Medicare Part B Updates and Changes 2016/2017 Presented by Tammy Ewers, CPC Education and Outreach Representative
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 http://www.noridianmedicare.com and the CMS website at http://www.cms.gov. 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 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. May 2016 2
Agenda Changes for 2016 Noridian Medicare Portal Enrollment Revalidation Updates MACRA Quality Payment Program (QPP) Ordering and Referring issues Review Contractor Changes Resources May 2016 3
Changes are a Coming!! May 2016 4
Medicare Beneficiary Identifier (MBI) The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires removal of Social Security Numbers (SSNs) from all Medicare cards by April 2019. 11-characters in length Made up only of numbers and uppercase letters (no special characters) All eligible beneficiary will receive a new Medicare card for Medicare transactions like billing, eligibility status, and claim status. October 2016 5
ICD-10-CM Updates Effective October 1, 2016, Noridian s medical review will look at diagnosis(es) With highest level of specificity ICD-10 family no longer acceptable Diagnosis appropriate based on documentation Does not change current system edits or LCD/NCD policy covered diagnosis(es) CMS published resources on ICD-10 follow-up and analyzing claims/data for potential problems See ICD-10 Next Steps Toolkit at: https://www.cms.gov/medicare/coding/icd10/downloads/icd1 0NextStepsToolkit20160226.pdf October 2016 6
CMS Page for ICD-10 information October 2016 7
ICD-10 grace period to end: 3 ways to avoid claim denials On October 1, the ICD-10 coding grace period will come to an end and three ways are suggested to assist in avoiding claim denials : Be specific: Documentation is used for more than billing Pay attention to trends in denials: Denial trends can be early identifiers Emphasize ICD-10 codes that focus on quality initiatives: It s particularly vital for practices to discuss and understand how to use codes to the highest level of specificity, reporting co-morbid conditions when necessary for patients with complex care needs, October 2016 8
Noridian Medicare Portal (NMP)
Noridian Medicare Portal Home Page October 2016 10
NMP Registration Tips Ensure Provider Administrator is enrolled before other users attempt to enroll Ensure TIN/SSN and NPI combinations in EDISS Connect are correct Need Trading Partner ID (EDISS Connect) Unable to sign into EDISS Connect? Call 877 908 8431 (main provider #) or http://www.edissweb.com/cgp/contact/ October 2016 11
Self-Service Reopenings Available Through NMP Providers with End User access to the Noridian Medicare Portal (NMP) are able to reopen certain claims within the portal. The End User must be approved for the Appeals functionality by their Provider Administrator. The following clerical corrections may be made: Add, replace or remove diagnosis code Add, replace or remove modifier Billed in error Reprocess claim Reopenings are available for claims that meet the following criteria: Claim was processed within one year Claim is finalized May 2016 12
Self-Service Reopenings Available Through NMP continue.. No Additional Documentation Request (ADR) was sent Claim was not reviewed Claim was not previously appealed Procedure code and modifier are not too complex After the reopening has been submitted, End Users may view the adjustment through the Claim Status option after one business day. See the User Manual and self-paced tutorial for step-by-step instructions. May 2016 13
Portal Online Recording Video Tutorial completed (18 mins.) Education/Schedule of Events (left corner) October 2016 14
Enrollment Changes and Revalidations
Noridian's Enrollment Page October 2016 16
Enrollment Revalidation Cycle 2 - https://data.cms.gov/revalidation Utilize search tool that will provide Due Date Email notice from Noridian within 2-3 months of established due date Must submit Revalidation before due date Always last day of month Note : Special Edition SE1605 provides additional information October 2016 17
Enrollment Revalidation If TBD listed, due date coming Do nothing and only submit Revalidation when due date provided Submit application via Internet-based PECOS Unsolicited revalidations more than 6 months will be returned Any questions? Contact Enrollment Contact Center October 2016 18
Revalidation Clinic Providers Retired Left the practice 855R application Close provider applications Prevent fraudulent activities Prevent unnecessary correspondence for revalidation October 2016 19
Locate Your Date October 2016 20
Enrolled for Sole Purpose of Ordering/Referring Services Complete the CMS-855O Applicable physician and nonphysician providers Must include statement they are enrolling only to order and refer and will not be submitting claims October 2016 21
Enrollment Appeals October 2016 22
MACRA Quality Payment Program (QPP) Medicare Access & CHIP Reauthorization Act (MACRA)
MACRA MACRA makes important changes how Medicare pays and ends Sustainable Growth Rate (SGR) House Resolution (H.R.) into law 2015 https://www.congress.gov/bill/114th-congress/ house-bill/2 Does not apply to hospitals, other facilities or Medicaid https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/Value-Based- Programs/MACRA-MIPS-and-APMs/MACRA- MIPS-and-APMs.html BIC Oct 2016 24
Consolidation MIPS/APM MACRA consolidates current programs ending December 2018 Physician Quality Reporting System (PQRS) Value-Based Modifier (VM) Electronic Health Records/Meaningful Use (EHR- MU) January 1, 2019 incentives begin Merit-Based Incentive Payment System (MIPS) Alternative Payment Model (APM) Eligible Providers start reporting 2017 BIC Oct 2016 25
MACRA Payments 2016 2019 =.05% annual fee increase Holds 2019 payment rates through 2025 Starting 2019, payment adjustments Physician participation in APM/MIPS program 2026+ has two payment rates APM = 0.75 % increase each year Other = 0.25% increase each year BIC Oct 2016 26
Eligible Providers (EPs) Eligible Providers (EPs) include: 2019 (MD, DO, DDS, DM, DPM, Optometry, Chiropractor, PA, NP, CNS and CRNA) After 2021, other EPs may be added EPs participate in MIPS or APM MIPS provider receives positive, negative or zero payment adjustment APM - provider may receive 5% incentive for 6 years BIC Oct 2016 27
BIC Oct 2016 28
Quality Payment Program: Pick Your Pace in Year One Clinicians will pick their pace for the first year both in how they participate and when. We expect that everyone who is eligible for the Quality Payment Program will participate. We ve announced four options that we plan to further describe in the final rule: Test Participation or Partial Participation or Full Participation or Advanced Alternative Payment Models BIC Oct 2016 29
Merit-Based Incentive Payment System (MIPS) or Alternative Payment Model (APM)
Two Provider Paths To Choose Path #1: MIPS MIPS requires Composite Performance Score Incorporates performance on those categories May receive upward, downward or no payment (neutral) Based on providers performance Quality Resource use Clinical practice improvement activities Meaningful use of certified EHR technology BIC Oct 2016 31
MIPS Point System Components of the MIPS Score MIPS scale (0-100 points) Effective January 1, 2019 Advance Care/ Meaningful Use (25%) Quality PQRS/VM (50%) Cost/ Resource Use (10%) Clinical Practice Improvement (15%) Payment determined two years after performance Performance Year Payment Year 2017 2019 2018 2020 2019 2021 BIC Oct 2016 32
MIPS Performance Categories Quality (50 percent of total score in year 1): Clinicians choose six measures that accommodate differences among specialties and practices Advancing Care Information (25 percent): Customizable measures that reflect how they use technology practice Emphasis on interoperability and information exchange Does not require all-or-nothing EHR or redundant reporting BIC Oct 2016 33
MIPS Performance Categories 2 Clinical Practice Improvement Activities (15 percent): Rewards clinical practice improvements Activities on care coordination, beneficiary engagement/patient safety Select from a list of more than 90 options Cost (10 percent): Score based on Medicare claims, meaning no reporting requirements Category uses 40 episode-specific measures for specialty differences BIC Oct 2016 34
Alternative Payment Model (APM) Path #2: APMs Qualifying APM participants not subject to MIPS adjustments Lump sum incentive payment equal to 5% CMS sees less than 30% providers in APM In 2026, fee schedule growth rate higher for qualifying APM participants than other practitioners BIC Oct 2016 35
APMs Include EHR Technology: BIC Oct 2016 36
Providers Contact QualityNet Help Desk: Portal password issues PQRS feedback report availability/access Individuals Authorized to Access CMS Computer Services (IACS) registration/login 866-288-8912 Email qnetsupport@hcqis.org BIC Oct 2016 37
Ordered and Referred Services Requirements & Documentation Reminders and Updates
Orders for Diagnostic Lab Tests Order is defined as communication from treating physician or NPP requesting diagnostic test be performed A physician order is not required to be signed Physician must clearly document, in medical record his/her intent that test be performed November 2016 39
Physician Intent Order or requisition signed by physician Not valid on its own Notation in patient s record is needed Verbal/telephone order documented at treating physician s office Email from physician to be verified May need physician signature attestation November 2016 40
Documentation Requirements Maintain in patient medical records Orders/communications from ordering physician/ NPP Orders delivered in writing, via phone or emailed Additional, conditional tests requested Test results Record date service was performed November 2016 41
Signature Requirements Unsigned physician orders or unsigned requisitions alone do not support physician intent. Physicians should sign all orders for diagnostic services to avoid potential denials. If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. Attestation statements are not acceptable for unsigned physician orders/requisitions. November 2016 42
Insufficient Documentation Errors Signatures Missing Physician Order Related Orders Missing Orders Unsigned Intent to order not included in note Documentation to support intent to order (for example, a progress note or office visit note); and Documentation to support the medical necessity of ordered services. November 2016 43
Documentation Requirements Unlisted Codes For unlisted lab codes: When billing electronically, Item 19 or narrative should have: Most complete, accurate description Don t be brief Lots of characters to explain test performed Being descriptive will expedite pricing of claims November 2016 44
Quality Testing Medicare does not pay for quality testing perform by labs for the sake of validating testing methods. November 2016 45
Claim Review Programs
Supplemental Medical Review Contractor (SMRC) Strategic Health Solutions, LLC Omaha, NE Variety of medical review tasks to lower improper payments Medicare or SHS not authorized to reimburse for records printing/mailing https://strategichs.com/smrc/ October 2016 47
CERT Contractor Update 10/07/16- AdvanceMed will be performing all tasks All inquiries and records should be sent to CERT Documentation Center 1510 East Parham Road Henrico, VA 23228 Fax: 804-261-8100 Customer Service: 443-663-2699 Toll Free: 888-779-7477 Email: certmail@admedcorp.com November 2016 48
CERT Reviews Lab- Clinical Chiropractic Services ( excessive numbers) Timed Codes ( critical care ) Ambulance Transports ( non emergent) Physical Therapy Evaluation and Management - Outpatient May 2016 49
Recovery Audit Mass Adjustment October 2016 50
Resources May 2016 51
CMS How to Use CCI Tools Dated April 2015 Current in Mar. 2016 16 page booklet Informative, detailed guide April 2016 52
Ordering and Referring Fact Sheet October 2016 53
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