Palmetto GBA Jurisdiction 11 - TSI Healthcare€¦ ·

Palmetto GBASM Jurisdiction 11 Medicare Updates, Changes,

and Reminders

Provider Outreach and Education

Palmetto GBA, J11 Part B 2

Disclaimer

The information provided in this presentation was current as of 8/20/2012. Any changes or new information superseding the information in this presentation are provided in articles with publication dates after 8/20/2012, posted on our Web site at:

www.PalmettoGBA.com/J11B

CPT codes, descriptors and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

http://www.palmettogba.com/J11B

–Palmetto GBA, J11 Part B –3

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Provider1


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Forms on the Palmetto GBA Web Site

• New application to help you access necessary forms on the Palmetto GBA Web site.

• New application will require you to answer a few basic questions to direct you to the appropriate form.

• A demonstration video is on J11 Part B News section.


New Web Forms


Advanced Beneficiary Notice of Noncoverage (ABN)

• New version of the ABN CMS Form CMS-R-131, was released by CMS in May of 2011

• Effective January 1, 2012 • Revision date of 3/2011 in the lower left

corner. • New form and instructions located at: http://www.cms.gov/BNI/02_ABN.asp#TopO

fPage

http://www.cms.gov/BNI/02_ABN.asp

http://www.cms.gov/BNI/02_ABN.asp

Palmetto GBA, J11 Part B 16 Palmetto GBA, J11 Part B 16

New CLIA Waived Tests

CMS announces new waived tests approved by the Food and Drug Administration under Clinical Laboratory Improvement Amendments of 1988. For a full list of waived tests: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/waivetbl.pdf

MM7868

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/waivetbl.pdf







Appeals Update

• Annual reevaluation of the dollar amount in controversy required for an Administrative Law Judge (ALJ) hearing or Federal District Court review

• ALJ hearing request – no change in amount in controversy for 2012 – remains $130

• The amount that must remain in controversy for Federal District Court review requests filed –On or before December 31, 2011 is

$1,300 –On or after January 1, 2012, $1,350


Place of Service (POS)

• Effective 10/1/2012 - all services paid under the MFPS where there was a face-to-face encounter – POS code will be assigned as the same setting in which the

beneficiary received the face-to-face service. – In cases where a physician/practitioner provides the

PC/interpretation of a diagnostic test from a distant site, the POS code will be setting in which the beneficiary received the TC of the service. • Example: MRI performed in an outpatient hospital - hospital submits

a claim for the TC portion of the MRI - the physician furnishes the PC portion from his/her office location – POS code 22 will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.

MM7631


Immediate Recoupment Process

• Effective July 1, 2012 “Immediate recoupment” process allows providers to request that recoupment begin prior to day 41

• Election of this option may avoid paying interest if the overpayment is recouped in full prior to day 31

• Details added to the “Overpayments” page of the Palmetto GBA Web site

MM7688


Provider Refunds

• Beginning July 30, 2012, when Medicare makes a refund: – Within five to seven business days of a refund

identified on an remittance notice, Palmetto GBA will send out a new standard refund notification letter.

– This letter will contain the following information: • Refund Amount (Principal and Interest) • Patient Information (Beneficiary Name & Dates of Service) • Remittance Advice (RA) Date on which refund was included • Refund Reason (e.g., 'Appeal – Favorable Decision,' 'RAC –

Partially Favorable Decision,' 'Reopening – Dismissed Decision')

• AR/Overpayment Number


Primary Care Incentive Program

• Primary Care Incentive Program continues in 2012. – Primary specialty of 08, 11, 37 and 38 or NPP

specialty 50, 89 and 97 • Rendering primary care services 99201-99215,

99304-99340, 99341-99350 • Between 1/1/2011 – 12/31/2015

– 10% incentive – Self-service tool

MM7060



Health Professional Shortage Area (HPSA)

• HPSAs are geographic areas, or populations within geographic areas, that lack sufficient health care providers to meet the health care needs of the area or population.

• Areas are designated as HPSAs by the Health Resources and Services Administration (HRSA) based on census tracts, townships, or counties.

• Designations are made for primary care, dental, and mental health.


HSPA • Incentive available for physician services provided in a

HPSA area – Primary Care – Mental Health

• 10% bonus payment equal to the amount paid, not the approved or billed amount and paid on a quarterly basis

• No modifier needed for services rendered in a zip code on the HPSA zip code file.

• For other services that are in a HPSA area , the HPSA modifier AQ must be appended to qualify for the HPSA bonus. – Claims with the AQ modifier are manually reviewed for appropriate use.

• Most current listing of HPSA areas: http://hpsafind.hrsa.gov.

• HPSA bonus has no affect on patients’ copayments

http://hpsafind.hrsa.gov/


HPSA Surgical Incentive

• HPSA Surgical Incentive continues in 2012. – Primary specialty of 02 (general surgery). – Performing surgical procedure with 10 to 90-day

global period paid under the Physician Fee Schedule. – In a HPSA area – 10% incentive – Performed on or after January 1, 2011, and before

January 1, 2016. – www.hpsafind.hrsa.gov/HPSASearch.aspx

MM7063

Improper use of the AQ Modifier


• Verify area is still a HPSA qualified.

http://hpsafind.hrsa.gov.

http://hpsafind.hrsa.gov/


–What do you need to do to receive your Medicare EHR incentive payment? •Successfully register for the Medicare EHR Incentive Program;

•Meet meaningful use criteria using certified EHR technology; and

•Successfully attest, using CMS' Web-based system, that you have met meaningful use criteria using certified EHR technology.

–Contact the EHR Information Center Help Desk for Questions concerning registration, (888) 734-6433 / TTY: (888) 734-6563 https://www.cms.gov/EHRIncentivePrograms/

Medicare Incentive Programs

http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp

http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

https://www.cms.gov/EHRIncentivePrograms/


Physician Quality Reporting System (PQRS)

• PQRS – Note: PQRS measure documents for the

current program year may be different from the PQRS measure documents for a prior year.

– Eligible professionals are responsible for ensuring that they are using the Physician Quality Reporting System measure documents for the correct program year. • www.cms.gov/PQRI/01_Overview.asp

SE1107

http://www.cms.gov/PQRI/01_Overview.asp


Eprescribing (eRx)

eRx measure specifications for the current program year may be different from the eRx measure specifications for a prior year. • Providers are responsible for ensuring that they

are using the eRx measure specification documents for the correct program year

• Earning an eRx incentive for 2011 will not necessarily exempt an eligible professional or group practice from the negative payment adjustment in 2012

• Eligible providers who did not successfully report at least 10 instances of ePrescribing in 2011 are receiving a negative payment adjustment in 2012

www.cms.hhs.gov/ERxIncentive


2013 Hardship Codes and Hardship Exemption Requests

CMS may exempt certain EPs from 2013 payment adjustment

– Inability to electronically prescribe due to state, or federal law, or local law or regulation

– EP prescribes fewer than 100 prescriptions during a 6–month payment adjustment reporting period

– EP practices in a rural area without sufficient high-speed Internet access (G8642)

– EP practices in an area without sufficient available

pharmacies for electronic prescribing (G8643)


eRx Hardship Exemption Reminders

Special notes • Providers must have applied for the exemption before

6/30/2012 • Hardship G-code must also be submitted at least once on a

claim during the 6-month, 2013 eRx payment adjustment reporting period (1/1/2012 – 6/30/2012) if applicable

• Hardship G-code must be submitted on a claim with a billable Medicare Part B service

• Hardship G-code does not need to be submitted on a claim that contains eRx measure denominator codes

• Hardship exemptions must be renewed annually.

http://www.qualitynet.org/pqrs


ICD-10 Implementation HHS Secretary Kathleen Sebelius issued a press release announcing a proposed rule that would delay the compliance date for ICD-10 from October 1, 2013, to October 1, 2014.

– The comment period is now closed. Public comments are being reviewed and analyzed, and the Department will issue a final rule as expeditiously as possible.

On the final implementation date – coding will change from ICD-9-CM to ICD-10.

– Transition will occur throughout the health care industry – Preparation now can help avoid potential reimbursement issues

http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf


CMS Enrollment Revalidation Initiative

• Revalidation applies to - all providers and suppliers enrolled in the Medicare program prior to March 25, 2011

• Between now and March 23, 2015, Palmetto GBA will send out notices to begin the revalidation process

• Providers will have 60 days from the date of the letter to submit complete enrollment forms

• Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges

SE1126


Provider Enrollment Chain Organization System (PECOS)

• Improvements to PECOS: – Electronic Signature – ability to digitally sign and

certify the application – Ability to see if a request for revalidation has been

sent to a provider – Overall Usability

• Access previously-used address information when completing an application

• Quickly update and resubmit an application returned for correction via PECOS as part of any application submission

• Fewer screens and steps to navigate when you are changing information or revalidating your application


Unlisted Drugs and Biologicals

• HCPCS codes J9999, J3490, and J3590 – must include drug name, dosage administered and NDC number

• 5010 Format • Drug name and total dosage amount administered in the

narrative (documentation field) Loop 2300 or 2400, NTE 02 segment.

• NDC number in the NDC field – loop 2410, LIN 03 segment

– Paper claim submissions (small providers) must include all this information in Item 19 of the CMS-1500 claim form

– When using a NOC code – enter 1 in the number of units field – Reimbursement is based on the dosage indicated in the

electronic documentation field or in Item 19



Medical Review

• The J11 A/B MAC Medical Review department is performing service-specific prepay probe review based on data analysis for services with significant frequency or most frequently billed.

• Claim review will be performed on approximately 100 claims per states for each procedure code selected. – 17 hematology/oncology codes (other drugs). – 12 physical therapist in private practice outpatient services – 13 oncology radiation therapy outpatient services – 13 ophthalmology outpatient services

– Articles identifying each of the codes selected is posted to the Palmetto

GBA Web site under “News”

www.PalmettoGBA.com/J11B


Medical Review

• Additional Documentation Requests (ADRs) – Provide the documents listed on the ADR and any related physician’s orders. • Physician's signature must be legible or include an attestation of

signature. – Include a copy of the ADR with your documents – Pair each ADR letter with the corresponding documentation – Return documents to the mailing address or fax number located

in the body of the ADR letter – Respond within 30 days of the date on the ADR letter – Checklists to assist with responding to medical record

documentation requests are on the Web in the E/M Help Center


Electronic ADR Responses

• If you send a CD or DVD for medical record or appeal documentation, please send these to us in a TIFF format. • Don’t TIFF each page • One TIFF file per record is acceptable • No password is required; however, if you do use a password,

please ensure that we are able to link the CD with the password.

• Consider submitting your medical review documentation for ADR responses to us via electronic means. More information can be found on the esMD Web page at www.cms.gov/esmd

• We are not accepting appeals via esMD at this time

http://www.cms.gov/esmd


Top Denial/Rejections

CO-50 Medical necessity denials

CO-B15 Requires a qualifying service

PR-204 Noncovered service

CO-B15 (M80) Not covered separately when billed with another service

PR-170 Not covered by this provider type

CO-29 Time limit

CO-16 (MA04) MSP – need info regarding how primary payer paid claim

PR-49 Noncovered routine service or screening

CO-B7 Provider not eligible


Top Inquiry Reasons


Self Service Tools

• Status/Explanation/Resolution


Tips and Time Savers

• Tips on Using the Online Provider Service (OPS) Application to Save Your Office Time – Use to check:

• Claim status • Eligibility • MSP • Preventive service • Deductible information


Online Provider Services (OPS)

Check details of your patient’s eligibility: Deductibles Preventive services eligibility dates Medicare Advantage plan enrollment Insurance primary to Medicare (MSP) Home Health dates Hospice dates Inpatient / Skilled Nursing Facility (SNF)


Comprehensive Error Rate Testing

(CERT) Program


CERT

– Medicare contractors receive more than 2 billion claims per year.

– To help keep the Medicare program viable, CMS implemented CERT.

– CERT measures the accuracy of Medicare Fee-for-Service (FFS) payments. • Contractor Error Rate • Provider Compliance Error Rate (PCER)


Measures the accuracy of submitted claims – seen as a measure of

how effectively contractors educate

Providers

CMS guidelines

The Comprehensive Error Rate Testing (CERT) program measures the accuracy of Medicare Claims

Paid Claims Error Rate

% of incorrect payments $ incorrectly paid

Palmetto

Provider Compliance Error Rate

CERT


NC CERT Error

# of Claims

# of Claims in Error

# of Appealed Claims

Total Final Allowed Amount

1361 149 9 $118,268.77

Total Amount in

Error

Total Appealed Recalculated

Amount Error Rate Recalculated Error Rate

$19,227.21 $3,790.99 16.26% 13.32%


CERT Record Tips

• Billing provider is responsible for obtaining and providing records to support their claim, even from third parties (e.g., hospitals, nursing homes, etc.)

• The CERT requests do not specify the place of service • Letter will include:

– Procedure codes, modifiers, and ICD-9 diagnoses codes. No narrative descriptions

• No provider name is given only rendering/performing provider’s Medicare number will be shown

• Obtain the correct records for the specific patient/date or dates of service/code(s) and provider

• Pay attention to “service From/To dates” for the actual date(s) of service

• Not a violation of HIPAA to send records


J11 Part B CERT Analysis

Graph 3A - Distribution of Paid Incorrectly Amount by Error Code (NC)

68.49%

21.16%

1.48%

0.89%

0.88%

1.97%5.11%

0.00%

21 Insuff icient documentation

31 Service incorrectly coded

25 Medically unnecessary service or treatment

98 Span date error

16 Response received - improperdocumentation41 Services billed w ere not rendered

60 Unbundling

35 Not covered or unallow able service


CERT Resources

– CERT contractor Customer Service: (301) 957-2380. – Palmetto GBA CERT Web page. http://www.palmettogba.com/palmetto/providers

.nsf/docsCat/Providers~Jurisdiction%2011%20Part%20B~CERT~General%20Information?open&expand=1&navmenu=CERT||


Introducing the RAC Program

– Three year RAC demonstration in New York, Massachusetts, Florida, South Carolina, and California.

– Demonstration returned $900+ million to the Medicare Trust Fund!


http://www.connollyhealthcare.com/RAC

http://www.connollyhealthcare.com/RAC


Recovery Audit Contractor (RAC)

• Effective January 3, 2012 – MACs will issue demand letters for errors

called by the RAC and field questions related to the repayment process and appeal rights

– Recovery Auditor will continue to field questions that are audit specific such as the auditor’s rationale for identifying the potential improper payment.

MM7436


Self Service Tools


Resources

• Web site Address: www.PalmettoGBA.com/J11B • Palmetto GBA listserv

– www.PalmettoGBA.com/medicare • Select E-mail Updates

• CMS listserv – https://www.cms.gov/AboutWebsite/EmailUpdates/list.asp

• Contact Us by Email [email protected]

• Online Provider Service (OPS) Tool Listed under Self-service Tools

mailto:J11.PartB@Palmetto


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Palmetto GBA Jurisdiction 11 - TSI Healthcare€¦ ·

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