Medicare Update:
News To Use!
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Disclaimer
The information provided in this presentation was current as
of 04/17/2014. Any changes or new information
superseding the information in this presentation are
provided in articles with publication dates after 04/17/14
posted on our Web site at:
www.PalmettoGBA.com/J11A
CPT only copyright 2014 American Medical Association.
All rights reserved.
The Code on Dental Procedures and Nomenclature is published in Current
Dental Terminology (CDT), Copyright © 2014 American Dental Association
(ADA). All rights reserved.
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Agenda
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CMS Updates
CERT and Medical Review
Claim Submission Errors
Provider Customer Service Program
Palmetto GBA Upcoming Events
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What’s New with
CMS?
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Hospital Inpatient
Admissions Update
Final Rule CMS 1599-F
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Certification Requirements
• CMS released additional clarification
regarding physician order and certification
of hospital inpatient services
– Guidance can be found on CMS Hospital
Center website at:
http://www.cms.gov/Center/ProviderType/Hospital-Center.html
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Probe and Educate Reviews
• CMS extends the Inpatient Hospital
Prepayment Review “Probe & Educate”
process for 6 months
• MACs to review hospital compliance with
admission order requirements, certification
requirements, & the two-midnight benchmark
– Inpatient claims with admission dates of
October 1, 2013 through March 31, 2015
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Probe and Educate Reviews
• Reviews assess provider understanding and
compliance with CMS policy on inpatient hospital
& critical access hospital (CAH) admissions
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MACs will provide Individualized education and repeat
the process if necessary
• A 45 day timeframe is allowed before the MAC
requests additional documentation
•
Timeframe gives hospitals additional time to
implement strategies aimed at increased compliance
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Part B Inpatient (A/B) Payment
Updates
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CR 8445
• CR 8445 – Implementing Part B Inpatient
Payment Policies from CMS-1599-F
• Policies for A/B billing effective 4/7/2014
– Administrative Rule 1455 is longer in affect
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CR 8445
• Claims received on or after 4/1/14:
– TOBs 13x or 12x no longer processes under
1455 if admission date is on or after the
effective date of CMS-1599-F
• Regular timeliness policies are in effect
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CR 8445
• 12x TOB must contain:
– A/B Rebilling treatment authorization
– ‘A/B Rebilling’ and original denied inpatient
claim DCN noted in the Remarks
– Condition Code W2 attesting rebilling and that
no appeal is in process
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CR 8458 - Jimmo Settlement New Twists to
Skilled Services
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Jimmo vs Sebelius Settlement
• Issued 1/24/14: Focus on home health care,
skilled nursing & therapy care
• Intent to clarify that coverage cannot be denied
based on absence of the potential for
improvement or restoration
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Jimmo vs Sebelius Settlement
• No expansion of Medicare coverage
– Settlement agreement does not modify, contract, or
expand existing eligibility requirements for receiving
Medicare coverage
– CR Request 8458, Transmittals 176 & 179, Jimmo vs.
Sebelius Settlement Agreement (Fact Sheet)
http://www.cms.gov/site-search/searchresults.html?q=Jimmo%20fact%20sheet
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Part A LCDs Impacted
• Revisions were made to J11 Part A LCDs:
– Outpatient Physical Therapy L31581
– Outpatient Occupational Therapy L31591
– Outpatient Speech-Language Pathology
L31603
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Jimmo vs Sebelius Settlement
• Re-reviews of claims can be requested on
maintenance care denials that became final
and non-appealable from 1/18/11-1/23/14
– These will be handled as re-openings
– Requests may be submitted through 1/23/15
• CMS Fact Sheet http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/Downloads/Jimmo-FactSheet.pdf
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Take Away Message…
• Manual Changes and Documentation
Requirements mostly for SNF & HH;
– Also affects outpatient & Part B Therapy services
• Allows maintenance program performed by
skilled therapists.
– Allow PTA/OTAs in SNF
– No PTA/OTA-for HH, outpatient, and Part B.
LCDs effective 03/27/14 & IOM 100-02, Chapters 1, 7, 8 & 15
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CERT
A Partnership
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CERT Purpose and Process
Is Provider
Billing
Correctly?
Purpose
Select
Claims
Request
Medical
Records
Review
Is Contractor
Processing/Paying
Correctly?
Assign
Improper
Payment
Categories
Calculate
Improper
Payment
Rate
Educate
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Collaboration
• VIP to set a CERT point of contact (POC) responsible
for receiving CERT correspondence!
– https://www.certprovider.com/
• Correspondence includes, but is not limited to
– Letters
– Phone calls requesting records
– Reports listing facility error findings
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Collaboration
• CERT follow-up is carried out by notifying
provider of appropriate documentation
follow-up that is needed
– Includes CERT letters, CERT Tech Stop calls and
notification of repetitive incorrect billing issues
that increase the CERT error rate
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Collaboration
• POE provides education through a variety of
resources which include:
– Provider Education Letters
– Teleconferences
– Website (Articles, FAQs, Job Aids & more)
– Webcasts & Self-Paced Learning
– Workshops
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CERT Error Rate
6.8%
• National IP Hospital CERT Error Rate
7.7%
• Palmetto GBA Part A Error
IP Error Rate
0%
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Palmetto GBA’s
Target Error
Rate – 0%
WV CERT Error Statistics - March 2014
44 claims reviewed = Tentative Error Rate of 13.3%
Claim Error Error Description
Count
21
25
Medically unnecessary service or treatment
11
21
Insufficient documentation
7
26
1
31
Invasive procedure not medically necessary (IPPS
Only)
Incorrect Coding
1
32
DRG change due to wrong diagnosis code or
wrong principal diagnosis
1
33
DRG change due to wrong procedure code
2
90
Other errors
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WV CERT Error Statistics - March 2014
• Of the 44 claims reviewed; only 17 claims appealed!
– 6 claims were overturned = $35,959.66 paid
• 11 claims were found unfavorable due to
documentation = $149,358.69!
– 8 = 25 Medically unnecessary service or treatment
– 2 = 21 insufficient documentation,
– 1 = 32 DRG Change due to wrong diagnosis code or wrong
principal diagnosis.
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WV CERT Error Statistics - March 2014
• No appeal action taken on 27 claims =
$242,908.45 may have been overturned!
• If you receive CERT Denial:
– Always appeal the decision!
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Before Appealing a CERT Denial
• Check the records!
– Identify the reason each service was denied
– Make sure the records contain valid signature
• Stamped signatures are not acceptable
• Do not resubmit the claim
– Denial decision was based on review of medical
records; therefore, claims for these services may
not be resubmitted for payment consideration
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Reminder
If you can’t read it, we can’t read it!
Carefully pull and timely submit all the necessary
documentation to support all services!
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Medicare A/B Contractor
CERT Task Force
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Medicare A/B Contractor CERT Task Force
• National educational task force
– Includes representatives from each MAC
contractor across the country
– Shared goal of reducing CERT error rate through
national awareness & education
http://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/CERT/index.html
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Medical Review
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Medical Review Program
• Proactively identifies patterns of potential
billing errors through data analysis and
evaluation of other information
– Reviews data analysis reports and take action
• Publish local LCD policies to provide guidance
as to when services are eligible for payment
under Medicare statutes
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Current Medical Review Activities
Medical Review Activity Notifications
Probe Reviews for Progressive CAP for New 2Midnight Guidance for IPPS Claims
Probe of Inpatient Medicare Severity Diagnostic
Related Groups (MS-DRG)
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Completed MR Activities
Completion Pre-Payment Service-Specific Medical
Review
Extracapsular Cataract Removal w/insertion of
Intraocular Lens Prosthesis, Manual or Mechanical
Technique
Outpatient Pulmonary Rehab
Case Mix Group Stroke: Inpatient Rehabilitation
Facilities
SNF 14 Lower RUG Codes for 10/1/13 – 12/31/13
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Medical Review Spotlights
J11 Part A Medical Review Spotlights are prerecorded education at your convenience
• Cardiac Rehabilitation Coverage & Documentation
Requirements
• Hospital Admissions, Leave of Absences & Preventing
Overlaps
• Pulmonary Rehabilitation
• Cataract Removal Billing Guidelines
• Clinical Update Spinal Fusion DRG 459 & 460
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Medical Review Spotlights
• DRG 391: Esophagitis, Gastroenteritis w/ MCC,
DRG 392: Esophagitis, Gastroenteritis w/o MCC &
DRG 640: Miscellaneous Disorders of Nutrition,
Metabolism, Fluid/Electrolytes w/ MCC
• Ambulance Services
• SNF Basics Training Modules
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Medical Review Spotlights
• DRGs 302 Atherosclerosis w MCC, DRG 303
Atherosclerosis w/out MCC-One Day Stays
• DRG 689 Kidney and Urinary Tract Infections with
Major Complication or Comorbidity (MCC)
• SNF Beneficiary Edits, Lower RUG Codes &
Inpatient Rehabilitation Services
• Partial Hospitalization: A Treatment Bridge
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Medical Review Denials
Part A Denial Reason Codes
• Palmetto GBA Denial Resolution tool includes
resources for resolving the top claim medical
review denial reasons
• Save time & resources by looking here before you
pick up the phone
• Access denial reasons in plain language
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Medical Review Denials
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Claim Submission Errors
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Claim Submission Errors for March 2014
WV Denial
Rank Code
Claim
Count
1
2
3
4
5
6
7
8
9
10
4628
2502
1805
1319
1005
708
470
465
455
419
31324
31814
31241
31947
U5233
54NCD
38038
31711
38200
70034
% of Denied to
Total w/any
Denial Code
25.1
13.5
9.8
7.1
5.4
3.8
2.5
2.5
2.5
2.3
% of Denied to
Total Excluding
‘T’ Status Claims
3.8
2.1
1.5
1.1
0.8
0.6
0.4
0.4
0.4
0.3
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Help with Claim Denials
• Claims Submission Error Help Tool
– Provides a list of claim submission errors & how to resolve
• Top Denials and Reason Codes available on demand
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1st Quarter
Webcast – Published at the end of April
2st Quarter Webcast – Will be published by the end of July
• Available under the Learning and Education Link
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Claim Submission Error Help
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PCSP Updates
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PCC Training – Last Quarter
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Monthly Medicare Advisory Training
Policy and Coverage Regulations
Contractor Call Center Procedures
ITS Reporting
Reference Resources & Website Navigation
Online Provider Services (OPS)
Provider Enrollment
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Provider Inquiries
• The J11 Part A Provider Contact Center
(PCC) received 45,212 inquiries from
January 1 to March 31, 2014
• Total Inquiry count includes:
– Telephone
– Written Correspondence
• E-Mail/Fax/Letter
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Provider Inquiries – Jan. – Mar. 2014
18000
16,849
16000
14000
12000
11,812
General/Policy
Appeals
Financial
10000
8000
Denial/Adj/RTP
6000
Billing Assistance
4000
2000
0
Number of Inquiries
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Web Site ForeSee Survey
• Customer Satisfactory Survey
– Sponsored by CMS and conducted by ForeSee
– Gauges satisfaction with Palmetto GBA Website
– Results influence updates to layout, look and
feel, content, and other aspects of our website
• You are encouraged to complete the survey!
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Website – 2014 ForeSee Scores
Month
Participants
Satisfaction Score
January
304
70
February
301
71
March
302
72
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Claims Processing Issues Log (CPIL)
Operating systems are knowledge & rule based
• Beneficiary eligibility data
• Enforce billing regulations
• Medical policy control
All interface with each other:
• Common Working File
• Fiscal Intermediary Shared System
• Enterprise Data System
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Claims Processing Issues Log (CPIL)
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Upcoming Events
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Quarterly Events
• Ask the Contractor Teleconference (ACT) will
be in July 2014, 10 a.m.
– ACT Request – Submit a Question Form
• June Quarterly Updates, Changes &
Reminders Webinar is June 10, 2014, 10 a.m.
– Register via Event Registration Portal
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Educational Workshops
• Free educational workshops on reducing
provider error rates
– Improve provider cash flow
• Clinical context
• Focus on specific DRGs with high error rate
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Target Audience
• Target workshop audience will be:
– Finance team members
– Compliance officers
– Auditors
– Utilization review committee members
– Reimbursement managers
– Medicare billing managers
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Educational Workshops
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Columbia, SC Headquarters 7/22 & 7/23
Durham, NC = 7/31 & 8/1
Roanoke, VA = 8/19,
Richmond, VA = 8/26 & 27
• Flat Rock, WV = 8/6
Mark your calendar!
• Further information will be on our website!
– Event Registration Portal
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Social Networking
Ways to Stay Connected
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Thank you!
Please be sure that you register for daily email
updates from Palmetto GBA!
The Link is located on under “Email Updates”
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