Woodland Hills AAPCMedicare Seminar

Presented by

Kathy A. MontoyaSenior Provider Relations Representative

Palmetto GBA

The information provided in this presentation was current as of May 1, 2013. Any changes or new information super ceding the information in this

presentation will be provided in articles and publications dated after May1, 2013 posted at

www.palmettogba.com/J1B.

Objectives To enhance the knowledge base of

Medicare coverage and billing guidelines To decrease the National Paid Claims

Error Rate To protect the Medicare Trust Fund To ensure the delivery of quality care to

our Medicare beneficiaries

AgendaUpdates/Reminders

JE bidFee Schedule changesTherapy ServicesOrdering/Referring

AgendaDocumentation

Principles of documentationCommon ErrorsAmendments

A/B MAC Jurisdiction EMay 2013

Jurisdiction E Awarded Announced September 20, 2012

Noridian Administrative Services (NAS)

Jurisdiction ENoridian launched JE website April 16,

2013https://www.noridianmedicare.com/

je/Outlines implementation timelinePresents calendar of transition eventsStates physical presence in California

https://www.noridianmedicare.com/je/

Implementation DatesNoridian will be the MAC for

Jurisdiction E:Part A – August 26, 2013Part B –September 16, 2013

May 2013 10

Communication Resources Website/Listserv:

www.noridianmedicare.com/JE

Contact provider organizations/associations

Meet and Greet meetings with providers

Mailings to providers

Web based provider workshops/ACTs

11May 2013

Listserv2

For providers not registered with J1 prior to March 1, 2013Go to:

https://www.noridianmedicare.com and select “E-mail Newsletter Sign Up” at the bottom of the left hand navigation menu.

Instructions listed in Listserv article on JE website

May 2013 12

Key Website ItemsContact Information

phone numbers and mailing addresses

implementation questionsCurrent news and relevant changesIVRSchedule of Events

13May 2013

Key Website ItemsCutover datesPayment cyclesFAQsEDI - focus on vendors and direct

submittersProvider Portal

14May 2013

Contact Information Single Toll-free number after JE

ImplementationProvider Contact Center (PCC)Electronic Data Interchange

Support Services (EDISS) Telephone ReopeningsProvider Enrollment User Security

May 2013 15

Contact Information Questions regarding implementation

Email to JEQuestions@noridian.com or

Call Implementation Hotline at 1-800-361-8289

Hot Line available 8:00 am to 5:00 pm (PT), Monday-Friday

May 2013 16

WelcomeNoridian is proud to be your Medicare

Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1. They look forward to working with you in the near future to serve your Medicare needs.

New Costs

2013 Part B Deductible and Coinsurance Rates

Deductible-$147.00

Coinsurance 20% of eligible charges

2013 Part A Deductibleand Co-Pays

$1,184 deductible 1st 60 days of hospitalization

$296 co-pay Days 61-90

$592 co-pay Days 91 – 150 Lifetime Reserve

$148 co-pay SNF days 21 - 100

2013 Part B Premiums Income Parameters for Part B Premiums

Premium/Mthly Individual IncomeCombined Income (Married)

$104.90 < $85,000 < $170,000

$146.90 $85,000.01 to $107,000 $170,000.01 to $214,000

$209.80 $107,000.01 to $160,000 $214,000.01 to $320,000

$272.70 $160,000.01 to $214,000 $320,000.01 to $428,000

$335.70 $214,000.01 > $428,000.01 >

2013 Part A PremiumFewer than 30 quarters

$441.00 per month30 to 39 Quarters

$243.00 per month

Updates

Payment ReductionApril 1, 2013

The Budget Control Act of 2011Requires Federal spending

reductions, sequestrationThe American Taxpayer Relief Act of

2012 postponed sequestration for two monthsPresident Obama issued a

sequestration order on March 1, 2013

Payment ReductionApril 1, 2013

Medicare FFS claimsPart B - dates-of-service ≥ April 1,

2013Part A - dates-of-discharge ≥ April

1, 2013Two percent reduction

CR7825

Transitional CareManagement Services (TMC)

New codes 99495 and 99496Established patientModerate to high complexity

medical decision making

Transitional CareManagement Services (TMC)

Transition period from an inpatient setting (IP, LTC, SNF, rehab) to the patient’s community setting

TMC begins on date of discharge + 29 days

One face-to-face visit combined with non FTF services provided by physician or clinical staff

Transitional CareManagement Services (TMC)

Medical decision making/date of the first face-to-face visit are used to select the code99495 TMC service

Communication with patient/caregiver within 2 business days

Moderate complexity Face to face within 14 calendar days of

discharge

Transitional CareManagement Services (TMC)

99496 TMC serviceCommunication with patient/caregiver

within 2 business daysHigh complexityFace to face with 7 calendar days of

discharge

Transitional CareManagement Service (TMC)

Date of Service = 30th dayPlace of Service = POS for face to

face visitWhat if patient dies during the 30 day

periodBill E/M code only

PsychiatryInitial Psychiatric Evaluation

90801 and 90802 were deletedDistinction made between service

by MD and one by non physician

Psychiatry – New Codes90782 = Initial evaluation with

physician services 90791 = Initial evaluation done by a

non physician90785 = New add on code for

interactive complexity

Multiple Procedure Payment Reduction (MPPRs)

CR7848Effective January 1, 2013Reduction to Technical Component

(TC)Diagnostic CardiovascularOphthalmology procedures

Multiple Procedure Payment Reduction

Multiple services to same patient, same date

Affected codes http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

Remittance AdviceAdjustment Reason Code 59

Multiple Procedure Payment Reduction

Cardiovascular ServicesSame physician, or multiple

physicians in same groupFull TC payment with highest valueSubsequent TC paid at 75%

Multiple Procedure Payment Reduction

Ophthalmology servicesSame physician, or multiple

physicians in same groupFull TC payment with highest valueSubsequent TC paid at 80%

MPPRs Cardiovascular Payment Reduction Example

Sample Cardiovascular Payment Reduction

Code 78452

Code 93306

Total Currant

Total 2013 Payment

Payment Calculation

PC $77.00 $65.00 $142.00 $142.00 No reduction

TC $427.00 $148.00 $575.00 $538.00 $427 + (.75 x $148)

Global $504.00 $213.00 $717.00 $680.00 $142 + $427 + (.75 x $148)

MPPRs Ophthalmology Payment Reduction Example

Sample Ophthalmology Payment Reduction

Code 92235

Code 92250

Total Currant

Total 2013 Payment

Payment Calculation

PC $46.00 $23.00 $69.00 $69.00 No reduction

TC $92.00 $53.00 $145.00 $134.40 $92 + (.80 x $53)

Global $138.00 $76.00 $214.00 $203.40 $69 + $92 + (.80 x $53)

CR7260Health Insurance Claim Number

(HICN) and Name MismatchEffective October 1, 2012Claims will reject MA 130 and MA61Take information exactly as shown on

Medicare card

MEDICARE HEALTH INSURANCE

SOCIAL SECURITY ACT

NAME OF BENEFICIARY

JOHN D. DOE

MEDICARE CLAIM NUMBER SEX

123-45-6789A MALE

IS ENTITLED TO EFFECTIVE DATE

HOSPITAL INSURANCE (PART A) 1/1/98MEDICAL INSURANCE (PART B)

SIGN HERE John D. Doe

Therapy Services

Multiple Procedure Payment Reduction

(MPPR) for Selected Therapy Services

CR 8206Effective April 1, 2013MPPR increased to 50% from 20%

for all settingsApplies to the practice expenseApplies to HCPCS codes on the

“always therapy” list

2013 Financial Limitation for Outpatient Therapy Services

Effective January 1, 2013 2013 Therapy Cap amounts:

$1,900 for OT$1,900 combined PT and SLP

2013 Financial Limitation for Outpatient Therapy Services

Section 603 of American Taxpayer Relief Act of 2012

Outpatient Therapy claims capExtended through DOS December

31, 2013$3,700 for PT and SLP $3,700 for OT

Manual Review of claims > $3,700

Changes for Therapy Services in 2013

Reporting requirementsUse Functional status codesUse Functional Limitation modifiersEvery 10 treatments or 30 calendar

days, whichever is earlier

Functional Reporting G-Codes

G Codes Functional Limitation

G8978, G8979, G8980 Mobility: Walking & Moving Around

G8981, G8982, G8983 Changing & Maintaining Body Position

G8984, G8985, G8986 Carrying, Moving & Handling Objects

G8987, G8988, G8989 Self Care

G8990, G8991, G8992 Other PT/OT Primary Functional Limitation

G8993, G8994, G8995 Other PT/OT Subsequent Functional Limitation

G8996, G8997, G8998 Swallowing

Functional Reporting G-Codes

G Codes Functional Limitation

G8999, G9157, G9158 Motor Speech

G9159, G9160, G9161 Spoken Language Comprehension

G9162, G9163, G9164 Spoken Language Expression

G9165, G9166, G9167 Attention

G9168, G9169, G9170 Memory

G9171, G9172, G9173 Voice

G9174, G9175, G9176 Other SLP Functional Limitation

Functional Status CodesThree codes

Current status Goal status Discharge status

Severity Complexity ModifiersModifier Impairment Limitation Restriction

CH 0 % impaired, limited or restricted

CI At least 1% but less than 20% impaired, limited or restricted

CJ At least 20% but less than 40% impaired, limited or restricted

CK At least 40% but less than 60% impaired, limited or restricted

CL At least 60% but less than 80% impaired, limited or restricted

CM At least 80% but less than 100% impaired, limited or restricted

CN 100% impaired, limited or restricted

Functional ReportingUse of G codes and modifiers is

requiredAt the onset of therapy episode of

careAt least once every 10 treatment

days

Functional ReportingSame date of service that an

evaluation/re-evaluation procedureAt the time of discharge from

therapy episode of careOn the same date of service the

reporting of a functional limitation is ended

Claim ReportingOnset of therapy and each reporting

periodReport two G codes with modifiers

Current status, goal status

DischargeReport two G codes with modifiers

Current status, discharge status

Manual Medical Review CMS Update March 21, 2013Recovery Auditors (RA) to conduct

MMR at $3,700 thresholds (PT and SLP, OT)Prepayment Review Demo –

CaliforniaPos-tpayment Review – Nevada,

Hawaii

Manual Medical Review

Reference

http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html

Manual Medical ReviewPrepayment Review

CaliforniaPalmetto GBA to send a Additional

Documentation Request (ADR) to provider Request documentation be sent to the RA

The Recovery Auditor will conduct prepayment review

Within 10 business days of receiving documentation Will notify Palmetto of payment decision

Manual Medical ReviewPostpayment Review

Hawaii and NevadaPalmetto GBA to send a Additional

Documentation Request to the provider Request documents be sent to the RA

The Recovery Audition will conduct a post payment review

Will notify Palmetto GBA of the payment decision

Ordered and Referred Services

Reminders and Updates

Phase 1Ordering/Referring Rejects

Affordable Care Act §6405 Required Ordering/Referring providers to be

enrolled in Medicare Name and NPI needed on claim

Phase 1 Began October 5, 2009 Incorrect, Missing information – rejected

claim Informational messaging on Remittance

Advices

New EditPhase 2

Planned Effective/Implementation May 1, 2013 - Delayed

Claims will be denied when Ordering/Referring provider needed

Provider not enrolled in MedicareNo NPI on claimWrong specialty for service/supply

Denied as Non-covered

Denial Reason CodesN264 = Missing/incomplete/invalid

ordering provider nameN265 = Missing/incomplete/invalid

ordering provider primary identifier

New EditResources

SE1305CRs 6421, 6417, 6696, 6856Ensure your in PECOS

Look up your NPIhttp://www.cms.gov/Medicare/

Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

Order or ReferralMust Include

Specific services requestedCPT/HCPCS code Indicate preventive or diagnostic Use appropriate gender specific

codes if applicable

Order or ReferralMust Include

Applicable ICD-9-CM codeScreening versus diagnostic codesSign or symptoms Patient diagnosisUse appropriate gender specific

codes if applicable

Order or ReferralMust Include

Ordering/Referring Provider’s Name and NPI number

Ordering/Referring Provider’s signature if necessary

Plan of Care if applicable

Reporting Ordering/Referring Information

Don’t use nicknamesDon’t enter credentials (Dr.)First name first, Second name second

John SmithUse individual not group information

ResourcesFact Sheet

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

NPI registryhttps://www.nppes.cms.hhs.gov/

NPPES/Welcome.do

ResourcesEnrollment

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

DocumentationImportant for BillingImportant for Audits

Basic Coverage Rule

Social Security Act in Section 1862 (A) 1No payment for expenses not

reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

855 I, Section 15, Bullet 4Abide by Medicare laws, regulations

and program instructionsProvider must know

Claim payment based upon ClaimUnderlying transactionSupplier’s compliance with conditions of

participation

Medicare AuditsThey happenBe prepared

Create thorough documentationRead request carefullyUse Medicare Self Help toolsLearn from mistakes

Medicare AuditsMedical Review of Palmetto GBAComprehensive Error Rate Testing

(CERT) programRecovery Audit Contractors (RACs)Zone Program Integrity Contractors

(ZPICs)

AuditsPre-payment or post payment Documentation

Follow industry, specialty, CMS and Palmetto GBA guidelines

Additional DocumentationRequest (ADR)

Outlines requested informationIndicates date of service(s)Outlines timeline for return of

documentsProvides return address

Use Medicare Self HelpTools And Articles

www.PalmettoGBA.com/J1BCERT sectionArticles sectionADR Checklists

Learn From MistakesReview results

Medical review auditsCERT and RAC auditsOffice of Inspector General (OIG)

Code of Federal Regulations42 CFR 424.5 (a) (6)

Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

Medical RecordDocumentation

Thorough proper documentationVerifies service/level providedKey to audit successEnsures payment for services

renderedProtects patients and provider

Documentation ShouldPaint a Picture

CHOOSE A NORMAN CHOOSE A NORMAN ROCKWELL OR ANDREW ROCKWELL OR ANDREW WYETH PAINTINGWYETH PAINTING

NOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE

Medical RecordDocumentation

Evaluate, plan and monitorCommunication, coordination and

continuityClaims payment and reviewUtilization and quality evaluationsResearch and education

Principles of DocumentationComplete and legible

Transcribe if necessaryReason for encounterRelevant historyPhysical examination

Principles of DocumentationDiagnostic test

Rationale for orderingResults

Assessment, clinical impression or diagnosis

Plan for careDate and legible signature

Principles of DocumentationPast and present diagnosesIdentify health risk factors Patient's progressResponse to and changes in treatmentRevision of diagnosis Support CPT and ICD-9-CM code

selection

General Documentation Tips

Patient name on each page and date of service

Templates/forms OK, but must be individualized

Computerized notes OK, but must be individualized

General Documentation Tips

Document time when coding is based on time (face to face)

Must be legible, when in doubt transcribe

Each entry must be signed (first, middle, last) with credentials Signature log O.K. to useElectronic signature O.K. to use

IllegibilityRead by others for treatment/careProof of services renderedIllegibility leads to denials‘If it isn’t documented it didn’t happed’ Auditors cannot use inference in

evaluation of records

Missing Provider Signatures Acceptable signature required

Each entry First, middle and last name Include credentials Date

Use signature log or attestation statement (CR) 6698

www.cms.gov/transmittals/downloads/R327PI.pdf

Insufficient DocumentationDocumentation should answer

What was wrong?How was it manifested?What did it look like?What was the procedure to fix it?What was the plan of care

Insufficient Documentation Paint picture of need for serviceVague statements not detailed

enough ‘Status quo’, ‘no change’ or

‘patient stable’ Give details

Insufficient Documentation Medical documentation submitted

does not include pertinent patient facts (e.g., patient’s overall condition, diagnosis, extent of services performed)

Use narrative with chart templates Document need for a complete or

comprehensive services

Incorrect Date Of ServiceIncorrect date of service receivedRead ADR letter carefullyCheck before respondingSend multiple dates if asked

Missing Patient NameMissing patient name on

documentationCheck copies before mailing

Both sidesBeware of photocopies

New Patient VersusEstablished Patient Denials

‘New patient’Not seen within the previous three

yearsFrom physician or physician group

practice (same physician specialty) Hospital services count

Combined BillingPhysicians in same group, different

specialtiesBill and paid regardless of group

Combined BillingPhysician in same group, same

specialtiesBill and paid as single physicianOnly one E/M per dayUnless unrelated problemsSelect E/M level to incorporate all

Documenting ServicesComments Field – NTE 02

Provide explanation of multiple physician treatment

Identify subspecialty if applicableSend documentation when requested

or for appealsShow need for1+ visits per day Identify subspecialty if applicable

E & M Guidelines“1995 Documentation Guidelines for

Evaluation and Management Services” “1997 Documentation Guidelines for

Evaluation and Management Services.”

Use either setUse only one per E & M service

E & M Guideline ResourcesIOM 100-04, Chapter 12, §30.6

http://www.cms.gov/manuals/downloads/clm104C12.pdf

CMS “Evaluation and Management Services Guide”http://www.cms.gov/

MLNEdWebGuide/25_EMDOC.asp

http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

E & M ServicesGrouped by categories and

subcategoriesSettingType of service3 to 5 levels of service

Components of E/M Services

Chief complaintHistoryExamDecision making

Components of E/M Services

CounselingCoordination of careNature of presenting problemTime

Evaluation and Management Scoresheet Tool

Basic Patient Information

History Components

Review of Systems

Physical Examination

Medical Decision Making

Amount and Complexity of Data Reviewed

Assessment of Risk

Counseling and/orCoordination of Care

Select ‘Update”for CPT codeselection

Select ‘Print’to print a copyof scoresheet

Selection of Code

Common E/M Documentation/Coding Errors

Common E/MDocumentation Errors

Missing documentation Beneficiary’s name Date of Service Rendering physician’s/NPP’s signature Supporting documentation (referred

to ROS, PFSH, or orders) Minimum documentation requirements

not met (down coded)

Common E/MDocumentation Errors

Medical necessity/reasonableness was not established

Illegible documentation Billed in error (per physician/NPP) Cloned records

Common E/MDocumentation Errors

The chief complaint/reason for visit was not clearly documented

Billed higher level services Extensive PFSH was documented for

lower-level services

Common E/MDocumentation Errors

Complete PFSH was missing New patient or initial services

Expansive ROS was documented for lower-level services

Missing ROS for the system(s) related to the presenting problem or system(s) related to the presenting problem were “negative”

Common E/MDocumentation Errors

Documented diagnoses under ROS Extensive examination was documented

for lower level services Unable to determine if diagnosis/problem

is stable or worsening

Common E/MDocumentation Errors

The assessment contained a list of diagnoses/problems that were not addressed during the encounter

Documented “labs reviewed” without further information

Unable to determine if the physician/NPP independently reviewed image, tracing, or specimen

Common E/MDocumentation Errors

Didn’t summarize old records/history from others

Ancillary staff/scribe documentation requirements were not met

Counseling/coordination of care missing time/documentation

Incident to requirements were not met

Medical Record Amendments

Medical RecordAmendments

General Medicare requirementsAfter medical records are

sign & datedAdditional information can be added

in form of an appropriate Amendment or addendums

On rare occasions & not used as common practice

Accepted as an Appropriate Addendum to Medical Records

Must be added timely within a few days/one week

Must contain individualized, patient-specific clinical information for each date of service amended.Blanket statements, declarations

or attestations not accepted

Accepted as an Appropriate Addendum to Medical Records

Should be chronological in records Must be legible, signed and datedShould address additional, clinically

relevant informationNot added to meet regulatory

requirementsNot added to support downcoded

claim

Making Correctionsto the Medical Record

Follow legal requirements Never write over, erase, or

obliterate an entryDraw a single line through

incorrect information Write correction near deletion All information should still be legibleShould be signed and dated

Making Correctionsto the Medical Record

A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed A full explanation of why the record

was in errorPractitioner should sign and date

the correction

Questions?

Please fill out Evaluations