Maryland AAHAM
March 15, 2013
Disclaimer
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All Current Procedural Terminology (CPT) only copyright 2012 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.
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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.
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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.
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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.
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Novitas Solutions does not permit videotaping or audio recording of training events.
Agenda
• Medicare Updates and Notifications
• Contractor Updates
• Comprehensive Error Rate Testing
Program (CERT)
• Self Service Options
Medicare Updates and
Notifications
New FISS Consistency Edit to Validate
Attending Physician National Provider
Identifier (NPI)
• Change Request 7902
– Effective: January 1, 2013
– Implementation: January 7, 2013
• Key Points:
– Edit for institutional claims to ensure that the
institutional provider has not used their billing NPI in
the Attending Provider NPI Data Element
• For more information:
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(Part A)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM7902.pdf
April Outpatient Perspective
Payment System (OPPS) Update
• Change Request 8228
– Effective/Implementation Date: April 1, 2013
– New Services Payable
• C9734
• C9735
– Drug and Biological Additions
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C9130
C9297
C9298
J7315
Q4127
– Influenza Vaccine Flucelvax Covered
• 90661
(Part A)
Place Of Service (POS)
Coding Instructions
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Change Request #7631
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Effective: April 1, 2013, Implementation: April 1, 2013
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Key Points:
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Adds provisions regarding use of POS codes 22 and 24
The POS code to be used will be assigned as the same setting in which the beneficiary received
the face-to-face service
Two 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:
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(Part B)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7631.pdf
Implementation of
Ordering/Referring Edits
• SE 1305
• Full Implementation of Edits on the Ordering/Referring Providers in
Medicare Part B, DME, and Part A Home Health Agency (HHA)
Claims
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• Phase 1
– Informational messaging:
– Began October 5, 2009
• Phase 2
– Effective May 1, 2013,
– CMS will turn on the edits to deny Part B, DME, and Part A HHA claims
that fail the ordering/referring provider edit
(Part B)
American Taxpayer Relief
Act of 2012
• Issued: January 03, 2013
• Section 603 - Extension Related to Payments for
Medicare Outpatient Therapy Services
– Extends the exceptions process for outpatient therapy
caps through December 31, 2013
– Extends the application of the cap and threshold to
therapy services furnished in a hospital outpatient
department, and counts outpatient therapy services
furnished in a Critical Access Hospital towards the
cap and threshold
(Part A & B)
2013 Therapy Cap Values
• Change Request # 8129
– Effective: January 1, 2013
– Implementation January 7, 2013
• Key Points
– $1,900 combined for Physical Therapy and Speech-Language Therapy
– $1,900 for Occupational Therapy
• For more information:
– http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2012-TransmittalsItems/R2600CP.html
(Part A & B)
2013 Manual Therapy
Review
• Article issued 3/1/2013
– https://www.novitas-solutions.com/bulletins/all/news-03012013.html
• Therapy above $3,700 threshold subject to
Complex Medical Review
• Pre-approval process not applicable
• Services above $3,700 threshold will
suspend for pre-payment Medical Review
• Follow instructions on ADR for submitting
review documents.
New Claim-based Therapy
Reporting Requirements
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Change Request (CR) #8005
– Effective: January 1, 2013
– Implementation: January 7, 2013
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Key Points
– New claims-based data reporting
– 42 New G-codes, to report patient function
– 8 New Modifiers, to describe severity
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For more information:
– http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2012-TransmittalsItems/R2603CP.html
(Part A & B)
Services and Providers Affected
by CR 8005
• Applies to all services furnished under Medicare Part B
outpatient therapy benefit, as well as physical therapy,
occupational therapy and speech language therapy
provided by Comprehensive outpatient rehabilitation
facilities (CORF)
• Providers Types: Hospitals, Critical Access Hospitals,
Skilled Nursing Facilities, CORFs, Rehab agencies,
Home Health (Part B), Therapists in private practice,
physicians, and Non-Physician Practitioners
(Part A & B)
Outpatient Therapy Functional
Reporting Non-Compliance Alerts
• Change Request #8166
• Effective Date: April 1, 2013
• Key Points:
– For therapy claims, with dates of service on and after January 1, 2013,
processed on and after April 1, 2013 through June 30, 2013, providers
will be alerted to include the applicable 42 new G-codes and seven
modifiers on future therapy claims through a new Remittance Advice
message
– There will be no alert messaging for institutional claims between April 1,
2013, and July 1, 2013
– For professional and institutional claims, effective July 1, 2013 will
enforce the functional reporting requirements by requiring claims that do
not contain the required functional G-code and modifier information to
be returned or rejected
(Part A & B)
Multiple Procedure Payment Reduction
(MPPR) for Selected Therapy Services
• Change Request # 8206
• Effective date: April 1, 2013
• Key Points:
– American Taxpayer Relief Act of 2012 increased the Multiple
Procedure Payment Reduction (MPPR) on selected therapy
services to 50 percent for both office and institutional settings
– This is effective for claims with dates of service on or after April
1, 2013
(Part A & B)
ICD-10 Delayed
• ICD-10 compliance date delayed to October 1, 2014
• Keep Up to Date
– Sign up for CMS ICD-10 Industry Email Updateshttp://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD10_Industry_Email_Updates.html
– Follow @CMSGov on Twitter
– Subscribe to Latest News Page Watch https://public.govdelivery.com/accounts/USCMS/subscriber/new?top
ic_id=USCMS_609
(Part A & B)
Special Edition Article
SE1249
• The HIPAA (Health Insurance Portability and Accountability
Act) Eligibility Transaction System (HETS) will replace CWF
eligibility inquiries
– Part B - By April 2013 access to CWF eligibility queries will be
removed from Profession Provider Telecommunication Network
(PPTN)
– Part A - Soon thereafter, access to Health Insurance Query
Access (HIQA) and CWF inquiry menu option 10 will be
terminated
– For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1249.pdf
Mandatory Payment Reductions
– “Sequestration”
• Article posed March 11, 2013
– https://www.novitas-solutions.com/bulletins/all/news03112013.html
• Medicare Fee-for-Service claims with
dates of service or date of discharge on or
after April 1, 2013
• 2% reduction to Medicare payment
CMS Provider
Compliance
 CMS Provider Compliance Webpage
• Educational products on how to avoid billing errors and improper
payments
• Compliance Products
 Quarterly Newsletter with CERT and RA findings
 October 2012 RA Findings on Major Joint Replacement, Cardiac
Procedures, Acute Inpatient Respiratory Conditions
 Podcasts
 September 2012 RA Findings on Medical Necessity of Renal and
Urinary Tract Disorders
 Fact Sheet
 August 2012 Complying with Medicare Signature Requirements
• http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/ProviderCompliance.html
Program for Evaluating Payment
Patterns Electronic Report
(PEPPER)
• PEPPER provides hospital-specific data
for Medicare severity diagnosis-related
groups and discharges at high risk for
payment errors
• For short-term and long-term acute care
hospitals
• www.PEPPERresources.org
Contractor Updates
Local Determinations
(LCDs)
• The following J12 MAC LCDs were posted for notice. They
will become effective April 4, 2013:
– Circulating Tumor Cell (CTC) Assay (L32930)
– Intravenous Immune Globulin (IVIG) (L32937)
– Transcranial Magnetic Stimulation (TMS) for the Treatment of
Depression (L32055)
– Transoral Incisionless Fundoplication (L32932)
• The following J12 MAC Local Coverage Determinations
(LCDs) have been revised:
– Ambulance (Ground) Services (L32252)
– Removal of Benign or Premalignant Skin Lesions (L27527)
Required Information When
Calling About Claims Files
• Provider Bulletin Issued: March 8, 2013
– https://www.novitas-solutions.com/edi/refpub/bulletins/2013/03082013.html
• Customers should be aware that reports for all claims
submitted electronically are only available for retrieval and
review for 45 days, including the Electronic Remittance Advise
(ERA). If you require EDI assistance, you must call EDI within
45 days of submitting the electronic claims.
– Please obtain the following information before contacting EDI:
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The Date of the submitted claims to Medicare
The Time of the submitted claims to Medicare
The outbound Filename of the claims submitted to Medicare
The date of the deposit and check number or dollar amount when
calling for ERA
Claims Editing for Reason
Code 30940
• Provider Bulletin Issued: Issued: March 05, 2013
– https://www.novitas-solutions.com/bulletins/all/news03052013.html
• Reason code 30940 is received when attempting
to adjust a claim with a medically denied line
• If you are trying to add diagnosis codes, change
CPT codes or move denied charges from noncovered to covered, you must submit a
redetermination
Fax to Image
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Were you aware records for an Additional Development Request (ADR) can be faxed
directly to Novitas Solutions?
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The fax to image option allows for documentation to be submitted directly to Novitas
Solutions.
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Available 24 hours a day, 7 days a week
Fax ADR response to 1-877-439-5479
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Faxes should not exceed 200 pages
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The original ADR request must be submitted as the cover sheet to the records
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Supporting documentation, or requested medical records, should follow the ADR
letter
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Each ADR request must be faxed separately
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Additional Tips
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https://www.novitas-solutions.com/bulletins/parta/newsletter/2012/jan.html
https://www.novitas-solutions.com/bulletins/partb/med-reports/pdf/mr0312.pdf
Fax to Image
•
Were you aware records for an Additional Development Request (ADR) can be faxed
directly to Novitas Solutions?
•
The fax to image option allows for documentation to be submitted directly to Novitas
Solutions.
–
–
Available 24 hours a day, 7 days a week
Fax ADR response to 1-877-439-5479
•
Faxes should not exceed 200 pages
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The original ADR request must be submitted as the cover sheet to the records
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Supporting documentation, or requested medical records, should follow the ADR
letter
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Each ADR request must be faxed separately
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Additional Tips
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https://www.novitas-solutions.com/bulletins/parta/newsletter/2012/jan.html
https://www.novitas-solutions.com/bulletins/partb/med-reports/pdf/mr0312.pdf
Part B Redetermination
Request
• Correct clerical errors or omission by calling the Claims
Correction line
– J12 Providers 1-877-235-8073
– JH Providers 1-855-252-8782
•
Part B Redetermination Requests may be faxed
– Available 24 hours a day, 7 days a week
– 1-888-541-3829
• Complete and print the online redetermination request form
(use as fax cover sheet)
– https://www.novitas-solutions.com/partb/forms/pdf/partb-redetermform.pdf
• Appeals Status Inquiry Tool now available
– https://www.novitas-solutions.com/appeals/status.html
New Part B Appeals Status
Inquiry Tool
• Use the Appeals Status Inquiry Tool to
check the status of your submitted appeal
• Search By:
– Case Control Number (CCN)
– Provider Transaction Access Number (PTAN)
– PTAN and Internal Control Number (ICN)
– https://www.novitassolutions.com/appeals/status.html
Provider Enrollment
• Provider Enrollment Status Inquiry Tool
– https://www.novitassolutions.com/enrollment/status.html
• Release of Information
– Individual Physician or Practitioner
– Authorized Delegated Official
• Upcoming Revalidation Mailings
– http://www.cms.gov/Medicare/Provider-EnrollmentandCertification/MedicareProviderSupEnroll/Revalidation
s.html
Comprehensive Error Rate Testing
(CERT)
Comprehensive Error Rate Testing
(CERT)
• National Claim Paid Error Rate
– 6.8 % Inpatient hospitals
– 4.8 % Non-inpatient hospital facilities
– 9.9 % 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
J12 Part A Common Errors
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Insufficient documentation:
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No valid physician’s order
Inpatient stay
Missing or illegible documentation and/or physician signature
Procedure/service performed
No valid certification for therapy services
Skilled Nursing Facility (SNF) 3 day qualifying stay
Medical necessity errors:
– Need for an inpatient stay
– Related services
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Other errors:
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Diagnosis Related Group (DRG)
Discharge disposition code
Resource Utilization Group (RUG)
Laboratory services and
Debridement code
J12 Part B Common Errors
• Insufficient documentation:
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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:
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Evaluation and Management (E/M) codes
Critical care, discharge day management, physical therapy
Units of medication/infusion services
Laboratory services
Self Service Options
Jurisdiction 12 Customer Contact
Information
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Provider
– 1-877-235-8073
– Hours of Operation, Eastern Time (ET)
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Monday - Thursday: 8:00 am – 4:00 pm ET
Friday: 8:00 am – 2:00 pm ET
– Call Flow
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https://www.novitas-solutions.com/csc/call-flow-a.html
https://www.novitas-solutions.com/csc/call-flow-b.html
Interactive Voice Response (IVR)
– Hours of Operation
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Monday: 6:00 am – 8:00 pm ET
Tuesday - Friday: 4:00 am – 8:00 pm ET
Saturday: 6:00 am – 4:00 pm ET
– Step-by-Step Guide
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https://www.novitas-solutions.com/csc/ivr/parta.html
https://www.novitas-solutions.com/csc/ivr/partb.html
Beneficiary Contact
Information
• Patient / Medicare Beneficiary
– 1-800-MEDICARE (1-800-633-4227)
• http://www.medicare.gov/index.html
J12 Fiscal Intermediary Standard
System 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
• Delaware (DE)
– Monday – Friday
• 6 am – 6 pm ET
– Saturdays
• 6 am – 4 pm ET
Stay Informed
• Subscribe to our E-Mail Lists
– https://www.novitas-solutions.com/mailinglists.html
• Available mailing lists
– Jurisdiction 12 Part A or B General Education
– Jurisdiction 12 Part A or B Electronic Billers (EDI)
• Weekly podcast covering important Medicare news and
events
– Automatically delivered
– Easy to subscribe, just copy the link to your podcast software
• https://www.novitas-solutions.com/podcasts/
Calendar of Events
• Our Training and Events Center offers a wide variety of
education
• Join us for Workshops, Teleconferences, and Webinars
• To view the most current calendar of events, visit:
– https://www.novitas-solutions.com/training/index.html
Centers for Medicare and 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
• For additional resources visit:
– http://www.cms.gov/
Thank You
Janice Mumma, CPC, CPC-H
Supervisor Provider Outreach and Education
717-526-6528
Janice.mumma@highmarkmedicareservices.com