Novitas Solutions Medicare Updates - 2014 Maryland AAHAM March 21, 2014 Disclaimer • All Current Procedural Terminology (CPT) codes and descriptors used in this presentation are copyright© by the American Medical Association. All rights reserved. • 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. 2 Novitas Solutions • Education specific to providers in Medicare Administrative Contractor Jurisdiction L (JL) include: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania • Education specific to providers in Medicare Administrative Contractor Jurisdiction H (JH) include: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas • This education contains specific contractor guidance • If you are not a provider in Jurisdiction L or Jurisdiction H, please contact your Medicare contractor for specific guidance. 3 Agenda • Medicare Updates • ICD-10 Update • Comprehensive Error Rate Testing Program • Contractor Initiatives 4 Medicare Updates 5 Therapy Modifier Consistency Edits • Change request 8556 o Effective: July 1, 2014, Implementation Date: July 7, 2014 • Creates edits in original Medicare claims to ensure therapy evaluation and reevaluation codes are reported with correct modifier • Contractor will return claims if reporting HCPCS o o o 97001 or 97002 if modifier GP is not present 97003 or 97004 if modifier GO is not present 92521, 92522, 92523, or 92524 if modifier GN is not present • http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/MM8556.pdf 6 Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims • Change Request # 8401 • Effective: January 1, 2014, Implementation: January 6, 2014 • Key Points: o o It will be mandatory to report a clinical trial number on claims for items and services provided in clinical trials that are qualified for coverage as specified in the "Medicare National Coverage Determination (NCD) Manual," Section 310.1 For institutional paper or direct data entry (DDE) claims, the 8-digit clinical trial number is to be placed in the value amount for paper only value code D4/DDE claim UB-04 (Form Locators 39-41) Electronic Submission - Loop 2300 REF02 (REF01=P4) o For professional claims, the 8-digit clinical trial registry number proceeded by the 2 alpha characters “CT” will be placed in Field 19 of the paper Form CMS-1500 Electronic Submission – Loop 2300 REF02(REF01=PF) • For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8401.pdf 7 Additional Information on the 8Digit Clinical Trial Number on Claims • MLN Matters® Special Edition Article: SE1344 • Effective: January 1, 2014, Implementation: January 6, 2014 • Key Points: o o Alternative means of satisfying the requirement Report 999999999 • http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1344.pdf 8 Redaction of Health Insurance Claim Numbers (HICNs) in Medicare Redetermination Notices (MRNs) • Change Request # 8268 • Effective: January 1, 2014, Implementation: January 6, 2014 • Key Points: o o o Health Insurance Claim Numbers (HICN) redacted from all Medicare Redetermination Notices 5 or more values of the HICN replaced with X’s or asterisks (*) Last 4 or 5 digits of the HICN is displayed • For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8268.pdf 9 Implementing the Part B Inpatient Payment Policies from CMS-1599-F • Change Request 8445 • Effective: For admission on or After October 1, 2013, Implementation: April 7, 2014 • Key Points: o When an inpatient admission is found to be not reasonable and necessary o Payment will be allowed for all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient o If the hospital already submitted a claim to Medicare for payment under Part A, the hospital would be required to cancel its Part A claim prior to submitting a claim for payment of Part B inpatient services o Medicare requires the hospital to submit a Part A claim indicating that the provider is liable Occurrence Span Code “M1” and the inpatient admission Dates of Service o • Timely filing restrictions will apply for Part B inpatient services For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8445.pdf 10 Occurrence Span Code (OSC) 72 • Change Request #8586 • Effective December 1, 2013 Implementation February 25, 2014 • Key Points: The National Uniform Billing Committee (NUBC) redefined OSC 72 to allow hospitals to capture “Contiguous outpatient hospital services that preceded the inpatient admission” o Voluntary code, but use is encouraged o Used to report the number of midnights the beneficiary spent in the hospital from the start of care until formal admission o CMS can track the outpatient time on an automated basis o • For more information: o http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1334OTN.pdf 11 Extension of the Probe and Educate Period • Extend the Inpatient Hospital Prepayment Review “Probe & Educate” review process for an additional 6 months (through September 30, 2014) • Impacts of extension: Medicare Administrative Contractors (MACs) will continue to select claims for review with dates of admission between March 31, 2014 and September 30, 2014 o MACs will continue to review and deny claims found not in compliance with CMS-1599-F (commonly known as the “2-Midnight Rule”) o MACs will continue to hold educational sessions with hospitals as described below in “Selecting Hospitals for Review” through September 30, 2014 o Generally, Recovery Auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014. o 12 Additional Development Requests (ADR) Clarification • Currently there is no systematic way to determine that a claim is for services on the inpatient only list prior to developing for records, therefore you must respond to all development requests o o If it is determined after review that the claim is for a procedures on the inpatient only list it will be deleted from the probe sample, and released to continue processing A replacement claim will then be selected to ensure the correct probe sample size. 13 Inpatient Hospital Reviews Updates • Extension of the Probe and Educate Period through September 30, 2014 • Additional clarification of guidance on the Physician Order and Physician Certification for Hospital Admissions o • Update to the Reviewing Hospital Claims for Patient Status: Admissions Ono or After October 1, 2013 document o • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certificationand-Order-01-30-14.pdf http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/MedicalReview/Downloads/ReviewingHospitalClaims_forAdmission_forPosting_01312014_508Clean.pdf Medicare Learning Network (MLN) Connects National Provider Call o February 27, 2014 Two-Midnight Benchmark- Discussion of the Hospital Inpatient Admission Order and Certification • http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/201402-27-2Midnight.html For additional information: o http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Medical-Review/InpatientHospitalReviews.html 14 Common Working File (CWF) and Fiscal Intermediary Standard System (FISS) Informational Unsolicited Response (IUR) or Denial of Inpatient Services Related to a Hospice Terminal Diagnosis • Change Request # 8273 • Effective: April 1, 2014, Implementation: April 7, 2014 • Key Points: o An inpatient hospital claim will be denied when providers bill with a condition code 07 (Treatment of Non-terminal Condition for Hospice) on an inpatient claim and the principal diagnosis on the inpatient claim is found to match one of the diagnosis codes on the hospice claim • For More Information: o http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8273.pdf 15 Informational Unsolicited Response (IUR) or Reject for Ambulance Skilled Nursing Facility (SNF) to Skilled Nursing Facility Transfer • Change Request #8408 • Effective April 1, 2014, and Implementation on April 7, 2014 • Key Points: • o The Recovery Audit Contractor (RAC) through claim data has identified suppliers that were billing ambulance claims for SNF to SNF transfer separately under Part B resulting in overpayments o The SNF discharging the beneficiary to another SNF is financially responsible for the transportation fees and the ambulance providers should seek payment from the transferring SNF. o Ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services by the supplier. o A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8408.pdf 16 Point of Origin for Admission or Visit Code (Formerly Source of Admission Code) for Inpatient Psychiatric Facilities (IPFs) • Special Edition # 1401 • Key Points: o Inpatient Psychiatric Facilities hospitals are to use the Point of Origin for Admission or Visit Code “D” (formerly the Source of Admission Code) when A patient is discharged from an acute stay in a hospital and transferred to the same hospitals inpatient psychiatric Distinct Part Unit (DPU) • For More Information: o https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1401.pdf 17 Termination of the Common Working File - Delayed • The HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (HETS) will replace Common Working File (CWF) eligibility inquiries o o o Access to Health Insurance Query Access (HIQA) and CWF inquiry menu option 10 will be terminated For more information: MLN Matters Article MM8248 https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8248.pdf o Special Edition Article SE1249 http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1249.pdf 18 Remittance Advice Remark Code(RARC) and Claims Adjustment Reason Code (CARC) and Medicare Remit Easy Print (MREP) and PC Print Update • Change Request # 8561 • Effective : April 1, 2014, Implementation : April 7, 2014 • Key Points: o To update the Claim Adjustment Reason code (CARC) and Remittance Advice (RARC) lists to the most recently published version o Provides instructions to VIP’s and FISS to update Medicare Remit Easy Print (MREP) and PC Print systems • For More Information: o http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8567.pdf 19 Revised CMS 1500 Paper Claim Form: Version 2/12 • OMB approved revised CMS 1500 claim form, version 02/12, OMB control number, 0938-1197 • Changed the form to adequately accommodate and implement ICD-10-CM diagnosis codes • Revisions add the following functionality: o o o • Tentative timeline for implementation (subject to change) o o o • Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes. Expansion of the number of possible diagnosis codes to 12. Qualifiers to identify the ordering, referring and supervising provider roles (on item 17) January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12) January 6- March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05) April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12) For more information: o http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/201306-27Enews.pdf 20 ICD-10 Update 21 ICD-10 Implementation • October 1, 2014 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) • No more delays • ICD-10-CM will be used by all providers in every health care setting • ICD-10-PCS will be used only for hospital claims for inpatient hospital procedures o ICD-10-PCS will not be used on physician claims, even those for inpatient visits 22 ICD-10 Implementation • Single implementation date of October 1, 2014 for all users o Date of service for ambulatory and physician reporting Ambulatory and physician services provided on or after October 1, 2014 will use ICD-10-CM diagnosis codes o Date of discharge for hospital claims for inpatient settings Inpatient discharges occurring on or after October 1, 2014 will use ICD-10-CM and ICD-10-PCS codes 23 Split Claim Billing Claims that Span October 1, 2014 • Outpatient claims - SPLIT claim and Use FROM date • Inpatient claims – Use ONLY THROUGH date/DISCHARGE date – use ICD-10 codes • http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1325.pdf 24 CPT and HCPCS • No impact on Current Procedure Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes • CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients 25 ICD-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination • Change Request # 8109 and # 8197 • Key Points: Medicare contractors and Shared System Maintainers create and update National Coverage Determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes plus all associated coding infrastructure, such as procedure codes, Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, denial messages, frequency edits, Place of Service (POS), Type of Bill (TOB) and provider specialties, etc. o Operational changes that are necessary to implement the conversion of the Medicare system diagnosis codes specific to the Medicare National Coverage Database (NCD) spreadsheets attached to CR8109 and 8197. o • For more information: o o MLN Matters® Number: MM8109 and MM8197 http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/index.html 26 Display of ICD-10 Local Coverage Determinations (LCDs) on the Medicare Coverage Database (MCD) • Change Request # 8348 • Effective: October 2, 2013, Implementation: April 10, 2014 • Key Points: – – All ICD-10 LCDs and associated ICD-10 Articles shall be published on the MCD no later than April 10, 2014 All LCDs and Articles will receive a new LCD/Article ID number • For more information: – http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1293OTN.pdf 27 ICD-10 Resources • ICD-10 o • Provider Resources o • http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html MedScape Modules o • http://cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html CMS Sponsored ICD-10 Teleconferences o • http://cms.gov/Medicare/Coding/ICD10/ProviderResources.html Medicare Fee-For-Service Resources o • http://www.cms.gov/Medicare/Coding/ICD10/index.html http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedscapeModulesAvailableonICD10.pdf Sign up for the Centers for Medicare & Medicaid Services (CMS) ICD-10 Industry Email Updateso http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html • Follow @CMSGov on Twitter • Subscribe to Latest News Page Watch o https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609 28 ICD-10 MLN Resources • MLN Matters Articles: o o o o Special Edition Article SE1239 – Updated ICD-10 Implementation Information Special Edition Article SE1240 – Partial Code Freeze Prior to ICD-10 Implementation Special Edition Article SE1325 – Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date MLN Article MM7492 – Medicare FFS Claims Processing Guidance for Implementing ICD-10 • MLN Products o o o o ICD-10-CM/PCS Myths and Facts ICD-10-CM/PCS The Next Generation of Coding ICD-10-CM Classification Enhancements General Equivalence Mappings Frequently Asked Questions 29 ICD-10 eHealth University Resources • CMS has launched eHealth University, a new go-to resource to help providers understand, implement, and successfully participate in CMS eHealth programs o o o o o o o o o o • Fact Sheet- Introduction to ICD-10 Checklist- Transition Checklist: Large Practices Checklist- Transition Checklist: Small and Medium Practices Fact Sheet- Basics for Small and Rural Practices Guide- Introduction to ICD-10 for Providers Video- Small Practice Guide to a Smooth Transition Video- Roadmap for Small Clinical Practices Webinar- Preparing for October 2014 Compliance Date Guide- ICD-10 Online Guide Checklist- Talking to Your Vendors About ICD-10: Tips for Medical Practices http://www.cms.gov/eHealth/eHealthUniversity.html 30 ICD-10 End-to-End Testing • CMS will offer end-to-end testing to a small sample group of providers who volunteer to participate o • • End-to-end testing includes the submission of test claims to CMS with ICD10 codes and the provider’s receipt of a Remittance Advice (RA) that explains the adjudication of the claims The goal of this testing is to demonstrate that o o o • • Must complete the volunteer testing form by March 24, 2014 Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes) Accurate RAs are produced Week of July 21-25 2014 The volunteer testing form is available in the ICD-10 Implementation o o http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00003602 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8602.pdf 31 Comprehensive Error Rate Testing (CERT) 32 Comprehensive Error Rate Testing (CERT) • What is it? A program developed by Centers for Medicare and Medicaid Services (CMS) to randomly audit claims monthly to determine if they processed correctly • Why does it matter? To protect the Medicare trust fund and determine error rates nationally and regionally • Who is involved? You. A request for medical records from AdvanceMed alerts you that one of your claims has been selected as part of the monthly random sample • How does it work? A letter will be sent to your office requesting the medical documentation. You need to comply in a timely manner with the request • JL o http://www.novitas-solutions.com/webcenter/spaces/CERT_JL 33 Comprehensive Error Rate Testing (CERT) • National Claim Paid Error Rate 6.8 % Inpatient hospitals o 4.8 % Non-inpatient hospital facilities o 9.9 % Physician/Lab /Ambulance o • 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 34 JL Part A Common Errors • Insufficient documentation: o o o o o o • Medical necessity errors: o o • 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 Need for an inpatient stay Related services Other errors: o o o o o Diagnosis Related Group (DRG) Discharge disposition code Resource Utilization Group (RUG) Laboratory services and Debridement code 35 Contractor Initiatives 36 Website Improvements • Based on your feedback we continue to update the Novitas Solutions website to better service your needs and to allow for better navigation • New features are available Website content displayed by contract and line and business o Improved search functionality o Enhanced left-side navigation bar o 37 Novitas Home Page 38 JL Part A Center 39 JL MAC Local Coverage Determinations (LCDs) • • • • • • • • • • • Effective March 27, 2014 Cataract Extraction (including Complex Cataract Surgery) (L34344) Frequency of Dialysis (L34388) Glaucoma Treatment with Aqueous Drainage Device (L34355) Intraoperative Neurophysiological Testing (L27499) Lacrimal Punctum Plugs (L34358) Outpatient Sleep Studies (L27530) Surgery: Blepharoplasty (L34396) Vascular Access for Hemodialysis (L32465) Wireless Capsule Endoscopy (L34342) Wound Care and Cellular and/or Tissue-Based Products for Wounds (CTPs) (L27547) (formerly titled Wound Care and Bioengineered Skin Substitutes) 40 Retired Local Coverage Determinations (LCDs) • Novitas began directing customers to the Medicare Coverage Database (MCD) for retired LCDs and previous versions for currently active LCDs • Medical Policy page has been updated with a link to the MCD o http://www.cms.gov/medicare-coverage-database/ • Active and Draft policies can be found on our website o http://www.novitassolutions.com/webcenter/spaces/MedicalPolicy_JL 41 Enrollment Revalidation MLN Matters® Special Edition Article SE1126: • • • • • All providers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from Medicare. Newly enrolled providers who submitted applications on or after March 25, 2011, will not be affected. Between now and March 2015, Medicare will send notices on a regular basis to begin the revalidation process. The application fee is $542.00 for Calendar Year (CY) 2014. Providers have 60 days to respond to the revalidation letter. www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1126.pdf 42 Jurisdiction L Customer Contact Information • Provider Contact Infomation o o 1-877-235-8073 Hours of Operation, Eastern Time (ET) Monday - Thursday: 8:00 am – 4:00 pm ET Friday: 8:00 am – 2:00 pm ET • Interactive Voice Response (IVR) o Hours of Operation Eligibility and General Information – 24 Hours a day 7 Days a week Full IVR Options – – Mon- Fri 6:00am – 9:00pm ET Saturday 6:00am - 4:00pm ET Step-by-Step Guide http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004403 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004415 43 Stay Up-to-Date • Weekly Podcast o o Weekly podcast of the latest Medicare Updates and other informative topics Subscribe http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag ebyid?contentId=00008119 • Web Updates o Daily E-mail of the latest Medicare Updates http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag ebyid?contentId=00007968 44 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: JL http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid ?contentId=00008204 45 Centers for Medicare & Medicaid Services (CMS) • The CMS website offers valuable resources such as: o o o o CMS Internet Only Manuals (IOMs) Medicare Learning Network (MLN) Matters Articles Open Door Forum MLN Connects http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2013-0627Enews.pdf • For additional resources visit: o http://www.cms.gov/ 46 Thank You! QUESTIONS??? 47