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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.
Disclaimer
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Medicare Administrative Contractor (MAC)
Jurisdiction 12 and Jurisdiction H
◦ Medicare Part B
J12 - Delaware, District of Columbia (DC), Maryland, New
Jersey, and Pennsylvania; and
JH – Arkansas, Louisiana, Mississippi, Colorado, New Mexico,
Oklahoma and Texas
Novitas Solutions
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Comprehensive Error Rate Testing Program
Contractor Updates
New Quarterly Updates
Recurring Updates/Reminders
Medicare Initiatives and Incentive Programs
Preventive Services
Fraud Prevention
Self Service Options
Agenda
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Provide a clear understanding of the changes in Medicare and to assist the provider community in complying with new guidelines by providing educational information and resources
Explain the Comprehensive Error Rate Testing (CERT) Program and provide tips in preventing the most frequent errors
Identify and promote the use of self service options and preventive services
Objectives
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Comprehensive Error Rate Testing (CERT)
Program
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National Claim Paid Error Rate: ◦ 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
Comprehensive Error Rate Testing (CERT)
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Insufficient documentation: ◦ Missing documentation requirements to support the need for a service based on a related Local
◦ Medical Record Documentation and/or physician signature was missing or was not legible; ◦ Medical record was missing the operative report to support the medical necessity and intent for the
procedure requiring pathology services;
◦ Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed;
◦ Medical record did not contain a valid physician’s order, documented order intent or clinical indication for the service;
◦ No documentation of the physical therapy certified plan of care; ◦ Documentation that did not support the Internal Classification of Disease (ICD-9) Code billed; and
◦ Documentation that did not adequately describe the service defined by the reported Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code.
Medical necessity errors: ◦ Medical record documentation did not support the medical necessity for an annual Pap smear for a
beneficiary that was not at a high risk for cervical cancer;
◦ Medical record documentation did not support the medical necessity for an Electrocardiography (ECG) to be performed;
◦ Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed; and
◦ Related services that were required as a result of the primary service were denied because the medical necessity of the primary service was not justified, e.g. venipuncture.
Incorrect coding errors: ◦ Documentation did not substantiate the level of care billed based on one or more of the key
components (history, exam, medical decision making); ◦ Requirements for critical care, discharge day management, ambulance and infusion services,
Electroencephalograms (EEGs), dialysis services and Mohs Micrographic surgeries were not met.
Cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.
Ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day.
The MPPRs apply to TC services and to the TC of global services.
National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR) Change Request #7897
◦ Effective: May 1, 2012 Implementation: January 7, 2013
Key Points: ◦ A NCD was issued covering TAVR under Coverage with Evidence
Development (CED)
◦ When the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA-approved indication for use with an approved device, CED requires that each patient be entered into a qualified national registry or participate in a qualifying clinical study
For More Information: ◦ http://www.cms.gov/Regulations-and-
Effective: April 1, 2013, Implementation: April 1, 2013
Key Points:
◦ Adds special considerations provisions regarding use of POS codes 22 and 24, for outpatient hospitals and Ambulatory Surgery Centers
◦ The POS code to be used by the physician and other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service
◦ Two (2) exceptions to this face-to-face provision/rule in which the physician always uses
the POS code where the beneficiary is receiving care as a hospital inpatient or an outpatient of a hospital, regardless of where the beneficiary encounters the face-to-face service
◦ In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner will be the setting in which the beneficiary received the TC of the service
For more information: ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/MM7631.pdf
Revised and Clarified Place of Service (POS) Coding Instructions
Medicare learning Network (MLN) Matters Special Edition Article SE1226 Physicians are required to identify the
place-of-service on the health insurance claim forms that they submit to Medicare contractors. The correct place-of- service code ensures that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting.
Overview of place of service coding https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html
A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic, or rehabilitative services to the individual.
Place of Service Code 18
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Change Request # 7600
Effective: April 1, 2012 Implementation: October 1, 2012
Key Points:
◦ New physician specialty codes for Sleep Medicine (C0) and Sports Medicine (23)
For more information: ◦ http://www.cms.gov/Regulations-and-
Key Point(s): ◦ In order to be granted a timely filing extension, the provider,
supplier, or beneficiary must furnish an official letter from the Social Security Administration (SSA) that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service
◦ If an official SSA letter to the beneficiary is not submitted, Medicare contractors must check the Common Working File (CWF) database
For more information ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Modifying the Timely Filing Exceptions on Retroactive Medicare Entitlement and Retroactive Medicare Entitlement Involving State Medicaid Agencies
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October Update to the CY 2012 Medicare Physician Fee Schedule Database (MPFSDB) – MM8017 http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2530CP.html
2013 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2526CP.html
October 2012 Update of the Ambulatory Surgical Center Payment
System (ASC) http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2525CP.html
2013 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder
Individual eligible professionals who meet one of the criteria are automatically excluded from the 2013 Electronic Prescribing (eRx) payment adjustment:
◦ The eligible professional is a successful electronic prescriber during the 2011 eRx 12- month reporting period
◦ The eligible professional is not an MD, DO, podiatrist, Nurse Practitioner, or Physician Assistant by June 30, 2012, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES)
◦ The eligible professional does not have at least 100 Medicare Physician Fee Schedule (MPFS) cases containing an encounter code in the measure’s denominator for dates of service from January 1, 2012 through June 30, 2012
◦ The eligible professional does not have 10% or more of their MPFS allowable charges (per TIN) for encounter codes in the measure’s denominator for dates of service from January 1, 2012 through June 30, 2012
◦ The eligible professional does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between January 1, 2012 and June 30, 2012.
For more information: ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE1206.pdf
2013 Exclusion Criteria
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If you have questions regarding the eRx Incentive Program, eRx payment adjustments, or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or via [email protected].
They are available Monday through Friday from 7am to 7pm CST.
Several new resources can help you successfully navigate the Medicare EHR Incentive Program: ◦ A new attestation page on the Centers for Medicare/Medicaid
Services website, where participants in the Medicare EHR Incentive Program can find important information on attestation
◦ The Meaningful Use Attestation Calculator allows Eligible Professionals (EPs) and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EPs or eligible hospital's specific measure summary.
◦ The Eligible Professional User Guide and the Eligible Hospital and Critical Access Hospital User Guide provide step-by-step guidance for EPs and eligible hospitals on navigating the attestation system.
Electronic Health Record (EHR) Incentive Program
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EHR Incentive payments are distributed based on each year of participation, and follow a specific payment schedule
◦ Medicare Learning Network Matters Special Edition (SE) article SE1111 – Medicare Electronic Health Record (EHR) Incentive Payment Process
Additional incentive for services provided in a Health Professional
Shortage Area (HPSA)
EHR payments will be issued by a Payment File Development
Contractor
Questions about your EHR incentive payment should be directed to:
◦ EHR Information Center at 1-888-734-6433 or 1-888-734-6563 (TTY)
◦ Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time) Monday through Friday, except federal holidays.
Electronic Health Record (EHR) Incentive Program
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Preventive Services
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Preventive Services Annual Wellness Visit Bone Mass Measurements Cancer Screenings Cardiovascular Disease
Training Glaucoma Screening Hepatitis B Vaccine Human Immunodeficiency
Virus (HIV) Screening Influenza Virus Vaccine
Initial Preventive Physical Examination
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
Medical Nutrition Therapy Prostate Cancer Screening Pneumococcal Vaccine Screening Mammography Screening Pap Test Screening Pelvic Exam Smoking and Tobacco Use
Cessation Counseling Ultrasound Screening for
Abdominal Aortic Aneurysm
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Medicare Learning Network (MLN) Products for Preventive Services
Help Keep Your Medicare Patients Healthy In 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. ◦ http://www.cms.gov/MLNProducts/35_PreventiveServices.asp
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Preventive Services
Quick Reference Chart for Medicare Preventive Services ◦ http://www.cms.gov/Outreach-and-
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: https://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp#TopOfPage
Recovery Auditors (RA) 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 Performant Recovery ◦ http://www.dcsrac.com/
For more information about the Recovery Audit Program ◦ http://www.cms.gov/rac/
Recovery Audit Program
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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
MLN Matters articles have been consolidated with the transmittals
If you are looking for 2012 MLN Matters articles, go to the
URL for the 2012 transmittals, www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals.html
Sort by article number (MM Article #) or key in article # in the “Filter on” field
From the Centers for Medicare and Medicaid Services (CMS) homepage, http://www.cms.gov/ , click on Transmittals in the Top 5 Links section at the bottom right hand side of the page