to date Notifications & Updates https://www.noridianmedicareportal.

20 Noridian Medicare Portal (NMP) New quick link Keep up to date Notifications & Updates Have New Users? Get them registered Functionality: Verify eligibility Check claim status Reopening Submit an appeal April

21 NMP Advantages Over the IVR NMP Users enter information using computer keyboard Users able to view information as it is entered Users able to view immediate inquiry results Users can download and save viewed information Offers "How To" tutorials Continuous updates with increased access coming soon IVR Callers must follow voice prompts and use telephone touch-tone keypad or voice recognition to enter information Callers must wait for an audio response to verify information entered Callers must wait for audio response to hear inquiry results Callers able to hear inquiry results only No tutorials available No future enhancements planned April

22 Portal - Reopenings Corrections effective February 5, 2018 Billed amount Diagnosis Modifiers - exceptions apply Month/day of service changes MSP type Place of service Procedure code, modifier and billed amount Rendering National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) or Referring NPI Reprocess claim (without changes) Units, modifier and/or billed amount February

23 Elimination of Paper Remits Part B only CR10151 effective January 1, 2018 Elimination of paper remits All providers receiving electronic remittance advice (ERAs) for 45 days or more Effective January 1, 2018 All providers EDI-enrolled receiving ERAs and standard paper requests (SPRs) Effective February 14, 2018 Some exceptions for natural disaster or CMS discretion All Part B portal users with Remittance functionality access April

CMS Appeals ALJ Settlement Low volume appeals (LVA) settlement option: Pending at Office of Medicare Hearings and Appeals (OMHA) and Medicare Departmental Appeals Council 62% settlement of net

24 CMS Appeals ALJ Settlement Low volume appeals (LVA) settlement option: Pending at Office of Medicare Hearings and Appeals (OMHA) and Medicare Departmental Appeals Council 62% settlement of net allowed Eligibility for either Part A or Part B claims: Total billed <$ <500 claims pending Education/Outreach/NPC/Downloads/ Appeals-Settlement-Presentation.pdf April

25 Appeals Timeliness Calculators topics/appeals/calculators April

26 First Quarter

27 HIGLAS Enhancement for Overpayment Based Denials CR Effective April 1, 2018 Under Code of Federal Regulation (CFR) (a)(6)(i), enrollment applications may be denied if enrolling provider, supplier or owner thereof has existing Medicare overpayment greater than or equal to $1, HIGLAS will report this information to PECOS April

28 Qualified Medicare Beneficiary (QMB) Indicator CR 9911 Effective October 2, 2017 claims processed on/after this date Implemented April 2, 2018 Medicare Summary Notices (MSNs) to include message 62.0 when date of service falls within QMB period This notice contains claims covered by the Qualified Medicare Beneficiary (QMB) program, which pays your Medicare costs. When you re enrolled in the QMB program, providers and suppliers who accept Medicare aren t allowed to bill you for Medicare deductibles, coinsurance, and copayments. April

29 Inpatient Information Only Claims for Beneficiaries Enrolled in MA Plans CR Effective April 1, 2015 Implementation April 2, 2018 CWF will set edit 5233 on inpatient information only claims billed with condition codes 04 and 30 for Investigational Device Exemption (IDE) Studies and Clinical Studies Approved Under Coverage with Evidence Development (CED) Allows FISS to zero out payment April

30 TDAPA for AKI CR Effective April 1, 2018 Transitional Drug Add-on Payment Adjustment (TDAPA) for patients with Acute Kidney Injury (AKI) Under ESRD PPS drug designation process, CMS provides payment using TDAPA for new injectable or intravenous drugs and biologicals that qualify under 42 CFR (c)(1) Reason codes 36228C and 36229C added to RTP claims back for billing with modifier AX or- billing with HCPCS J0604 or J0606 April

31 Remove Obsolete Edits from FISS CR Effective April 1, 2018 CMS requests FISS remove and archive 26 obsolete reason codes 31715, 31724, 32222, 32223, 32231, 32245, 32361, 32396, , April

32 Telehealth Services: Elimination of GT Modifier CR10152 effective January 1, 2018 Eliminates requirement to use GT modifier on professional claims for telehealth services Via interactive audio and video telecommunications systems GQ modifier is still required when applicable Critical Access Hospital (CAH) method II on institutional claims, still require GT modifier Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements April

33 2018 Telehealth Originating Site Q3014 = $25.76 (national) G0296 Visit to determine low dose computed tomography (LDCT) eligibility and Health Risk Assessment G0506 Care Planning for Chronic Care Management and Psychotherapy for Crisis Interactive Complexity April

34 Mammography Production Alert CPT 77065, and can be used for both film and digital mammography Codes set as requiring film certification Research determined it was more applicable to have them set up to allow both certification types Noridian updated codes to allow both certification types on January 18, 2018 A mass adjustment will be completed for claims denied incorrectly April

35 New Prolonged Preventive and Anesthesia Service Codes Prolonged preventive services Add-on payment; deductible and coinsurance waived CPT G0513 first 30 minutes CPT G0514 any additional minutes Anesthesia services conjunction support of colorectal cancer service screenings CPT anesthesia for lower intestinal endoscopic procedures CPT anesthesia for lower intestinal endoscopic procedures, screening colonoscopy PT modifiers waves the deductible and coinsurance waived April

Therapy Cap Values Update: Congress repealed February 8, 2018 There will be no therapy cap for 2018, but there will be a threshold Threshold is dollar amount deemed as the reasonable and necessary

36 Therapy Cap Values Update: Congress repealed February 8, 2018 There will be no therapy cap for 2018, but there will be a threshold Threshold is dollar amount deemed as the reasonable and necessary amount of therapy prior to a review of additional services CR10341 effective January 1, 2018 Physical therapy and speech-language pathology combined CY 2018 cap is $2,010 Occupational therapy, CY 2018 cap is $2,010 April

37 Payment Reduction Computed Radiography- Modifier FY Effective January 1, 2018 Modifier FY X-ray taken using computed radiography Reduction only technical component and technical component of global fee Services furnished during CY 2018 to 2022 at 7% reduction 10% reduction starting CY 2023 and all future years Beneficiary is not liable for the reduction Part A All imaging services are listed in the OPPS Addendum B Deletion of Modifier CP April

38 Correcting Payment of IPPS Transfer Claims- Part A CR10145 effective January 1, claims date of service and after Medicare Severity - Diagnosis Related Group (MS-DRG) 385 Inflammatory bowel disease with Major Complication or Comorbidity (MCC) should be subject to transfer policy Part A deductible will be allowed on Medicare Secondary Payer (MSP) same day transfer claims Identified by a value code April

39 RHC/FQHC Care Coordination Services and Payment CR10175 effective January 1, two new HCPCS added with payment amount set at Average of 3 national non-facility PFS payment rates for chronic care management (CCM) and general behavioral health integration (BHI) codes General Care Management (G0511) Psychiatric Collaborative Care Model (CoCM) (G0512) Billing CPT on or after January 1 will be denied April

40 340B Drug Program Part A Extends front-end discounts on covered outpatient drugs to eligible facilities/covered entities Maximum statutory price that may be charged by the manufacturer Modifier JG indicates the drug or biological was acquired with the 340B drug pricing program discount Modifier TB indicates the drug or biological was acquired with the 340B drug pricing program discount and is reported for informational purposes Questions Contact government contractor Apexus at or apexusanswers@apexus.com April

41 NCD Leadless Pacemakers Part B only CR10117 effective January 18, 2017 Contractors allow payment with Coverage with Evidence Development (CED) when billed using: CPT codes: 0387T, 0389T, 0390T, and 0391T Claims for leadless pacemakers are only payable in Place of Service (POS) 06, 21, 22 or 26 If claim doesn t contain modifier Q0 edit 113L will set Contain diagnosis code Z00.6 or the 114L will set April

42 Medicare Part A/B Review Contractors Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), Targeted Probe & Educate (TPE), Officer of Inspector General (OIG), Zone Program Integrity Contractor (ZPIC)

Responding to The Letter Request for documentation: CERT, Medical Review, RAC,SMRC,TPE, and ZPIC Documentation request letters have due date for response Verify your address is correct in PECOS

43 Responding to The Letter Request for documentation: CERT, Medical Review, RAC,SMRC,TPE, and ZPIC Documentation request letters have due date for response Verify your address is correct in PECOS Respond timely with organized documentation Make sure signatures are present and legible Submit an attestation if missing or illegible signature Ensure all required information is sent to correct review contractor April

Noridian Review Contractor Resources https://med.noridianmedicare.

44 Noridian Review Contractor Resources Jurisdiction F Medicare Part A/B Medical Review Targeted Probe & Educate (TPE) Other Review Entities Comprehensive Error Rate Testing (CERT) Office of Inspector General (OIG) Recovery Auditor (RAC) Supplemental Medical Review Contractor (SMRC) ZPIC April

45 Comprehensive Error Rate Testing (CERT)2 AdvanceMed CERT Review Contractor Attn: CID# 1510 E. Parham Road Henrico, Virginia Phone: Fax: Include requested medical documentation along with bar coded sheet Website dmedcorp.com/ April

46 Jurisdiction F Part B National Error Rate: 10.2% Breakdown by State: State Projected Error Projected Improper Payment Rate Overall JF 7.2% $1,231,662,868 AZ 13.6% $553,572,353 WA 4.0% $161,390,236 MT 16.4% $104,163,334 OR 3.3% $94,084,207 UT 4.6% $70,738,681 ID 8.4% $55,632,865 CA 9.6% $55,067,884 SD 4.7% $46,474,707 ND 2.7% $23,924,747 WY 10.1% $19,224,030 April

Recovery Audit Contractor (RAC) https://racinfo.hms.com/home.

47 Recovery Audit Contractor (RAC) HMS Federal Solutions (HMS) New name for Region 4 post pay auditor Region 4 is all Noridian states (JE/JF A/B) Medicare Part A/B Identifies Medicare overpayments and/or underpayments through audits April

48 RAC Issues Oct Recovery Audit Contractor (RAC) examples: Excessive/Insufficient Drug and Biological Units E/M within 0 & 10 Day Global Procedures Critical care same day as Emergency room services April

49 Supplemental Medical Review Contractor (SMRC) Strategic Health Solutions, LLC Conducts medical review based on analysis Part A/B or DME fee for service Claims, services/provider specialties April

50 Website SMRC Current Projects Current Projects: 3/16/17 Outpatient Drugs - Completed 4/7/17 Incorrect Place of Service - Completed 4/11/17 Bone Marrow and Stem Cell Transplant 7/10/17 Cardiac Rehabilitation - Completed April

Office of Inspector General (OIG) https://oig.hhs.

51 Office of Inspector General (OIG) Compliance with Nation's fraud and abuse laws Educate public Monthly reporting orts-andpublications/workplan/i ndex.asp#current April

52 Targeted Probe & Educate (TPE) Noridian Pilot review process - June dicare.com/web/jfb/ cert-reviews/targetedprobe-educate Medical Review (MR) conducting reviews One-on-one education April

53 TPE Key Elements Noridian selects topics and providers based on current data analysis 1-3 rounds of prepayment probe review Goal to lower provider error rates Learn from education/improve results in next "round IOM , Chapter 2 Guidance/Guidance/Manuals/Downloads/pim83c02. pdf April

54 Subsequent Hospital Codes Procedure codes 99223,99232,99233 Requested 2,754 Denied 2,485 Rational services were not received with in 45 days % Services were downcoded two levels Failure to support levels billed Signatures missing % April

55 Resources and Educational Tools

56 Look to Noridian Website Part A Part B April

Noridian Website https://med.noridianmedica re.

57 Updated Medicare Secondary Payer (MSP) Calculator Tool determines line by line claim payment calculations when Medicare is secondary Noridian Website re.com/ Jurisdiction F Medicare Part A/B Browse by Topic Medicare Secondary Payer (MSP) April

58 New Enrollment Application Search Tool Noridian Website dicare.com/ Jurisdiction F Medicare Part A/B Enrollment Enrollment Application Status Search April

59 New Enrollment Application Search Tool2 December 14, 2017 Checking your status Information needed to complete search: Application/tracking # or web-tracking ID Progression: Received In Progress Corrections Requested Completed Unable to Complete April

60 Find Us On Utube! April 2018 Noridian Healthcare Solutions, LLC 60

61 April

62 Download Google Play April 2018 Noridian Healthcare Solutions, LLC 62

63 Education on Demand Recordings View self-paced recordings at your convenience Certificate ed upon completion Part B Topics: Claim Submission Endoscopies Chronic Care Management (CCM) Transitional Care Management (TCM) Medically Unlikely Edits (MUEs) Incident To Correct Coding Initiative (CCI) Annual Wellness Visit (AWV) Initial Preventive Physical Exam (IPPE) FLU/PPV Roster Billing April 2018 Noridian Healthcare Solutions, LLC 63

CMS Educational Materials MLN products downloadable or request copy free of charge Brochures, Fact sheets Web-based training MLN dedicated web pages

64 CMS Educational Materials MLN products downloadable or request copy free of charge Brochures, Fact sheets Web-based training MLN dedicated web pages General Information ninfo Matters Articles tersarticles Products ducts April

Locating Quarterly Provider Updates https://www.cms.

65 Locating Quarterly Provider Updates Policies/QuarterlyProviderUpdates/index.html CMS website Regulations & Guidance Regulations & Policies Quarterly Provider Updates April

66 Questions? Thank you!

Initial Preventive Physical Examination (IPPE) Presented by Provider Outreach and Education (POE) December 2016

Initial Preventive Physical Examination (IPPE) Presented by Provider Outreach and Education (POE) December 2016 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC