J15 Part A Provider Outreach and Education
Annie Scriven and LJ Smith
Disclaimer
 This presentation was current at the time it was published or uploaded onto the CGS website.
Medicare policy changes frequently so 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.
 The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make
no representation, warranty, or guarantee that this compilation of Medicare information is errorfree and will bear no responsibility or liability for the results or consequences of the
use of this guide.
 This publication 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.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Objectives
 Discuss the changes to the beneficiary eligibility queries
 Provide an overview of the updates and new reporting
requirements for outpatient therapy services
 Provide updates and request feedback on current and
future POE activities
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Beneficiary Eligibility
 HIPAA Eligibility Transaction System (HETS) will replace
the Common Working File (CWF) eligibility queries.
 ELGB will be terminated effective April 1, 2013.
 The termination date for inquiry option 10, ELGA, HIQA,
and HUQA will be announced at a later date.
References:
 CMS MLN Matters article SE1249: http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1249.pdf
 CMS MLN Matters article MM8086: http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8086.pdf
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Beneficiary Eligibility
Beneficiary eligibility information will still be accessible via:
 CGS Part A IVR: 1.866.289.6501
 myCGS Web portal: http://www.cgsmedicare.com/parta/index.html#
 HETS: http://www.cms.gov/Research-Statistics-Data-andSystems/CMS-Information-Technology/HETSHelp/index.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
IVR
CGS J15 Part A IVR User Guide:
http://www.cgsmedicare.com/parta/help/CGS_J15_PartA_IVR_U
ser_Guide.pdf
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
What is myCGS?
The myCGS application provides real-time information access
over the Web for the following online services:
 Eligibility
 Claims Status
 Remittances Online
 Financial Information
• Payment floor and last three checks paid
 Part A Redetermination Requests
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Registration
Registration is a very simple three step process!
Step • Go to the myCGS home page (http://www.cgsmedicare.com)
1 • Click Register Now.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Registration
Step • Complete the registration page and agree to the Terms of Use.
2 • Click Submit.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Registration
Step
3
• As part of the Registration Process, you will be required to set up
validation information in order to secure your User ID and Password.
• Complete the Information, and Click Submit.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Registration Confirmation
Once finished, you will receive an email to verify
your registration. Click the link in the email to
complete the process.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Registration
After successful registration you can log into myCGS.
• If granted access from Provider Administrator
• Must change password, accept Terms of Use and answer security question
• Security question used if password is forgotten
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Home Tab
myCGS Home Tab
• The myCGS Welcome screen is default after successful log on.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
View beneficiary eligibility by clicking on the Eligibility tab.
Subscriber is the Medicare patient.
Enter suffix (e.g., Jr., Sr.) if one is shown
on the Patient’s Medicare card.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Eligibility Sub-Tab
 General summary of patient eligibility
•
•
•
•
•
Published March 5, 2013
Part A
Part B
Inactive periods
Address
ESRD info
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Deductibles/Caps Sub-Tab
 Part B deductible
 Occupational Therapy cap
 Physical Therapy and
Speech-Language Pathology cap
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Preventive Sub-Tab
 Smoking Cessation Therapy
 CPT/HCPCS of other preventive services
• Next eligible date
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Plan Coverage Sub-Tab
 Name, ID and address of
Medicare Advantage (MA) plan
• Information is available for 24
months from the current date
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Medicare Secondary Payer (MSP) Sub-Tab
 Effective date, name, and address of insurance primary to Medicare
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Hospice/Home Health Sub-Tab
 Start/stop dates of Hospice coverage and Home Health episodes
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Eligibility Tab
Inpatient Sub-Tab
 Identifies hospital and Skilled Nursing Facility (SNF) stays
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
HETS
 HETS 270/271
• Must obtain a secure IP connection to the CMS Extranet
• Must develop or acquire a mechanism to construct and send 270
eligibility request files and receive and deconstruct 271 eligibility
response files in a real-time environment.
 HETS User Interface (UI)
• Internet-based application that is currently being tested
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Annual Financial Limitations
Therapy Cap
2012
2013
PT and SLP services
combined
$1,880
$1,900
OT services
$1,880
$1,900
CMS MLN Matters article MM8129:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8129.pdf
Therapy Threshold
2012
2013
PT and SLP services
combined
$3,700
$3,700
OT services
$3,700
$3,700
CMS eNews dated January 3, 2013:
http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2013-01-03Standalone.pdf
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Multiple Procedure Payment Reduction
(MPPR)
 The MPPR will increase from 25% to 50% effective for
claims with dates of service April 1, 2013, and after.
 Applies to the Practice Expense (PE) payment when more
than one unit/procedure is provided to the same patient
on the same day.
 Full payment is made for the unit/procedure with the
highest PE payment.
 Each subsequent unit/procedure is reduced by 50%.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
MPPR Rate File
http://www.cms.gov/Medicare/Billing/TherapyServices/index.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Claims-Based Data Collection
 CMS MLN Matters article MM8005:
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8005.pdf
 Testing period:
• Dates of service January 1 - June 30, 2013
• CGS will process claims with or without the functional limitation
HCPCS codes and modifiers
 Implementation period:
• Dates of service on and after July 1, 2013
• CGS will RTP claims without the functional limitation HCPCS codes
and modifiers
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Provider Types Affected
 Outpatients and inpatients who receive Part B therapy
services
 Rehabilitation agencies
 Home health agencies
 Comprehensive Outpatient Rehabilitation Facilities
(CORFs)
 Outpatient hospitals, including emergency departments
 Critical Access Hospitals (CAHs)
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Functional-related G-code Sets
• 42 functional HCPCS G-codes, 14 sets of 3 codes each
• Each functional G-code set contains:
• Current status
• Projected goal status
• Discharge status
Mobility
Motor speech
Changing and maintaining body
position
Spoken language comprehension
Carrying, moving, and handling objects Spoken language expressive
Self care
Attention
Other PT/OT Primary
Memory
Other PT/OT Subsequent
Voice
Swallowing
Other SLP
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Selecting a G-code
 Primary functional limitation or primary reason for
treatment
 Most clinically relevant to a successful outcome for the
beneficiary
 The one that would yield the quickest and/or greatest
functional progress (e.g., select mobility over self-care
even though both are addressed simultaneously and
therapist expects beneficiary will attain self care goals
before mobility goal)
 The one that is the greatest priority for the beneficiary
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Severity/Complexity Modifiers
HCPCS
Modifier
Impairment Limitation Restriction
CH
0% impaired, limited or restricted
CI
At least 1% but < 20% impaired, limited or restricted
CJ
At least 20% but < 40% impaired, limited or restricted
CK
At least 40% but < 60% impaired, limited or restricted
CL
At least 60% but < 80% impaired, limited or restricted
CM
At least 80% but < 100% impaired, limited or restricted
CN
100% impaired, limited or restricted
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Reporting Requirements
 Required throughout the entire episode of care
 Only one functional limitation is reported at a time
 Exception:
• When the beneficiary has reached his or her goal or progress has
been maximized on the initially reported functional limitation, but
the need for treatment continues, reporting is required for a
second functional limitation using another set of HCPCS G-codes.
• In these situations, two or more functional limitations will be
reported for a beneficiary during one therapy episode of care.
• Reporting on more than one functional limitation may be required
for some patients, but not simultaneously.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
When to Report
 On the date of service of the initial therapy service
 At least once every 10 treatment days
 On the DOS of every evaluative procedure
 Upon discharge from the therapy episode of care
 When therapy for a particular functional limitation ends
or changes
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Number of G-codes
 Two functional G-codes are required on a claim under
one therapy plan of care:
• Current status and goal status
• Discharge status and goal status
 May require more than two G-codes when a patient
receives therapy services under multiple POCs from the
same provider
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Line Item Information
 Functional HCPCS G-code
 HCPCS therapy modifier (GP, GO, GN)
 HCPCS functional severity modifier
 Date of service
 Nominal charge (e.g., $0.01)
 Another billable and separately payable (non-bundled)
service
 HCPCS modifier KX and CPT modifier 59 do not apply
CPT only copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS\DFARS Restrictions Apply to government use.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Documentation Requirements
 Functional HCPCS G-codes and severity modifiers must
be documented in the patient’s medical record for each
required reporting.
 Must be completed by:
• The qualified therapist furnishing the therapy services
• The physician/NPP personally furnishing the therapy services
• The qualified therapist furnishing services incident to the
physician/NPP
• The physician/NPP for incident to services furnished by “qualified
personnel” who are not qualified therapists.
• The qualified therapist furnishing the PT, OT, or SLP services in a
CORF
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Resources
 CGS website: http://www.cgsmedicare.com/
 CGS ListServ registration:
http://www.cgsmedicare.com/medicare_dynamic/ls/001.
asp
 CGS Part A PCC: 1.866.590.6703
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Resources
 CGS Electronic Data Interchange:
http://www.cgsmedicare.com/parta/index.html#
• EDI enrollment
• Electronic Remittance Advice (ERA)
• PC-ACE Pro32 software
• Direct Data Entry (DDE) software
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Resources
 CMS Medicare Learning Network (MLN) Products:
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/index.html
 CMS MLN FFS National Provider Calls:
http://www.cms.gov/Outreach-andEducation/Outreach/NPC/index.html
 CMS Open Door Forums: http://www.cms.gov/Outreachand-Education/Outreach/OpenDoorForums/index.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
J15 Part A
Provider Customer Service Program
CMS requires all Medicare contractors have a Provider
Customer Service Program to assist providers in
understanding and complying with Medicare’s
operational processes, policies, and billing procedures.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
J15 Part A Provider Outreach and
Education (POE)
 Frequently Asked Questions (FAQs)
 Webinars
 Ask-the-Contractor (ACT) teleconferences
 Articles
 POE Advisory Group
 Partnering with external entities
 Training requests
 Comprehensive Error Rate Testing (CERT)
 CGS website enhancements
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
FAQs
 Are created based on provider inquiry analysis/reports
 Play a large part in provider education efforts developed and
implemented
 Used to develop and deliver training to Provider Contact
Center (PCC) staff
 FAQ topics received from the POE Advisory Group
 FAQs reviewed on a periodic basis to ensure current
information is offered and published
 New FAQs! – Medical Review, Medical Policy/Coverage, EDI,
Customer Service
 FAQ link: http://www.cgsmedicare.com/parta/index.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Webinars
 Planned on a quarterly basis
 Content based on current topics and suggestions solicited
from POE Advisory Group members
 Some training topics developed based on FAQs
 Current schedule - Wednesdays (same time) for
consistency’s sake and provider convenience
 Toll-free and easy access (no charge to providers)
 Repeated if popular demand dictates
 Same schedule and topics for Kentucky and Ohio providers
 CGS webinar page:
http://www.cgsmedicare.com/parta/education/ky/webinars.
html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
ACT Teleconferences
 Provides a means for providers to ask specific questions
concerning billing, Medicare policies or procedures.
 Provides a method of sharing information, and function as a
tool for listening to the provider community.
 Toll-free (no charge to providers)
 Q&A document posted on CGS website within 30 days after
event
 Encore available
 Same schedule and topics for Kentucky and Ohio
 CGS ACT website:
http://www.cgsmedicare.com/parta/education/ky/act/index
.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Articles
 Developed based on current topics, requests from
providers and suggestions from the PCC
 Topics also solicited from POE Advisory Group members
 Input from medical directors and other medical staff
 News and Publications on the CGS website:
http://www.cgsmedicare.com/parta/pubs/news/index.ht
ml
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
POE Advisory Group
 Primary functions:
• To assist CGS in the creation, implementation, and review of
provider education strategies and efforts
• Provides input and feedback on training topics, provider
education materials
 Used as a provider education consultant resource (not
as an approval or sanctioning authority)
 Convenes quarterly
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
POE Advisory Group
 Members selected via a membership drive
 Represents professional and geographic diversity,
comprised of major provider specialties or provider
institutions they serve
 CGS’ POE Advisory Group website:
http://www.cgsmedicare.com/parta/education/POEAG.
html
 Contains minutes from meetings, upcoming meetings
dates and locations, list of organizations or entities
comprising the Advisory Group
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Partnering With External Entities
 CGS establishes and maintains partnerships with
external entities to help disseminate Medicare provider
information.
 Partnership activities do not take the place of CGS-led
POE events, but supplements them.
 Establishes a collaborative information dissemination
effort:
1.
To obtain Medicare program information through a variety
of sources
2.
Disseminate Medicare information to
partners/associations, via their newsletters, websites,
training events, conferences, etc.
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Training Requests
 CGS offers educational opportunities through special
training requests
 Tailored to meet the needs of the providers we serve
 Education/training via webinars and teleconferences
(cost effective)
 J15 Part A Outreach and Education Request Form
http://www.cgsmedicare.com/parta/education/pdf/educ
ation_request_form.pdf
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Comprehensive Error Rate Testing
(CERT)
 A way for the Centers for Medicare & Medicaid Services (CMS) to look at
the Medicare accuracy of claims processed by all Medicare Administrative
Contractor (MAC)
 An independent contractor that determines the paid claims error rates
 CERT contractor reviews a random sample of processed claims, measures
improper payments in the Medicare fee-for-service (FFS) program and
reports results to CMS
 Not considered a measure of fraud
 CGS maintains an active internal CERT workgroup
 Specialized CGS staff calculates CGS’ CERT errors
 POE incorporates CERT information into training material
 CGS’ CERT website:
http://www.cgsmedicare.com/parta/cert/articles/006.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
CGS Web Site Enhancements
 New look! - corporate web page
 Search engine: now powered by Google
 Under discussion - enhancing and reorganizing some
education pages to allow for easier access to material
 CGS website feedback:
https://www.cgsmedicare.com/feedback.html
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
How can we assist you?
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.
Thank you for attending!
Published March 5, 2013
© 2013 Copyright, CGS Administrators, LLC.