Presented by:
Patti Day, Billing Manager, Mercy Medical Center &
Erica Fletcher, CPAT/CCAT, Medicare Reimbursement
Specialist, Mercy Medical Center
Janet Wells, Medicaid Reimbursement, Mercy Medical
Center
December 9, 2011
DISCLAIMER

 This information shared here today is intended to
help our fellow PFS members. The interpretation is
based on the information gathered from webinars,
handouts, day to day experiences and internet
exploration. The information gathered by Patti Day,
Erica Fletcher & Janet Wells are not necessarily the
thoughts and beliefs of Mercy Medical Center. It is
recommend that each person research the websites to
further interpret the Medicare and Medicaid
reimbursement policies. Solicitation of Erica or Janet
for possible employment is strictly forbidden!
Self-Administered Drug
Billing

 Self-Administered Drug Billing on same claim with
the other services from the date of service.
 Bill Revenue code 637 with HCPCS code A9270 with
modifier GY and place the charges in the non-covered
column.
Self-Administered Drug
Billing

 Advantages
 Not having to pay for two claims to be transmitted
through clearinghouse or electronic claims vendor.
 Self-administered drug charges automatically crossed
over to secondary insurance
 Provides for improved customer service
 Reduces patient complaints
 Reduces special requests to have self-administered
drug charges billed to secondary insurance companies
 Reduces number of EOB’s to store
Billing Pneumonia and Influenza
Vaccine Administration

 Type of bill=121
 From and Thru Dates = date of inpatient discharge
 Condition Code= A6
 Revenue Code= 636 with the appropriate
HCPCS/CPT Code for the Vaccine
 Revenue Code= 771 with the appropriate HCPCS
Code for the Administration
 Use the date of discharge from the inpatient stay for
the line item date of service
Billing Pneumonia and Influenza
Vaccine Administration

 Advantages of billing for Inpatient Pneumonia and
Influenza Vaccine and Administration on a 121 bill
vs. through Roster billing
 Increase productivity-By sending the charges on the
UB, it allows the remit to automatically post in the
mainframe system because the hospital account
number is used.
 Increased accuracy-The EOB will be attached to the
claim in the billing software
Billing Pneumonia and Influenza
Vaccine Administration

 Increased efficiency-It helps to identify cases where
the doctor had ordered the vaccine(s) to be
administered, but the patient refused it, or the
patient was discharged prior to it being
administered.
 Increased accuracy-Many systems charge the drugs
as they are dispensed through automated pharmacy
systems for the patient, and not when the
medication is actually administered.
Billing Pneumonia and Influenza
Vaccine Administration

 Increase accuracy-It adds a double check, because
Medical Records must code one of the 3 special
diagnosis’s that indicate that the pneumonia only, flu
only or both were administered to the patient. When
Roster billing, you don’t use or need the special
diagnosis that indicate that the vaccine was
administered, you only use the admitting diagnosis.
 Having Medical Records code the diagnosis for the
correct administration can identify cases where the
account has been charged, but the vaccine(s) were not
given.
Billing Pneumonia and Influenza
Vaccine Administration

 Assisted with avoiding potential Billing errors that
may not have been identified until a RAC audit, Cert
Audit or ADR request.
 Some providers have found that this identified as
much as 10-25% of the vaccine and administrations
charged to the patients account were not documented
in the medical record. If it’s not documented, it didn’t
happen.
Billing Pneumonia and Influenza
Vaccine Administration

 Providers are receiving denials from Medicare due to patient
exceeding the frequency limits for Flu & Pneumonia
 Flu once per flu season
 Pneumonia one per lifetime
 Can appeal if there is medical justification documented in the
medical record to explain the need for more frequent
vaccinations. Exceeding the frequency limitations should be a
rare thing, not a common practice.
 MLN Product, Quick Reference Information: Medicare
Immunization Billing
 http://www.cms.gov/MLNProducts/downloads/qr_immun_
bill.pdf
Composite Payment Rates

 CMS first introduced Composite Rate Payments in 2008 & CMS has
once again increase the number and types of services that are being
paid under the composite rate method.
 As noted in 42 CFR Parts 410, 411, 416, 419, 489, and 495 [CMS-1525FC Pages 192-193] Some commenters requested that CMS provide
separate APC payment when multiple imaging services are provided
on the same date of service but at different times, because according
to the commenters, services at different times require additional
resources than services performed together. The commenters
indicated that hospitals providing emergent services are more likely
than other hospitals to provide multiple imaging services, some of
which are provided in the same day but at different times.
Commenters requested that hospitals report a modifier or condition
code to report situations in which multiple imaging services are
provided on the same date but at different times, in order to afford
additional payment in those circumstances.
Composite Payment Rates

 CMS’s response “as stated in the CY 2010 and CY 2011 final
rules , we do not agree with the commenters that multiple
imaging procedures of the same modality provided on the
same date of service but at different times should be exempt
from the multiple imaging composite payment methodology.
As we indicated in the CY 2009 through CY 2011 OPPS/ASC
final rules, we believe that composite payment is appropriate
even when procedures are provided on the same date of
service but at different times because hospitals do not expend
the same facility resources each and every time a patient is seen
for a distinct imaging service in a separate imaging session.”
Composite & Packaged
Status Indicators

ADDENDUM D1.—FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2012
Indicator Item/Code/Service OPPS Payment Status
Q1
STVX-Packaged
Codes
Paid under OPPS; Addendum B displays APC assignments when
services are separately payable.
(1) Packaged APC payment if billed on the same date of service as
a HCPCS code assigned status indicator “S,” “T,” “V,” or “X.”
(2) In all other circumstances, payment is made through a separate
APC payment.
18
Composite & Packaged
Status Indicators

Indicator
Q2
Item/Code/Service
OPPS Payment Status
T-Packaged Codes
Paid under OPPS; Addendum B displays APC
assignments when services are separately payable.
(1) Packaged APC payment if billed on the same
date of service as a HCPCS code assigned status
indicator “T.”
(2) In all other circumstances, payment is made
through a separate APC payment.
19
Composite & Packaged
Status Indicators

Indicator
Q3
Item/Code/Service
Codes That May Be Paid
Through a Composite APC
OPPS Payment Status
Paid under OPPS; Addendum B displays APC
assignments when services are separately payable.
Addendum M displays composite APC
assignments when codes are paid through a
composite APC.
(1) Composite APC payment based on OPPS
composite-specific payment criteria. Payment is
packaged into a single payment for specific
combinations of services.
(2) In all other circumstances, payment is made
through a separate APC payment or packaged
into payment for other services.
20
Composite Payment Rates

Review Addendum M for list
of composite services
Packaged Service

 Medicare has encouraged providers to report all
services separately even if the payment for the
service is packaged to allow for more accurate future
payment setting. If there is a HCPCS or CPT Code,
the item should be reported with that code in order
to allow for accurate claims payment rate setting in
the future.
Condition Code G0

 NHIC, Corp., Medicare Administrative Contractor
Jurisdiction 14 A/B MAC (J-14 MAC) has release a
“Reminder on Proper Use of Condition Code G0”
dated July 21, 2011
 http://www.medicarenhic.com/providers/articles/
ReminderonProperUseofCCG0.pdf
 States “by definition, Condition Code 'G0' indicates
that a 'distinct medical visit' has occurred.”
Condition Code G0

 When to use condition code G0 (zero):
 Condition Code 'G0' is reported by Outpatient Prospective
Payment System (OPPS) hospitals when multiple medical visits
occur on the same day (bill type 13X), with the same revenue
center, but only when the visits were not similar and represent
separate trips or appointments.
 For example: Patient was first seen in emergency room in the
morning for chest pains, and returned later on the same day with
a broken arm.
 Multiple medical visits in the same revenue center may be
submitted on two claims as long as one of the claims is submitted
with CC G0. A single claim can be submitted as well as long as
CC G0 is on the claim.
Condition Code G0

When not to use condition code G0 (zero):
Do not use condition code G0 (zero) when the claim
has rejected as a duplicate.
Providers are finding that appending condition code
G0 does the following:
Bypasses National Correct Coding (CCI) edits
Bypasses Medically Unlikely Edits (MUE) edits
Bypasses Duplicate Service Edits
Even if every service on the claim is an exact
match
Condition Code G0

 G0 has a greater potential for fraud, abuse and
misuse than modifier 59.
 Modifier 59 bypasses edits at the line level
 Condition Code G0 bypasses edits on a claim level
 When 2 claims are billed, one without condition code
G0 and one with condition code G0, both claims will
pay, the concern is will that payment be correct and
will it withstand the review of CERT, ADR & RAC.
Condition Code G0

If services are billed on different
claims with condition code G0, the
composite payment rate will not
correctly apply.
Condition Code G0

 Hospitals need to have a clear policy in place that
defines situations where using the G0 condition code
is appropriate.
 Hospitals G0 policy should include specifics of what
defines a separate distinct visit.
 Is it a different location?
 A different time, how will time be determined?
 Does the patient actually need to level the premises and
how will that be determined?
Condition Code G0

 I.e.: is the patient presenting for PAT on the same
day as surgery an appropriate use of condition code
G0
Condition Code G0

 Remember to use measurable items that can be
duplicated in case of an audit.
 Policy should address that if billing 2 separate bills,
only the 2nd E&M should be billed on a separate
claim with the condition code G0, all other services
should be combined to allow for correct processing
of the claim.
 This would allow for CCI edits, MUE edits, Duplicate
edits and packaging rules to correctly be applied to the
claim and avoid the potential for incorrect payments.
Condition Code G0

Claim A
CPT Code
Claim C
$
CPT Code
$
36415
$3.00
36415
$3.00
80048
$10.33
80048
$10.33
84484
$13.85
84484
$13.85
85025
$10.94
85025
$10.94
74176
$405.60
99285
$323.14
99284
$218.99
$766.86
99285
$323.14
TOTAL A
Composite Payment For
70450 & 74176
$431.91
TOTAL C
$1,012.16
Claim B
CPT Code
$
70450
192.10
99284
218.99
TOTAL B
411.09
Claim A
$766.86
Claim B
$411.09
Total A+B
$1,177.95
Over Payment Difference
$165.79
Condition Code G0

 Condition code G0 has the potential to become the
next major watch or audit issue much like one day
stays.
 Hospitals policy should include safe guards and
specify reviews of compliance with the policy that
will be done.
Condition Code G0

 Advantages of sending 1 bill for all services for a single
date of service with modifier 25 on the first E&M and
modifier 25 & 27 on the second and subsequent E&M’s
with condition code G0 instead of sending multiple
claims with modifier 25 on the first E&M and condition
code G0 an modifier 25 & 27 on the E&M on second
claim include:




CCI edits fire
MUE edits fire
Duplicate services edits fire
Situational Packaging Rules Q1, Q2 & Q3 are correctly
applied
Condition Code G0

 Hospitals Policy on the use of Condition code G0 should
 Clearly define when appropriate to use condition code G0
 Clearly define what constitutes a distinct or multiple visits
on the same day
 Clearly define what service will be billed separately and
what services need to be billed all on one claim.
 Address if merely having a different ordering doctor is
enough to meet requirements to bill separately
 Address difference between giving 2 accounts at registration
to ensure sending records only to the ordering doctor vs.
billing the services as 2 separate accounts.
Condition Code G0

 Hospitals need to include safeguards to avoid
potential for inappropriate payments.
 Train staff on appropriate use of condition code G0.
 Monitor compliance to hospital policy for correct
payments.
 Condition code G0 needs to be treated with the same
care, guidance and monitoring that most facilities are
currently using with modifier 59.
Condition Code G0

 The following situation could occur
 Claim is billed twice, 1 pays and 1 denies for
duplicate.
 The denial is received first the other claim is still in
process to pay.
 Biller rebills the claim that denied for duplicate with
condition code G0 and the provider receives a
duplicate payment for the exact same account &
services.
Condition Code G0

 Address issue of Urgent Care & ER on same day, the
E&M’s needs to be billed on to 2 separate claims.
First visit with modifier 25 and 2nd visit with a G0
condition code and modifier 25 & 27 on the E&M.
Inpatient CERT Requests

 The Cert Contractor is now targeting accounts where
the provider’s total charges on the inpatient claim
were less than the Medicare DRG allowed amount.
 Providers may want to review these accounts to
determine if their charges are accurately capturing
the facilities cost to care for these patients.
 Review to verify that all services performed where
correctly charged to the patients account.
RAC Audits

 RAC Audits are being expanded, they will continue
to include post pay reviews, and beginning in 2012,
CMS is expanding RAC reviews in the state of Ohio
to include prepay reviews too.
 They will be focusing on short inpatient stays i.e., 1
and 2 day stays.
ADR

 ADR’s no longer being used to review outpatient
accounts only anymore. Providers are beginning to
see ADR requests on inpatient acute care stays.
 CGS is currently conducting an ADR Prepay probe
on inpatient stays; providers are beginning to
receive requests.
 Disadvantages
Potential Impact on AR Days
Potential Impact on Cash Flow
ADR

 Advantages
 If denied, normal appeal rights will apply
 Potential to rebill as 121 ancillary services bill if denial received
within timely filing limits
 Request limits for




RAC Post Pay- 300 every 45 days
CERT Post Pay- no provider limit, only a random sample limit
ADR Pre Pay- no disclosed limits
RAC Pre Pay- no limit disclosed yet
 It’s hard enough to get the correct payment to begin with; you
need to make sure that you will be able to keep the payments.
Inpatient Readmissions

 According to CMS research, hospitals have made almost no
headway in cutting readmissions in 2009, the most recent data
available, 1 in 6 Medicare patients were readmitted within 30
days for the same condition.
 Hospitals will begin to see payment penalties for high
readmissions rates starting in 2012.
 Medicare is focusing on readmission rates for:





CHF
Pneumonia
Surgery, and surgery complications
Hip fractures
And other Medical conditions
 Surgery patients were the least likely to be readmitted
Observation

 On November 4, 2011, a group of 7 patients in
Connecticut, Massachusetts & Texas filed a lawsuit
challenging a Medicare policy that allows hospitals
to place patients under “observation status” for days
without admitting the patients.
 According to CMS data, hospitals’ use of observation
status has increased from 828,000 claims in 2006 to
more than 1.1 million in 2009.
 CMS data also shows that claims for observation
stays greater than 48 hours has increased by nearly
300% from 2006 to 2009.
Signature requirements for
lab test

Per (42 CFR Part 410, CMS-1436-P pages
38342-38343.) Hospitals may perform lab
tests without a physician signature required
on the “requisition”, but the hospital will be
required to get a copy of the signed “order”
from the physicians chart if the records are
requested for review or an appeal is filed.
Signature requirements for
lab test

 Many providers use the term “order” &
“requisition” interchangeable, however CMS has
two distinct definitions for these terms.
 an ‘‘order’’ is defined in Pub 100–02, Chapter 15,
Section 80.6.1, as a communication from the treating
physician or NPP requesting that a diagnostic test be
performed for a beneficiary.
 (74 FR61930) States that an “order” may be delivered
via any of the following forms of communication:
Signature requirements for
lab test

 A written document signed by the treating physician,
which is hand-delivered, mailed, or faxed to the testing
facility.
 A telephone call by the treating physician or his or her
office to the testing facility.
 An electronic mail, or other electronic means, by the
treating physician or his or her office to the testing facility.
 If the “order” is communicated via telephone, both the
treating physician, or his or her office, and the testing
facility must document the telephone call in their
respective copies of the beneficiary’s medical records.
Signature requirements for
lab test

 (74 FR 33642) defined a ‘‘requisition’’ as the actual
paperwork, such as a form, which is furnished to a
clinical diagnostic laboratory that identifies the test
or tests to be performed for a patient. The
“requisition” may contain patient information,
ordering physician information, referring institution
information, information on where to send reports,
billing information, specimen information, shipping
addresses for specimens or tissue samples, and
checkboxes for test selection.
Signature requirements for
lab test

 CMS stated that they believed that a written “order”,
which may be part of the medical record, and the
“requisition”, were two different documents, although a
“requisition” that is signed may serve as an “order”.
 The rule does not preclude labs from requiring a
physician signature on the requisition as part of their
facilities policies.
 Hospitals should use caution if accepting unsigned
requisitions, if the physician fails to maintain or provide
to the hospital in a timely manner the sign order to send
to Medicare, the lab services will be denied making the
facility responsible.
Drug Screens

 Medicare clarified that G0430 & G0431 are one per
encounter no matter how many drugs are tested for
and no matter the number of tests that are used.
Medicare stated that they will not pay for more than
one just because a provide choose to use individual
tests; rather than one test that can test for multiple
drugs.
Looking for possible lost
revenue

 Review outpatient accounts that have high dollar
amounts being reported under revenue code 250.
You could have services that are separately billable
and payable inappropriately assigned to revenue
code 250, which is packaged, instead of being
captured under revenue code 634, 635, or 636.
 Review high cost pharmacy items to verify that the
correct multiplier or conversion factor is being
reported based on the HCPCS Code description.
Looking for possible lost
revenue

 Do periodic reviews of high cost and separately
billable pharmacy items to assure that the correct
units are being captured on the bill. Remember the
units are determined based on the HCPCS code
description and not based on the way that the
medication is purchased. Ex per bottle, per vial, etc.
 Sort Addendum B to review J-codes that are
separately payable, and make sure that these items
are set up correctly in the charge master.
Looking for possible lost
revenue

 Identify your facilities top services and review and
evaluate the facilities charge amounts for these
services taking into account the allowed amounts for
Fee Schedules that are available for public use
Medicare, Medicaid and Worker’s Compensation.
Review charges to make sure that you are not losing
revenue because your charges are less than the
allowed amounts under these programs.
 Don’t leave revenue on the table due to your charges
being less than the allowed amounts.
GI Services

 GI Services for 2012 were split from 2 APC’s into 3
APC’s which overall resulted in an increase in
payments.
 Review and evaluate GI services to be sure that your
charges are accurately representing the facilities cost
to provide the service.
GI Services

 APC 0141 Level I Upper GI Procedures $591.71
 CPT Codes 43831, 43999, 43204, 43761, 43510, 43235, 43200,
43239, 43202, 43248, 43236, 43247, 43234, 43600, 43243 &
43241
 APC 0419 Level II Upper GI Procedures $886.90
 CPT Codes 91111, 43250, 43201, 43237, 43259, 43251, 43231,
43246, 43458, 49446, 43244, 43255, 49440, 43205, 43249, 43215,
43245, 43217, 43226, 49441, 43220, 44100, 43240, 43238, 43232,
43242 & 43258
 APC 0422 Level III Upper GI Procedures $1,818.96
 CPT Codes 43216, 43257, 43870, 43830, 43228 & C9724
5010

 5010, the new version of the x12 standards for HIPPA
transactions
 All electronic claims transmitted on or after January 1,
2012.
 5010 conversion will affect these transactions
 Sending electronic claims (837I Institutional & 837P
Professional Claims)
 Claim status requests (276) and responses (277)
 Payments (EFT) & remittance advices (835)
 Eligibility Inquiries (270) & responses (271)
5010

 5010 increases the number of diagnosis’s allowed on a claim.
 5010 distinguishes between principal diagnosis, admitting diagnosis,
external cause of injury and patient reason for visit codes.
 5010 will increase name fields for providers, patients, & subscribers
from 35 characters to 60 characters, this will allow for more accurate
reporting of full names.
 5010 will increase the length of the taxonomy codes field from 30
characters to 50 characters.
 5010 will increase the number of reportable insurance or payers from
3 to 12.
 BWC has stated a tentative readiness date of February 2012 for 5010
transactions.
ICD-10

 Required on all claims with dates of service on or after October
1, 2013. For claims with dates of service prior to October 1,
2013, ICD-9 coding is to be used.
 On inpatient claims, the date of discharge will determine the
correct version of ICD to use.
 Example patient admitted September 30, 2013 and discharge
October 1, 2013, would be coded using ICD-10.
 For both all outpatient claims that span from September 30,
2013 to October 1, 2013, the claims would need to be split
billed. This would include ER and observation patients.
 1 claim for services thru September 30, 2013 coded using ICD-9
 And a 2nd claim for services beginning October 1, 2013 coded
using ICD-10.
60
ICD-10

 The first 3-6 months after transition will require a learning
curve for
 Providers to learn & code correctly
 Health plans to interpret the codes & process them correctly
for payment.
 There is a great volume of unpredictability in revenue
flow as the new codes are being used to make payment
decisions that providers needs to be aware of and
prepared for.
 Have extra cash on hand.
 Reduce billing and coding back logs and try to have all
coding, billing and follow-up current.
ICD-10

 Scared of ICD-10? ICD-11 is in the wings, ICD-10 is coming
in 2013 and ICD-11 is likely coming in 2015, they are
already in the process of revising and modifying ICD-10,
and the United States hasn’t even begun to use it yet!
 It has taken the U.S. healthcare industry 23 years to
implement ICD-10, since it was first released and ready for
use.
 ICD-9 was originally released in 1977.
 ICD-10 is currently being used in 117 of 193 countries.
 ICD-11 better referred to as ICD-2015 will be built on an
internet platform to allow for easier updates and conversions.
ICD-10

 If providers fail to be prepared and convert to ICD-10, they will no
longer be paid for their services.
 ICD-10 will force clinicians to become more detailed with
documentation and will force hospitals to more closely monitor that
the medical record is being completely and accurately documented.
 ICD-10 is just one of the many issues that are currently straining
providers resources, others include
 Meeting meaningful use
 Building accountable care organizations
 Reviewing the potential impact that Value based purchasing could have
on the organizations
 Myriad of reporting requirements
 Trying to achieve reductions in readmissions
ICD-10

 CMS says Implementing ICD-10 will allow for
Accurate anatomical descriptions
Differentiation of risk & severity
Key parameters to differentiate disease manifestations
Optimal claim reimbursement
Value-based purchasing methodologies
For analyzing of healthcare utilization
Costs & outcomes
Resource use & allocation
Performance measurement
Further streamline automated claim processing
Reduction in claims-payment delays or denials
Provides opportunities to develop & implement new pricing & reimbursement
structures including fee schedules & hospital & ancillary pricing scenarios.
 Allow for more effective detection & investigation of potential fraud or abuse
 Expand available code from 13,000 to 68,000 potential codes












ICD-10

 ICD-10 will affect not only almost every department
within a hospital with few exceptions like
Housekeeping, Maintenance and Cafeteria.
 BWC has stated that they will accept ICD-10 codes
by the October 1, 2013 implementation date.
Medicare Credit Balances

 Providers must report all credit balance that result in a
change in payment, if the credit balance existed and was
not resolved by the last day of the reporting quarter.
 Providers need to maintain supporting documentation
that all the Medicare accounts that had credit balances on
there were reviewed, recommend notating the report with
who the refund is needed to or that it was due to a
posting, or contractual issue. Just keeping the attestation
sheet is not sufficient and would not provide adequate
supporting documentation in case of an audit.
Medicare Credit Balances

 Accounts where the credit balance is due to a change in
contractual only do not need to be report on the CMS 838 credit
balance report, but should be resolved by the end of the
reporting period.
 All supporting documentation including copies or originals of
the attestation sheets should be maintained in one location,
sorted by quarter, even if multiple staff members are
responsible for working/resolving the credit balances, such as
with an alpha split, in case of an audit.
 CGS Medicare is not currently able to accept the 838 Medicare
credit balance report electronically through the DDE, it must be
manually logged and faxed or mailed to them with a signed
attestation sheets.
Accountable Care
Organizations

 Accountable Care Organizations will require the
following
 Network development and management
 Care coordination on all levels, between






Hospitals
Doctors
Health plans
Pharmacies
Patients
Patients Family
Accountable Care
Organizations

 A Providers care for patients will no longer begin when the
patient presents to the providers facility and end when the
patient leaves the facility.
 Under Medicare’s vision for ACO’s, the provider will be
responsible for the health, welfare and care of the patient 24
hours a day 7 days a week.
 Providers will be expected to initiate a tremendous volume of
the contact with the patient, providers will no longer be able to
wait for the patient to contact your organization for
appointments and testing, providers will have to contact the
patient to coordinate and schedule necessary screening exams
and follow-up care, as well as making “well check” phone calls
to see how the patient is doing.
Miscellaneous Tidbits

 For HCPCS Codes that end with a T, if there is no LCD for
these codes, the code is considered experimental or
investigational and is only payable in some areas, not
nationally covered by Medicare.
 CGS has stated that for Pharmacy Waste, that modifier JW is
required on the claim on a separate line with the corresponding
HCPCS Code and date of service if providers wish to request
payment for the waste, in addition to documenting the waste in
the Medical Record. This is a change from NGS, which had
allowed providers to bill for the total amount given plus the
waste all on 1 line and just document the wasted units in the
Medical Record.
Miscellaneous Tidbits

 If Physician Supervision requirements are not meet,
based on CPT Code description, every service that
was provided for that date of service can be denied.
 If audited, what documentation will you be able to
produce to ensure the auditors that physician
supervision was in place and maintained?
 Hospitals that fail to meet quality reporting program
requirements will face a 2% reduction in
reimbursement in 2012.
 This will also reduce beneficiary liability to the
hospital.
Miscellaneous Tidbits

 CGS Medicare is no longer supplying providers with the
contact information of the overlapping facilities, like NGS
used to. CGS is only providing the Medicare Provider
numbers of the overlapping facilities.
 There is a listing of providers by provider numbers
available at http://www.cms.gov/costreports/
 The website includes the contact information for
hospitals, skilled nursing facilities, renal facilities, hospice
providers and home health agencies.
 Sort the files by state, county and city to make the files
more usable to match your service area.
MITS

 Use the cancel button if you make a mistake while working on a claim in
the system. You can reload the original claim you were correcting.
 Once you have a processed claim and you have an ICN# the option for
RESUBMIT – CANCEL – VOID OR CANCEL ALL APPEARS.
 Once you have voided a claim you have the option to copy a claim. You
can make your corrections and when you submit it you will know at that
moment if the claim will pay or not.
 If you have a paid claim and want the payment taken back or a zero pay
you use the VOID button.
 Make sure you LOG your issues with ODJFS. Request a ticket number.
According to customer service you can expect a call back in 2-3 MONTHS.
 If you have the error code 7400 and are unable to get these claims to go
through RECHECK the payer portion. This amount is filled in by MITS
and we found to be incorrect.
MITS CONTINUED

 Claim form 6653 – Is a Claim Review Request form.
It is uploaded as an attachment.
 We have been told by ODJFS Customer Service to fill
out this form with every attachment you upload or
send.
MITS CONTINUED

 For the attachments, go to the section marked attachments
hit the add button to add an attachment. It will then bring
up a box for mailing or upload. To upload hit the upload
button it will bring up a drop down box with the
description pick the one that best describes the upload.
There is also a description box to add a note of your own
which is optional. Submit the claim it will then give you
the option to hit the upload again. When you press that
button you get a second page. Click on the attachment on
the top line it will give you the option to browse for your
attachment. Once you have found your desired
attachment hit the submit button it will give you a
tracking number for your attachment.
After you click the add button in the attachment
section, you will see the above screen. Follow the on
screen instructions and click submit once completed.
MITS CONTINUED

 Claim form 6614- The Health Insurance Fact Request
is the only way to get the MITS system corrected for
the TPL (Third Party Liability) coverage. Fax this
form to (614) 728-0757. Check eligibility screen in
two weeks if the TPL is not corrected refax form.
MITS CONTINUED

 PARAGRAPH K- This option may soon go away, but
in the meantime if you have a high dollar supply OR
lab you may chose to bill the one charge only for
higher reimbursement. You need to follow the rules
in the hospital handbook in paragraphs J and K.
Some pregnancy services may also reimburse more if
billed without the other charges.
THANK YOU
Happy Holidays
From Your Friends at Mercy
Medical Center