BILLING COMPLIANCE
COMMITTEE MEETING
September 15, 2011
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MEETING AGENDA
1. Introductions of New Compliance Staff
2. Active Medicare Local Coverage
Determinations (“LCD”)
3. Upcoming Medicare Training and
Education Sessions
4. Medicare Advanced Beneficiary Notice
(“ABN”) Form Change
5. Provider Enrollment Revalidation
Requirements for Providers Participating
in Medicare, Medicaid and the Children’s
Health Insurance Program (“CHIP”)
April 8, 2015
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AGENDA MEETING
(cont’d)
6. Medicare and Medicaid Audit Updates
7. FY 2012 Compliance Audit Work Plan
8. Discussion of Each Clinics’
Responsibility to Maintain Internal Billing
Guidelines and Conduct Self Audits
9. Compliance News and Updates
April 8, 2015
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Medicare Active LCDs
• Source:
https://www.highmarkmedicareservices.com/policy/
Active LCDS
• Acute Care: Inpatient, Observation and Treatment Room
Services
• B-Type Natriuretic Peptide (BNP) Assays
• Blepharoplasty/Blepharoptosis
• Blood Glucose Monitoring in a Skilled Nursing Facility
• C-Reactive Protein Testing
• Cardiac Rehabilitation Program Services
• Erythropoiesis Stimulating Agents (ESAs)
April 8, 2015
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Medicare Active LCDs Cont’d
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Cardiac Rhythm Device Evaluation
Cardiovascular Nuclear Medicine
Cardiovascular Stress Testing
Cataract Surgery
Complex Cataract Extraction
Chiropractic Services
Co-Management of Surgical Procedures
Computed Tomographic Angiography of the Chest
Continuous Glucose Monitoring
Coverage of services and Procedures in Nursing Facilities
End-Diastolic Pneumatic Compression Therapy
Evaluation and management Services Provided in a Nursing
Facility
April 8, 2015
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Medicare Active LCDs Cont’d
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Cytogenetic Analysis
Debridement of Mycotic Nails
Diagnostic Laryngoscopy
Dynamic Electrocardiography
Electrocardiography
Electromyography (EMG) and Nerve Conduction Studies
Extended Ophthalmoscopy
Fluorescein and Indocyanine Green Angiiography
Fundus Photography
Human Skin Equivalents
Hyperbaric Oxygen Therapy
Infrared Photocoagulation (IRC) of Hemorrhoids
Intraoperative Neurophysiological Testing
April 8, 2015
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Medicare Active LCDs Cont’d
• Injectable Collagenase Clostridium Histolyticum for Dupuytren’s
Contracture
• Isolated Ultrafiltration for Managemnet of Fluid Overload in
Cardiac Disease
• Loss of heterozygosity Based Topographic Genotyping with
PathFinder TG
• Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
• Magnetic Pelvic Floor Stimulation (MPFS)
• Magnetic Resonance Angiography (MRA)
• Magnetic Resonance Imaging (MRI) of the Breast
• Moh’s Micrographic Surgery
• Monitored Anesthesia Care
• Non Covered Services
April 8, 2015
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Medicare Active LCDs Cont’d
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Non-Invasive Cerebrovascular Arterial Studies
Non-Invasive Peripheral Venous Syudies
Non-Vascular Extremity Ultrasound
Ophthalmic A and B Scans
Ophthalmic Biometry for Intraocular Lens (IOL) Power
Calculation
OVA – 1 Assay
Paraathormone (Parathyroid Hormone)
Physical Medicine & Rehabilitation Services; PT, OT
Proton Beam Therapy
Psychiatric Therapeutic Procedures
Pulmonary Rehabilitation Services Program
Wound Care
April 8, 2015
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Medicare Active LCDs Cont’d
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Qualitative Drug Testing
Radiation Therapy Services
Radiofrequency Treatment for Urinary Incontinence
Radiologic Examination of the Chest
RAST Type Tests
Real-Time Outpatient Cardiac Telemetry
Removal of Benign or Premalignant Skin Lesions
Removal of Impacted Cerumen
Routine Foot Care
Scanning Computerized Ophthalmic Imaging
Visual Fields
Vitamin B12 Assays
Vitamin D Assay Testing
April 8, 2015
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Medicare Active LCDs Cont’d
• Serotypes A and B Botulinum
• Sleep Disorders Testing
• Speech Language Pathology (SLP) Services;Communication
Disorders
• SLP Services: Dysphagia;Includes VitalStim Therapy
• Stereotactic Body RadiationTherapy (SBRT)
• Surgical Treatment of Nails
• Thermotherapies (MISTS) for Benign Prostatic Hyperplasia
• Transesophageal Echocardiography (TEE)
• Transforaminal Epidural, Paravertebral Facet and Sacroiliac
Joint Injections
• Treatment of Varicose Veins of the Lower Extremeties
• Trigger Point Injections
April 8, 2015
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Upcoming Medicare Education and
Training Sessions
• Observation Services
Workshop
• Rehabilitation Billing
• Blood Glucose
• SNF Rehabilitation
Resource Utilization
Group (RUGs)
• Hyperbaric Oxygen
• Billing Laboratory and
Radiology Services
• Inpatient Versus
Observation for Acute
Care Facilities
• Chemotherapy ,
Injection and Infusion
Services
• Sleep Studies
• Wound Care
• Modifiers for Part A
providers
Medicare Advanced Beneficiary
Notice (“ABN”) Form Change
• Revised ABN form CMS R-131 has a mandatory use
date of 11/1/2011. We must get rid of all old versions
of the ABN and discontinue using them.
• All required sections of the ABN must be completed
for the form to be valid. (Medicare Claims Processing
Manual, Chapter 30, section 50.6.3)
• The ABN must list the specific items or services
believed to be non-covered.
• The estimated cost provided on the ABN must be
within $100 or 25 percent of the actual costs.
April 8, 2015
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Required Medicare and Medicaid
Provider Enrollment Revalidation
• On 8/10/11 CMS published a MLN
Matters article SE1126 to inform
providers of new enrollment revalidation
and screening processes.
• Rules apply to any provider who
enrolled in Medicare, Medicaid, and the
Children’s Health Insurance Program
(“CHIP”) on or before 3/25/11.
April 8, 2015
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Required Medicare and Medicaid
Provider Enrollment Revalidation
• CMS will issue letters between now and
March 2013 to all providers that need to
revalidate enrollment.
• Do not revalidate until requested by CMS
• Assistance in completing the application
process is available. Please contact
Stephanie Mackowiak at (410)955-8577
• No Medicare or Medicaid enrollment or
revalidation forms should be submitted
without review by Compliance!!
April 8, 2015
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Medicare Recovery Audit
Contractor (“RAC”) Updates
**Approved for Maryland**
RAC Medical Necessity Reviews
1. Cardiac Catherization for Ischemic Heart Disease
2. Chest Pain
3. Syncope
4. Transient Ischemia
5. Vertigo and Other Labyrinth Disorders
6. Chronic Obstructive Pulmonary Disease
April 8, 2015
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Medicaid RACs
• Currently on hold until States can better
operationalize. No firm date to start in sight. Will look
for overpayments and underpayments and
supplement the work of current Medicaid audit
programs (e.g., MICs, MCFCU, etc.)
• Recommend close tracking of cases so no
duplication occurs. Medicaid does not have the ability
to track like Medicare.
• Insights from Maryland’s (DHMH) Office of the
Inspector General
April 8, 2015
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FY 2012 Compliance Audit
Work Plan
• Health System Wide Compliance
Initiatives
- Practitioner Licensure and Credentialing
Verifications
- Education Initiatives to include:
1.Observation Services
2. Medicare One-Day Stays
3. ED Visit Documentation and Billing Rules
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
JHBMC Scheduled Audits
1.Pulmonary Rehabilitation Services
2.Community Psychiatry IOP Program
3.Cardiology Diuresis Clinic
4.PET Scan Services
5.Wound Care
6.ATS Program
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
JHH Scheduled Audits
1.Interventional Radiology Services
2.Wilmer Eye Low Vision Clinic
3.Outpatient Psychiatric Services
4.Weinberg Outpatient Pharmacy
5.Infusion Services
6.Radiation Oncology
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
HCGH Scheduled Audits
1.Blood Transfusion Services
2.ED Visit Level Billing
3.Pain Management Services
4.Medical Nutrition Services
5.Wound Care Services
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
Suburban Hospital Scheduled Audits
1.Cardiac Rehabilitation Follow Up
2.Ultrasound Services
3.Partial Hospitalization Services
4.Ambulatory Surgery Center
5.Eye Surgeries
6.Outpatient Breast Reconstruction
Surgeries
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
Sibley Scheduled Audits
1.Outpatient Infusion Services
2.Inpatient Rehabilitation Services and 3
Day SNF Qualifying Stay
3.ED Visit Billing
April 8, 2015
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FY12 Compliance Audit Work Plan
JHHCG Scheduled Audits
1.Home Health Face to Face Encounter
Requirement
2.Medicaid Home Health Agency Claims
Review to Include Adult and Pediatric
Lines of Business
3.DME & IV Credit Balance Review
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
JHHCG Scheduled Audits
4. Review of Compliance with DMEPOS
Supplier Standard #28
5. Pharmaquip Compliance with Medicare
Coverage Requirements for CPAP
Devices
April 8, 2015
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FY12 Compliance Audit Work Plan
Cont’d
Other JHHS Scheduled Audits
1.Potomac Home Health Agency
2.Cardiovascular Specialists of Central
Maryland (via the CPA)
3.HCGH OB/GYN Associates Series
April 8, 2015
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Discussion of Internal Billing Guidelines and
Self Audit Processes
• Each department should have a policy
or procedure that describes how you
document and bill services
• Self Audits should be performed
monthly to insure billing policies and
procedures are being followed.(JHHS
Finance Policy Fin 125)
April 8, 2015
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Compliance News & Updates
• Medicare Focused Review activities
• New OIG reviews show OIG targeting multiple
risk areas at the same time inclusive of a
review of internal controls and compliance
program effectiveness review (See OIG report
number A-01-10-00527, Fletcher Allen Health
Care)
• Updates on Medicare Appeals and ALJ
Hearings
April 8, 2015
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What’s on the Horizon…
• New ICD 9 CM procedure codes go into effect
October 1, 2011. The CMS website link is :
https://ww.cms.gov/ICD9ProviderDiagnosticCodes/04-addendum.asp
• Clarifications to Condition code 44 policy issued
9/2/11 and effective 10/1/11. (See Medicare
Transmittal 2296 and Medicare Claims Processing
Manual, Chapter 1, section 50.3.1 and 50.3.2
April 8, 2015
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QUESTIONS??
**The BCC presentation and all
handouts are available on the
Compliance Website:
www.insidehopkinsmedicine.org/JHHSCompliance
THANKS FOR YOUR PARTICIPATION!
April 8, 2015
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