Medicare Updates
MD AAHAM
November 20, 2015
Disclaimer

All Current Procedural Terminology (CPT) only are copyright 2014 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.
Novitas Solutions
 Education specific to providers in Medicare Administrative
Contractor Jurisdiction H (JH) include: Arkansas, Colorado,
Louisiana, Mississippi, New Mexico, Oklahoma, and Texas
 Education specific to providers in Medicare Administrative
Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of
Columbia, Maryland, New Jersey, and Pennsylvania
 This education contains specific contractor guidance
 If you are not a provider in JL or JH, please contact your Medicare
contractor for specific guidance
Agenda
 ICD-10 Assistance and Advice
 Part A/B Updates
 Preventive Services
 Novitas Initiatives
 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
Acronym List
Acronym
Definition
CERT
Comprehensive Error Rate Testing
CMS
Centers of Medicare & Medicaid Services
EDI
Electronic Data Interchange
ICD-10
International Classification of Diseases, 10th Edition
IPPS
Inpatient Prospective Payment System
LCD
Local Coverage Determination
MLN
Medicare Learning Network
NCD
National Coverage Determination
OPPS
Outpatient Prospective Payment System
ICD-10 Assistance and Advice
ICD-10 Tips
 ICD-10 billing tips:
•
•
•
•
Use ICD-10 codes with dates of service on and after October 1, 2015
Use proper qualifiers on the proper codes- ICD-10 qualifiers (ABK/ABF)
May not use ICD-9 codes with dates after 10/1/15
Bill separate claims for September and October dates of service
 CMS ICD-10 Implementation Page:
•
http://www.cms.gov/Medicare/Coding/ICD10/index.html
Flexibility to Coding Accuracy for
Physician
 No medical review denials the first year related to coding errors as long
as the code is in the “appropriate family” of ICD-10 codes
•
Applicable for services paid under the Medicare Fee-for-Service Part B
physician fee schedule
 No grace period, codes must be valid, carried out to the highest level of
specificity
 Claims subject to LCD/NCD guidelines may deny if not carried out to
the highest level of specificity
 No penalties on 2015 quality reports
 Reference:
•
•
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedicareProviderI
CD-10.pdf
https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-andAnswers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf
Part A Appeal/Clerical Error and
Claim Process
 No changes with the appeals/clerical error or claim process:
•
•
Denied claims continue to follow appeal/CER process
Rejected claims can be adjusted (if applicable via the TPE-to-TPE field)
 i.e. incorrect diagnosis code billed, incorrect units billed, wrong date of
service, incorrect PT STATUS, etc.
 Resubmitted claims will reject as duplicates
•
RTP claims can be corrected and restored (F9) or rebilled
Part B Appeal/Clerical Error and
Claim Process
 No changes with the appeals/clerical error or claim process:
•
Denied claims continue to follow appeal process:
 Providers will continue to use the claims corrections line or the Novitasphere
portal to correct clerical errors
 i.e. incorrect diagnosis code billed, incorrect units billed, wrong date of service,
incorrect modifier, etc.
 Resubmitted claims will deny as duplicates
•
Rejected claims need to be rebilled
CMS Communication and
Collaboration Center
 Drawing from best practices of other technology implementation:
•
Monitor the implementation
• Quickly identify issues
• Initiate fixes
 Check the validity of ICD-10 codes:
•
2016 ICD-10 and GEMs (zip file titled “icd10cm_codes_2016.txt”)
 https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-CodeDescriptions-in-Tabular-Order.zip
Ombudsman
 Ombudsman for physicians and other providers:
•
Located at the ICD-10 Coordination Center
• Triage and answer questions about claim submissions
• Ask coding questions
• Dr. William Rogers
 ICD10_Ombudsman@cms.hhs.gov
AHA Central Office Coding
Questions
 Free assistance and advice
•
•
Providing ICD-10 and ICD-10-PCS coding advice
Does not replace learning how to code
 Questions should be submitted via
http://www.codingclinicadvisor.com/:
•
Not limited to AHA members, but registration required
• Review FAQ section for details on how to submit questions




Formulate coding question, not just “what is the code for XYZ”
Provide documentation
Specify whether inquiry refers to a certain setting
Cannot answer questions on payment/coverage
CMS Teleconferences and Videos
 CMS sponsored ICD-10 teleconferences:
•
http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10Teleconferences.html
 MedScape modules:
•
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
 CMS has created “Road to 10” to help jump start the transition to
ICD-10:
•
http://www.roadto10.org/
CMS Tools and Fact Sheets
 CMS ICD-10 Fact Sheets:
•
•
•
•
•
•
•
Intro Guide to ICD-10
The ICD-10 Transition: An Introduction
ICD-10 Basics for Medical Practices
Talking to Your Vendors About ICD-10: Tips for Medical Practices
ICD-10 and CMS eHealth: What’s the Connection?
ICD-10 Basics for Small and Rural Practices
Online ICD-10 Implementation Guide
 ICD-10-CM/PCS Billing and Payment FAQs:
•




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ICD-10BillingandPaymentFAQs.pdf
ICD-10 Quick Start Guide
ICD-10 Infographic
ICD-10 Website Wheel Educational Tool
Reference:
•
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
CMS Resources
 The CMS International Classification of Disease, Tenth Revision (ICD10) website:
•
http://www.cms.gov/icd10
 Sign up for Centers and Medicare & Medicare Services (CMS) ICD-10
Industry Email Updates:
•
http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD10_Industry_Email_Updates.html
 Subscribe to Latest New Page Watch:
•
https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=
USCMS_609
Part A/B Updates
Sequestration Update
 Mandatory Payment Reduction of 2% continues
through March 31, 2016, for the Medicare Fee For
Service Program
 For more information:
•
http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/201503-19-eNews.pdf
 Frequently Asked Questions:
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/p
age/pagebyid?contentId=00007998
New and Revised Place of Service
Codes (POS) for Outpatient
Hospitals
 Change Request # 9231
•
Effective: January 1, 2016
• Implementation: January 4, 2016
 Key Points:
•
POS 19 Off Campus-Outpatient Hospital
• POS 22 On Campus-Outpatient Hospital
• POS 17 Walk-in Retail Health Clinic
• POS 26 Military Treatment Facility
 Reference:
•
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM9231.pdf
Claims Processing Instructions for
Diagnostic Digital Breast
Tomosynthesis
 Change Request # 9191
•
•
Effective: January 1, 2015
Implementation: January 4, 2016
 Key Points:
•
Payment for code G0279 will be permitted only when billed in
conjunction with codes G0204 or G0206
• Deductible and coinsurance will be applied to claim lines with code
G0279
• Institutional claims for code G0279 will be paid for type of bills 12X,
13X, 22X, 23X, and 85X when submitted with revenue code 0401
• Professional claims for code G0279 will be paid for TOB 85X when
submitted with revenue code 096X, 097X, or 098X
 Reference:
•
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM9191.pdf
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
National Coverage Determination for Single
Chamber and Dual Chamber Permanent
Cardiac Pacemakers

Change Request # 9078
•
•

Effective: August 13, 2013
Implementation: July 6, 2015
Key Points:
•
•
Implanted permanent cardiac pacemakers, single chamber or dual chamber, are
reasonable and necessary for the treatment of non-reversible symptomatic
bradycardia due to sinus node dysfunction and second and/or third degree
atrioventricular block
Covered indications
 Documented non-reversible symptomatic bradycardia due to sinus node dysfunction
 Documented non-reversible symptomatic bradycardia due to second degree and/or third
degree atrioventricular block
•

Contractors shall accept the inclusion of the -KX modifier on the claim line(s) as an
attestation by the practitioner and/or provider of the service that documentation is on
file verifying the patient has non-reversible symptomatic bradycardia
Reference:
•
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3204CP.pdf
Deactivation of Associated Shared
System Edits
 CMS released Change Request (CR) 9078 implementing national
coverage determination (NCD) 20.8.3 on 7/6/15 for beneficiaries that
meet specific coverage criteria
 Temporary delay in implementing NCD 20.8.3
 All editing and coverage relative to CR 9078 will be made at the
local Medicare Administrator level until notified by CMS
 This information was included in the MLN Connects Provider eNews
article:
•
https://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2015-09-10eNews.pdf
Updates on the Therapy Cap
 Exceptions to the therapy cap will remain in effect for claims with
dates of service through December 31, 2017
 Hospital outpatient therapy claims will continue to apply to the
therapy cap through December 31, 2017
 Suspension for therapy services that exceed $3,700 will remain in
effect for therapy services through December 31, 2017
 https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?r
edirect=/TherapyServices
Applying Therapy Caps to
Maryland Hospitals
 Change Request # 9223
•
•
Effective: January 1, 2016
Implementation: January 4, 2016
 Key Points:
•
Revises Original Medicare systems to ensure therapy services provided
in Maryland hospitals are subject to the outpatient therapy perbeneficiary caps
• The therapy caps and related provisions apply to hospitals paid under
the Maryland All-Payer Model
• Medicare will use the rates established under the All-Payer Model to
count the therapy services of Maryland hospitals toward the therapy
caps and threshold total of beneficiaries
 Reference:
•
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM9223.pdf
Instructions for Submitting Requests to
Reopen Claims that are Beyond the
Claim Filing Timeframes
 SE1426 Revised, Related CR 8581
• Effective: Claims received on or after January 1, 2016
• Implementation: January 1, 2016
 Key Points:
• Due to ICD-10 implementation, currently scheduled for October
2015, the NUBC is going to delay implementation of the new bill
type and condition codes until January 1, 2016
• Provide additional information, coding instructions and scenarios
for requesting a reopening of a claim that is beyond the filing
timeframe
• Institutional reopenings must be submitted with a “Q” frequency
code to identify them as a Reopening
 Reference:
• http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1426.pdf
Special Edition Articles (SE)/Fact
Sheets
 Updates to ICD-10 Local Coverage Determinations:
•
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1421.pdf
 Fact Sheet: Two-Midnight Rule:
•
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2015-Fact-sheets-items/2015-07-01-2.html
Preventive Services
Medicare Learning Network (MLN)
Products for Preventive Services
 Help Keep Your Medicare Patients Healthy In 2015!
 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/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/PreventiveServices.html
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
o
o
o
Breast Cancer (mammograms and clinical breast
exam)
Cervical and Vaginal Cancer (pap test and pelvic
exam [includes the clinical breast exam])
Colorectal Cancer




o


Fecal Occult Blood Test
Flexible Sigmoidoscopy
Colonoscopy
Barium Enema
Prostate (Prostate Specific Antigen blood test and
Digital Rectal Exam)
Cardiovascular Disease Screening
Depression Screening in Adults












Diabetes Screening
Diabetes Self-Management Training
Glaucoma Screening
Hepatitis C Screening
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
Influenza Vaccine Payment
Allowances - Annual Update for
2015-2016 Season



Change Request #9299
• Effective Date: August 1, 2015
• Implementation : No later than November 24, 2015
Key Points:
• These payment allowances are updated on an annual basis
• The pending payment allowances will be updated in the influenza
vaccine pricing webpage
• Providers may visit the webpage for the updated prices
 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-BDrugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html
Reference:
• https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM9299.pdf
Screening for Colorectal Cancer Using
Cologuard™ - A Multitarget Stool
DNA Test

Change Request # 9115
•
•

Key Points:
•
•
•
•
•

Effective: October 9, 2014
Implementation: September 8, 2015
Effective for claims with dates of service on or after October 9, 2014, contractors shall
recognize new HCPCS code G0464 (colorectal cancer screening; stool-based DNA
and fecal occult hemoglobin) as a covered service.
The Cologuard™ test will be covered once every three years for beneficiaries who
meet all of the following criteria:
• Age 50 to 85 years,
• Asymptomatic
• At average risk of developing colorectal cancer
All other screening stool DNA tests not otherwise specified above remain nationally
non-covered
There is no coinsurance or deductible for tests paid under the Clinical Laboratory Fee
Schedule (CLFS), including HCPCS code G0464 (Colorectal cancer screening; stoolbased DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3))
Only laboratories that are authorized by the manufacturer to perform the Cologuard™
test may bill for this test
Reference:
•
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9115.pdf
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
Preventive Services Resources
 Quick Reference Chart for Medicare Preventive Services:
o
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads
/MPS_QuickReferenceChart_1.pdf
 Improve Your Patients’ Health with the Initial Preventive Physical
Examination (IPPE) and Annual Wellness Visit (AWV):
•
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1338.pdf
Novitas Initiatives
Website Satisfaction Surveys
Policy Search Application
 Updated customized “Policy Search Application”
 Search:
•
Current, retired or draft policies
• ICD-9 LCDs and Articles
• ICD-10 LCDs and Articles
• National Coverage Determinations
 Gives more search power, more accurate results, the new options
allows for search by date of service
 Policy Search:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/LcdSearch
JL Local Coverage Determinations
and Articles Updated
 October 29, 2015
•
The following JL ICD-10 Local Coverage Determinations have been
revised:









Cardiac Rhythm Device Evaluation (L34833)
Cardiovascular Nuclear Medicine (L35085)
Diagnostic Abdominal Aortography and Renal Angiography (L35092)
Lower Extremity Major Joint Replacement (Hip and Knee) (L36007)
Monitored Anesthesia Care (L35049)
Non-Vascular Extremity Ultrasound (L35409)
Qualitative Drug Testing (L35006)
Scanning Computerized Ophthalmic Diagnostic Imaging (L35038)
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography
(L35035)
 Vitamin D Assay Testing (L34888)
Introducing Our New Novitas
Solutions eNews Mailing Schedule
 In response to your feedback, we are implementing a new delivery
schedule for our “Novitas Solutions eNews” e-mail
 Our emails will arrive in your inbox just twice a week – Every
Tuesday and Thursday
 These emails will still contain all the important Medicare news and
updates you need
 We will continue to send any urgent Medicare news or alerts to your
inbox instantly
Increasing Your Bottom Line: How
Much Does Rework Cost?
 Cost savings for providers by reducing the need for Clerical Error
Reopening requests:
•
Correct minor errors
• Omissions of claim specific information
 Education Initiatives:
•
Articles published to assist with proper use of specific modifiers
 New Web page dedicated to help you reduce rework and increase
your bottom line:
•
http://www.novitassolutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00092
539
Using Internet-based PECOS is
Easy
 Advantages of Internet-based Provider Enrollment Chain and
Ownership System (PECOS):
•
Completely paperless process
• Electronic signature and digital document features available
• Faster processing than paper-based enrollment
 JL Provider Enrollment Status Inquiry Tool:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00004864
Novitas is Now Accepting Part A
Appeal Request Forms by Fax
 Faxing Part A Redeterminations/Clerical Reopening requests:
•
Available 24 hours, 7 days a week , fax 1-888-541-3829
• On-line form available- Part A Redetermination and Clerical Error
Reopening (Form 1000)
• Submit one form for each claim in question
• Do not copy the form
• Do not submit more than 1,500 pages per fax
 JL online tutorial available:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00002684
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
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?conten
tId=00081806
What is Novitasphere?
 Free web-based Portal which allow enrolled users access to
Eligibility, Claim Information and Remittance Advice, Claim
Submission with File Status, Electronic Remittance Advice (ERA),
Claim Correction, and a Mail Box
 Available to JH and JL Part B providers, billing services and
clearinghouses servicing Part B practitioners
 For demonstrations and more information on Novitasphere visit:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00024648
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:
•
http://novitassolutions.com/cs/idcplg?IdcService=GET_FILE&RevisionSelectionMeth
od=LatestReleased&dDocName=00086496&allowInterrupt=1
Novitasphere Help Desk
1-855-880-8424
Calendar of Events
 Our Education and Training Center offers a wide variety of education
 Join us for Workshops, Teleconferences, and Webinars
 The most current calendar of events
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00008010
Stay Up-to-Date
 Electronic Mailing List:
•
Daily E-mail of the latest Medicare Updates
• Subscribe
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00007968
 Podcast:
•
Podcast of the latest Medicare Updates and other informative topics
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000
08119
 Educational Videos and Tutorials:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00082787
Upcoming Part A Webinars

Part A How to Avoid Top Claim Errors - Fourth Quarter
•

Proper Use of Modifiers
•

December 10, 2015 11:00am-12:30pm ET
ABILITY|PC-ACE
•

December 4, 2015 10:00am-11:30am ET
Credit Balance
•

December 3, 2015 2:00pm-3:30pm ET
Part A Effectively Using International Classification of Disease, Tenth Revision
(ICD-10)
•

December, 1, 2015 2:00pm-3:00pm ET
December 30, 2015 10:00am-11:00am ET
For a complete list of webinars
•
http://www.novitassolutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00008010
Upcoming Part B Webinars

Part B Evaluation and Management Score Sheet: Part 4: Scoring Medical Records Using the
Score Sheet
•

Novitasphere Claim Correction Overview
•

December 3, 2015 10:00am - 11:00am ET
Proper Use of Modifiers
•

December 2, 2015 10:00am - 11:00am ET
Part B Top Claim Errors - Fourth Quarter 2015
•

December 1, 2015 10:00am - 11:00am ET
Part B Initial Inpatient Services
•

November 25, 2015 2:00pm - 3:00pm ET
Novitasphere Portal Overview
•

November 24, 2015 10:00am - 11:00am ET
December 3, 2015 2:00pm-3:30pm ET
For a complete list of webinars
•
http://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00008044
Comprehensive Error Rate Testing
(CERT) Program
Comprehensive Error Rate Testing
(CERT)
 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:
•
http://www.novitas-solutions.com/webcenter/spaces/CERT_JL
Part A Common Errors
 Insufficient documentation:
Missing valid physician’s order
• Missing documentation to
support minimum 15 hours per
week of combined therapy
• Diagnosis insufficient to
support procedure or service
billed
• Missing Skilled Nursing
Facility (SNF) 3 day qualifying
stay
• Missing or illegible
documentation and/or
physician signature
• No valid certification for
therapy services
•
 Medical necessity errors:
•
Documentation did not support
inpatient stay
 Other errors:
•
•
•
•
•
Incorrect Diagnosis Related
Group (DRG) billed
Discharge disposition code
Resource Utilization Group
(RUG)
Laboratory services billed
incorrectly
Debridement codes
CERT Appeals vs. Claim
Adjustments
 Providers may not cancel or adjust claims selected in the CERT
review process
 Notify CERT if an error has been made on a claim, do not cancel or
adjust claims
 Novitas initiate adjustments for necessary denials
 CERT adjustments in FISS appear as XXH Bill Type
 Appeal denials on XXH Bill Type as a means of submitting
corrections to claims using the Medicare Part A Redetermination
Request Form
 JL Article:
•
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00003498
Part B Common Errors
 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
Self-Service Options
Customer Contact Information
 Jurisdiction L Providers:
•
•
1-877-235-8073
JL Self-Service Tools:
 http://www.novitassolutions.com/webcenter/portal/CustomerServiceCenter_JL/SelfService+Tools
 Telecommunication Devices for the Deaf:
•
1-877-235-8074
 Patient / Medicare Beneficiary:
•
1-800-MEDICARE (1-800-633-4227)
 http://www.medicare.gov/index.html
Fiscal Intermediary Standard
System (FISS) Hours
 District of Columbia (DC), Maryland (MD), New Jersey (NJ),
Pennsylvania (PA)
•
Monday – Friday
 6 am – 9 pm, Eastern Time (ET)
•
Saturdays
 6 am – 4 pm ET
Centers for Medicare & Medicaid
Services (CMS)
 The CMS website offers valuable resources such as
•
•
•
•
CMS Internet Only Manuals (IOMs)
Medicare Learning Network (MLN) Matters Articles
Open Door Forum
http://www.cms.gov/
Summary
 Discussed the current change requests, giving key points and links
 Reviewed the Novitas tools that are needed to keep providers
updated
 Gave valuable resources from the CMS and Novitas websites
Provider Outreach & Education
Contact Information
Contact Information:
Denise Church
Provider Outreach and Education Manager
Denise.Church@novitas-solutions.com
412-802-1739
Janice Mumma
Jurisdiction JL Provider Outreach and Education Supervisor
Janice.mumma@novitas-solutions.com
717-526-3645
Thank You For Attending
Questions