JH Part B Fall Symposium Handout: 'Hot Medicare Topics'...Jul 01, 2013 · All JL should be using...

Novitas Solutions Medicare Part B Presents:

Hot Medicare Topics

JH Fall 2013 Symposium

Agenda

• Contractor Updates • New Quarterly Updates • Medicare Initiatives and Incentive

Programs • Recurring Updates/Reminders • Top Claim Submission Errors

Objectives

• Identify and understand the current Medicare changes

• Learn how to apply and comply with new guidelines

• Identify, retrieve and utilize educational resources and information

Contractor Updates

Medicare Reports • Latest edition- June 2013 • Published quarterly online at:

o https://www.novitas-solutions.com/partb/med-reports/index.html

• Includes articles on:

o General News o Coding Guidelines/Claim Reporting o Reimbursement o Coverage Issues o Specialty News o Medical Policy

https://www.novitas-solutions.com/partb/med-reports/index.htmlhttps://www.novitas-solutions.com/partb/med-reports/index.htmlhttps://www.novitas-solutions.com/partb/med-reports/index.htmlhttps://www.novitas-solutions.com/partb/med-reports/index.htmlhttps://www.novitas-solutions.com/partb/med-reports/index.html

Reminder- Providers Submitting Additional Documentation • Effective May 1, 2013, all documentation received that is not

submitted with the approved Novitas forms will be returned • Forms must be included with all faxed/mailed documentation

submitted to our office • Includes all information submitted when Novitas requests

additional documentation via the Additional Documentation Response (ADR) letter; or Medical Records requested during a Post Pay Review; or with the submission of Claim Supplemental Information Segment (PWK) Part A/B documentation

• For more information: o https://www.novitas-solutions.com/bulletins/all/news-

04032013.html

https://www.novitas-solutions.com/bulletins/all/news-04032013.htmlhttps://www.novitas-solutions.com/bulletins/all/news-04032013.htmlhttps://www.novitas-solutions.com/bulletins/all/news-04032013.htmlhttps://www.novitas-solutions.com/bulletins/all/news-04032013.htmlhttps://www.novitas-solutions.com/bulletins/all/news-04032013.html

Medical Review Signature Requirements • Listed below are examples of acceptable phrases for

electronic signatures: o Electronically signed by” with provider’s name o Verified by” with provider’s name o “Reviewed by” with provider’s name o “Signed by” with provider’s name o “Signed: John Smith, M.D.” with provider’s name o This is an electronically verified report by John Smith, M.D. o Authenticated by John Smith, M.D o Authorized by: John Smith, M.D o Confirmed by with provider’s name o Electronically approved by with provider’s name o Novitas expects the phrase/signature to be dated

• For more information:

o https://www.novitas-solutions.com/em/mr-sign-req.html

https://www.novitas-solutions.com/em/mr-sign-req.html

EDI Connections – Partnering For The Future • Changes To Connectivity

o Letters sent to all EDI Trading Partners on June 28, 2013 Dial-up Secure File Transfer Protocol (SFTP)

• Jurisdiction L (JL) Customers

o Begin using the new connections on July 29, 2013 o All JL should be using the new connections by September 27, 2013

• Jurisdiction H (JH) Customers including Indian Health Services, and Veteran

Affairs o Because of recent changes due to cutover activities, you may use the July 29th through

September 27th transition period as an opportunity to begin using the new connections o We encourage you to use the new connections by September 27, 2013

• Electronic Data Interchange (EDI) Help Desk o JL 1-877-235-8073, Option 3 o JH 1-855-252-8782, Option 3

• EDI Center

o https://www.novitas-solutions.com/edi/connections.html

https://www.novitas-solutions.com/edi/connections.htmlhttps://www.novitas-solutions.com/edi/connections.htmlhttps://www.novitas-solutions.com/edi/connections.html

New Quarterly Updates

International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related code Infrastructure of the Medicare Shared Systems as They Relate to National Coverage Determinations (NCDs)

• Change Request 8197 • Effective: October 1, 2014, Implementation: July 1, 2013 • Key Points:

o New and updated National Coverage Determination (NCD) hard-coded shared system edits that contain International Classification of Disease (ICD-9) diagnosis codes with the comparable ICD-10 diagnosis codes, along with all related coding infrastructure

o Operational changes to implement the conversion 30 NCDs affected ICD-9 and ICD-10 codes


o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8197.pdf

Incarcerated Beneficiaries

• Centers for Medicare & Medicaid Services (CMS) initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service o Penal facility o Supervised release o Medical furlough o Halfway house

Frequently Asked Questions: Incarcerated Beneficiaries

Resolution Timeframe • Q1: How is CMS resolving the claims denial issues associated with

the June and July 2013 incarcerated beneficiaries data?

• A1: The resolution of this situation will require a series of complex actions including the restoration of the original data on the Medicare Enrollment Data Base, the identification of the overpayments that will need to be abated or refunded, and the creation of claims processing system utilities to effectuate the necessary changes. We do not yet have a firm target date, but anticipate that the process will not be completed before October. We will advise you as additional information becomes available.

• For more information: http://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdf

http://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdfhttp://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-8-1-13.pdf

Centers of Medicare & Medicaid (CMS) 1500 Claim Form • Revised CMS-1500 Claim form: Version 02/12 • Features

o Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes

o Expansion of diagnosis codes o Qualifiers to identify provider roles

Ordering Referring Supervising

• http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

Tentative Timeline • Medicare anticipates implementing the revised CMS

1500 claim form (version 02/12) as follows: o January 6, 2014: Medicare begins receiving and

processing paper claims submitted on the revised CMS 1500 claim form (version 02/12)

o January 6 through 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)

o April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12)

• These dates are tentative and subject to change. CMS

will provide more information as it is available.

Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years • Change Request 8165 • Effective: 10/1/2013, Implementation: 10/7/2013 • Key Points

o Recovery Auditor identified claims for new patient visits paid more than once in three year period by same physician or physician group

o Contractor will be prompted to validate new patient claims when more than one service is identified in a three year period

o The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that Medicare interprets the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

• For more information

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8165.pdf

Detailed Written Orders and Face-to-Face Encounters • Change Request 8304

• Effective/Implementation :July 1, 2013

• Key Points o Documentation must show the physician, Physician Assistant (PA),

Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) had a face-to-face encounter examination with a beneficiary in the six months prior to the written order for certain items of Durable Medical Equipment (DME)

o DME ordered by a PA, NP, or CNS or a physician must document the occurrence of a face-to-face encounter by signing/co-signing and dating the pertinent portion of the medical record

• For more information o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/MM8304.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8304.pdf

Ocular Photodynamic Therapy (OPT) with Verteporfin for Macular Degeneration • Change Request 8292

• Effective: April 3, 2013, Implementation: July 16, 2013

• Key Points o The Centers for Medicare & Medicaid Services (CMS) will expand

coverage of Ocular Photodynamic Therapy (OPT), Current Procedural Terminology (CPT code 67221/67225) with Verteporfin, Healthcare Common Procedure Coding System (HCPCS J3396) for “wet” Age-related Macular Edema (AMD)

o Testing requirements revised to permit either Optical Coherence Tomography (OCT) or Fluorescein Angiogram (FA) to assess treatment response

• For more information: o MLN Matters® Number: MM8292

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8292.pdf

Current Procedural Terminology (CPT) only copyright 2012 American Medical Association. All rights reserved.

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Recovery of Annual Wellness Visit (AWV) Overpayments • Change Request 8153 • Effective/Implementation: July 1, 2013 • Key Points

o Claims with dates of service on and after January 1, 2011, that were processed by Medicare on and after April 4, 2011 through March 31, 2013, Medicare systems allowed for an AWV visit (Healthcare Common Procedure Coding System (HCPCS) G0438 or G0439) on an institutional claim and a professional claim for the same patient on the same day. In some cases, resulting in overpayments


o MLN Matters® Number: MM8153 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM8153.pdf



Laboratory Specimen Collection Update • Change Request 8339

• Effective/ Implementation: July 16, 2013

• Key Points o The Medicare Claims Processing Manual, “Chapter 16,

Section 60.1.4 – Coding Requirements for Specimen Collection, is revised to add the following: 36415 – Collection of venous blood by venipuncture P9615 – Catheterization for collection of specimen(s)

• For more information: o MLN Matters® Number: MM8339

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8339.pdf


Therapy Cap 2013

• Effective January 1, 2013

• Annual per beneficiary limit

• CR8129 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdf

Specialty Amount

Physical Therapy/Speech Language Pathology

$1900

Occupational Therapy

$1900

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8129.pdf

Therapy Cap

• Applied to allowed amount, less any coinsurance and/or deductible

• Applied to Medicare Secondary Payer (MSP) amount

• Medicare Summary Notice (MSN) messages reported to patients

President Obama Signs the American Taxpayer Relief Act of 2012 Section 603-Extension for Medicare Outpatient Therapy

• Extends the exceptions process for outpatient therapy caps

through December 31, 2013

• Extends the cap and threshold to therapy services furnished in a hospital outpatient department, and counts services furnished in a Critical Access Hospital towards the cap and threshold

• Extends the manual medical review of therapy services

furnished January 1, 2013 through December 31, 2013, when the beneficiary has reached a dollar aggregate threshold amount of $3,700

2013 Manual Review Prepayment Review: • The MAC will send an ADR to the provider requesting the

additional documentation be sent to the Recovery Auditor.

• The Recovery Auditor will conduct manual medical review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.

• CMS FAQs: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdfhttp://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/FAQ_OutpatientTherapy_04172013.pdf

2013 Annual Update to the Therapy Code List • Change request# 8126

o Effective: January 1, 2013 o Implementation: January 7, 2013

• Key Points: o Updates the list of codes that sometimes or always

describe therapy services o Sometimes therapy codes: G0456- Neg pres wound < 50 sq cm G0457- Neg pres wound > 50 sq cm

o 42 HCPCS have been added to the “always therapy” list


New Claim-Based Therapy Reporting Requirements

• Change Request (CR) # 8005 o Effective: January 1, 2013 Implementation: January 7, 2013

• Key Points o New claims-based data reporting o 42 New G-codes to report patient function o 7 New Modifiers to describe severity

• For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM8005.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8005.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8005.pdf

Services and Providers Affected

• Applies to all services furnished under Medicare Part B outpatient therapy benefit, as well as physical therapy, occupational therapy and speech language therapy provided by Comprehensive Outpatient Rehabilitation Facilities (CORF).

• Providers Types: Hospitals, Critical Access Hospitals, Skilled Nursing Facilities, CORFs, Rehab agencies, Home Health (Part B), Therapists in private practice, physicians, and Non-Physician Practitioners

Therapy Functional Reporting G-codes

• Mobility: Walking & Moving Around

• Changing & Maintaining Body Position

• Carrying, Moving and Handling Objects

• Self-Care • Other PT/OT Primary • Other PT/OT Subsequent

• Swallowing • Motor Speech • Spoken Language

Comprehension • Spoken Language

Expression • Attention • Memory • Voice • Other SLP

http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdf

http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdf

Severity/Complexity Modifiers Modifier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted

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

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

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

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

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

CN 100 percent impaired, limited or restricted

G Codes and Modifiers

Functional reporting using the G codes and the severity modifiers are required:

o At the outset of therapy episode of care o At least once every 10 treatment days o When a evaluation or re-evaluation is furnished and billed o At the time of discharge from the therapy episode of care o At the time reporting of a particular functional limitation is

ended in cases where the need for further therapy is necessary.

o At the time reporting is begun for a new or different functional limitation within the same episode of care

Therapy Modifiers

Value Description GP Services delivered under a Physical Therapy (PT)

plan of care GO Services delivered under a Occupational Therapy

(OT) plan of care GN Services delivered under a Speech Language

Pathology (SLP) plan of care KX Request for an exception from the therapy cap

59 Distinct procedural service for the same patient, same day & same provider

KX Modifier

• By appending the KX modifier, the provider is attesting that the services billed: o Are reasonable and necessary services that

require the skills of a therapist; (See Pub. 100-02, chapter 15, section 220.2)

o Are justified by appropriate documentation in the medical record, (See Pub. 100-02, chapter 15, section 220.3)

o Qualify for an exception using the automatic process exception

Liability Assignment Regarding Therapy Cap Claim Denials • Change Request 8321 • Effective: January 1, 2013, Implementation: October 1, 2013 • Key Points:

o The payment liability for therapy limit denials was revised changing denials from beneficiary liability to provider liability. As a result, when Medicare denies professional claims with Dates of Service (DOS) on or after January 1, 2013, that exceed the therapy caps and do not contain the GA modifier, claims denied with Group code CO (Contractual Obligation). Assignment of the PR (Patient Responsibility) code for DOS prior to January 1, 2013.

o Medicare will not adjust claims with a DOS on or after January 1, 2013, denied with the incorrect Group Code of PR prior to the implementation. Providers not required to refund any payments collected from beneficiaries associated with such denied claims and to take steps to avoid further collections from such beneficiaries based on the incorrect assigned liability on those denied claims.

• For more Information:

o MLN Matters® Number: MM8321 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8321.pdf

Enrollment Denials When Overpayment Exists • Change Request 8039 • Effective: October 1, 2013, Implementation: October 7, 2013 • Key Points:

o Medicare contractors may deny a Form CMS-855 enrollment application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or Change of Ownership (CHOW) is filed.


o MLN Matters® Number: MM8039 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/downloads/MM8039.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdf

Resources

• JH Local Coverage Determination (LCD) L32710 o https://www.novitas-solutions.com/policy/jh/l32710-r7.html

• Medicare Claims Processing Manual, Chapter 5

o http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c05.pdf

• National Correct Coding Initiative o http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-

Coding-Edits.html • Multiple Procedure Payment Reduction (MPPR) Change Request 7050

o http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdf

https://www.novitas-solutions.com/policy/jh/l32710-r7.htmlhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c05.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c05.pdfhttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.htmlhttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.htmlhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R826OTN.pdf

More Resources

• Revisions of the Financial Limitation for Outpatient Therapy Services Change Request 7785 o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


• Manual Medical Review of Therapy Services Change Request 8036

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8036.pdf

• Outpatient Therapy Functional Reporting Requirements o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/SE1307.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7785.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7785.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8036.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8036.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1307.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1307.pdf

Medicare Initiatives and Incentive Programs

2013 Physician Quality Reporting System (PQRS) Program

• PQRS payment authorized through 2014

• 0.5% incentive payment for 2012-2014

• Payment adjustments will begin in 2015 to eligible professionals who do not satisfactorily report data on quality measures for covered professional services

• For more information: o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/pqrs/index.html o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/PQRS/Spotlight.html o http://www.cms.gov/Outreach-and-

Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.htmlhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdfhttp://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

2013 Electronic Prescribing (eRx) Incentive Program • 0.5% eRx incentive for 2013 • Payment adjustment applies to those not successful electronic prescribers,

1.5% for 2013

• Four (4) significant hardship categories available o Unable to electronically prescribe due to local, state, or federal law, or

regulation o Has or will prescribe fewer than 100 prescriptions during a 6-month

reporting period (January 1 through June 30, 2012) o Practices in a rural area without sufficient high-speed Internet access

(G8642) o Practices in an area without sufficient available pharmacies for electronic

prescribing (G8643)

• For more information on the eRx Incentive Program o http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/ERxIncentive/index.html o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/MM7879.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.htmlhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdf

2013 Exclusion Criteria • Individual eligible professionals who meet one of the criteria

are automatically excluded from the 2013 Electronic Prescibing (eRx) payment adjustment:

o Successful electronic prescriber during the 2011 eRx 12- month reporting period o Not an Doctor of Medicine (MD), Doctor of Osteopathy (DO), Podiatrist, Nurse

Practitioner, or Physician Assistant by June 30, 2012, based on primary taxonomy code in the National Plan and Provider Enumeration System

o Does not have at least 100 Medicare Physician Fee Schedule (MPFS) cases containing an encounter code in the measure’s denominator for dates of service from January 1- June 30, 2012

o Does not have 10% or more of their MPFS allowable charges (per Tax Identification Number (TIN)) for encounter codes in the measure’s denominator for dates of service from January 1- June 30, 2012

o Does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between January 1- June 30, 2012

• For more information: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1206.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1206.pdf

Electronic Health Record (EHR) Incentive Program

• Several resources can help you successfully navigate the Medicare EHR Incentive Program: o An attestation page on the Centers for Medicare & Medicaid

Services website, where participants in the Medicare EHR Incentive Program can find important information on attestation

o The Meaningful Use Attestation Calculator allows Eligible Professionals (EPs) and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EPs or eligible hospital's specific measure summary.

o The Eligible Professional User Guide and the Eligible Hospital and Critical Access Hospital User Guide provide step-by-step guidance for EPs and eligible hospitals on navigating the attestation system.

Electronic Health Record (EHR) Incentive Program • EHR Incentive payments are distributed based on each year of

participation, and follow a specific payment schedule o Medicare Learning Network Matters Special Edition (SE) article SE1111

Medicare Electronic Health Record (EHR) Incentive Payment Process http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/SE1111.pdf

• Additional incentive for services provided in a Health Professional Shortage Area (HPSA)

• EHR payments will be issued by a Payment File Development Contractor

• Questions about your EHR incentive payment should be directed to: o EHR Information Center at 1-888-734-6433 or 1-888-734-6563 (TTY) o Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time) Monday

through Friday, except federal holidays. o http://www.cms.gov/EHRIncentivePrograms

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1111.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1111.pdfhttp://www.cms.gov/EHRIncentivePrograms

Preventive Services

Preventive Services • Annual Wellness Visit • Bone Mass Measurements • Cancer Screenings • Cardiovascular Disease

Screening • Colorectal Cancer Screening • Depression Screenings • Diabetes Screening Tests • Diabetes Self-Management

Training • Glaucoma Screening • Hepatitis B Vaccine • Human Immunodeficiency

Virus (HIV) Screening • Influenza Virus Vaccine

• Initial Preventive Physical Examination

• Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)

• Medical Nutrition Therapy • Prostate Cancer Screening • Pneumococcal Vaccine • Screening Mammography • Screening Pap Test • Screening Pelvic Exam • Smoking and Tobacco Use

Cessation Counseling • Ultrasound Screening for

Abdominal Aortic Aneurysm

Medicare Learning Network (MLN) Products for Preventive Services • Help Keep Your Medicare Patients Healthy In 2013!

• Ensure your patients take advantage of Medicare-covered

preventive services.

• Medicare covers a wide array of preventive services for eligible beneficiaries, including cancer screenings, certain immunizations, among others.

• The Medicare Learning Network (MLN) Preventive Services Educational Products Web Page provides descriptions and ordering information for MLN preventive services educational products and resources for health care professionals and their staff. o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/PreventiveServices.html

http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asphttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.htmlhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

Preventive Services • Quick Reference Chart for Medicare Preventive Services

o https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdfhttps://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

Informational and Systems Alerts

Informational Alerts

https://www.novitas-solutions.com/partb/info-alerts.html • Active and archived informational alerts

about billing, issues identified with corrective action and notices

https://www.novitas-solutions.com/partb/info-alerts.htmlhttps://www.novitas-solutions.com/partb/info-alerts.html

System Alerts

https://www.novitas-solutions.com/partb/alerts.html • Alerts that inform providers issues

identified with billing and a corrective action

https://www.novitas-solutions.com/partb/alerts.htmlhttps://www.novitas-solutions.com/partb/alerts.html

Alerts

Top Claim Submission Errors

Denials vs. Rejections

• Denials-not medically necessary, not covered under Medicare

• Rejection-incomplete or invalid information

• CO-16 – claim lacks information that is needed for adjudication

How To Determine If A Claim Can Be Appealed

• Appeal Rights o MA01 - “If you do not agree with what we approved for these

services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal, However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late”

• No Appeal Rights

o MA130 - “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is not able to be processed. Please submit a new claim with the complete / correct information.”

Top Claim Submission Errors (Part B)

• A listing of the top claim submission errors are listed by Jurisdiction o Each of the listings is then listed by individual

state within the jurisdiction • The reason code assigned, description of

the error and resolution are listed within the state option

• https://www.novitas-solutions.com/claims/index.html

https://www.novitas-solutions.com/claims/index.htmlhttps://www.novitas-solutions.com/claims/index.html

Claim Submission Errors

Arkansas Top Claim Errors • Non-Covered Charge(s)

• Duplicate Claim/Service

• Patients health identification number and name do not

match

• Claim is not covered by this payer/contractor.

• https://www.novitas-solutions.com/claims/submission_errors/partb/ar.html

https://www.novitas-solutions.com/claims/submission_errors/partb/ar.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/ar.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/ar.html

Colorado-New Mexico-Oklahoma Top Claim Errors • Non-Covered Charge(s)

• Duplicate Claim/Service


match.

• Claim is not covered by this payer/contractor.

• https://www.novitas-solutions.com/claims/submission_errors/partb/conmok.html

https://www.novitas-solutions.com/claims/submission_errors/partb/conmok.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/conmok.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/conmok.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/conmok.html

Mississippi Top Claim Errors • Non-Covered Charge(s)

• Provider not certified/eligible for this procedure/service.

• Patient health identification number and name do not

match.

• Duplicate claim/service.

• https://www.novitas-solutions.com/claims/submission_errors/partb/ms.html

https://www.novitas-solutions.com/claims/submission_errors/partb/ms.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/ms.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/ms.html

Louisiana Top Claim Errors • Non-Covered Charge(s)

• Claim/service lacks information needed for adjudication

• Duplicate claim/service


match • https://www.novitas-

solutions.com/claims/submission_errors/partb/la.html

https://www.novitas-solutions.com/claims/submission_errors/partb/la.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/la.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/la.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/la.html

Texas Top Claim Errors

• Non-Covered Charge(s)

• Claim not covered by this payer/contractor.

• Payment adjusted when performed/billed by a provider of this specialty.

• Patients health identification number and name do not match

• https://www.novitas-solutions.com/claims/submission_errors/partb/tx.html

https://www.novitas-solutions.com/claims/submission_errors/partb/tx.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/tx.htmlhttps://www.novitas-solutions.com/claims/submission_errors/partb/tx.html

Non-Covered Services

• Routine dental care • Dentures • Cosmetic surgery • Hearing aids • Most dental procedures • http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/bp102c16.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c16.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c16.pdf

Duplicate Services

• Services already processed

• Duplicate currently processing

• Allow claim to process

• To find the duplicate claim though the Interactive Voice Response say “Next Claim” after listening to your denial.

• The Redetermination form is available at: https://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdf

https://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdfhttps://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdf

Provider Not Certified/Eligible

• Performing service not eligible or out of scope of practice

• If you do not agree with the denial, you may request a appeal/redetermination

• The Redetermination form is available at: https://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdf

https://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdfhttps://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdfhttps://www.novitas-solutions.com/partb/forms/pdf/partb-redeterm-form.pdf

Health Insurance Claim (HIC) & Name Do Not Match Or Incomplete/Invalid HIC

• Verify the name on the official red, white, and blue Medicare card matches the claim

• Double check the HIC to ensure it was keyed correct

• Periodically update patient’s information

• Remittance Advise messages o MA130 o MA27

Not Covered By This Payer/Contractor

• Service not processed by Novitas

• Find appropriate contractor and submit

Denied When Performed By This Type Of Provider

• Performing provider type not eligible or out of scope of practice

• Request redetermination including the reason it should be covered for the particular specialty

Part B Redetermination Request

• Correct clerical errors or omission by calling the Claims Correction line o JH Providers 1-855-252-8782

• Part B Redetermination Requests may be faxed o Available 24 hours a day, 7 days a week o 1-888-541-3829

• Appeals Status Inquiry Tool now available o https://www.novitas-

solutions.com/appeals/status.html

https://www.novitas-solutions.com/appeals/status.htmlhttps://www.novitas-solutions.com/appeals/status.html

Recurring Updates & Reminders

Mandatory Payment Reductions – “Sequestration” • Medicare Fee-for-Service claims with dates of service or date

of discharge on or after July 1, 2013 • 2% reduction to Medicare payment • The fees shown on our website do not reflect the

sequestration payment adjustment • Payment adjustments shall be applied to all claims after

determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible and any Medicare Secondary Payment adjustments


o https://www.novitas-solutions.com/sequestration/index.html

https://www.novitas-solutions.com/sequestration/index.htmlhttps://www.novitas-solutions.com/sequestration/index.htmlhttps://www.novitas-solutions.com/sequestration/index.htmlhttps://www.novitas-solutions.com/sequestration/index.html

ICD-10 Compliance • ICD-10 deadline date is October 1, 2014

• Keep Up to Date

o http://www.cms.gov/Medicare/Coding/ICD10/index.html o Sign up for the Centers for Medicare & Medicaid Services (CMS)

ICD-10 Industry Email Updates- http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html

o Follow CMS on Twitter- http://twitter.com/cmsgov

o Subscribe to Latest News Page Watch -

https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609

http://www.cms.gov/Medicare/Coding/ICD10/index.htmlhttp://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.htmlhttp://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.htmlhttp://twitter.com/cmsgovhttps://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609

Medicare Quarterly Provider Compliance Newsletter • The “Medicare Quarterly Provider Compliance Newsletter [Volume

3, Issue 4]” Educational Tool (ICN 908625) was revised. Designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. Includes information on corrective actions that health care professionals can use to address and avoid the top issues of the particular Quarter. o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN908787.pdf • Index of Recovery Audit and Comprehensive Error Rate Testing

(CERT) findings from current and previous newsletters is available. Customized by provider type to identify those findings that impact specific providers. o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN908787.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN908787.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdf

Medicare Learning Network MLN Matters® Articles

• Medicare Learning Network Matters Articles or MLN Matters® articles developed by the Centers for Medicare & Medicaid Services (CMS) to help health care professionals avoid improper activities

• List is updated as related articles are issued and

revised o http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdf

Special Edition Articles

• Place of Service Coding for Physician Services in an Outpatient Setting: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


• Pulmonary Procedures and Evaluation & Management (E/M) Services: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


• Incorrect Number of Units Billed for Rituximab and Bevacizumab Dose versus Units Billed: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


• Guidance to Reduce Mohs Surgery Reimbursement Issues: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


• Cataract Removal, Part B: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1313.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1313.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1315.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1315.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1316.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1318.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1319.pdf

Additional Special Edition Articles • Add-on Healthcare Common Procedure Coding System (HCPCS)

/Current Procedural Terminology (CPT) Codes Without Primary Codes: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/SE1320.pdf

• Hospice Related Services – Part B: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-


• Co-Surgery Not Billed with Modifier 62: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-


• Additional/Subsequent Procedures Performed During the 90 Day Global Period for Major Surgeries: o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1320.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1320.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1321.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1322.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1322.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1323.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1323.pdf

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: o https://www.novitas-

solutions.com/training/index.html

https://www.novitas-solutions.com/training/index.htmlhttps://www.novitas-solutions.com/training/index.html

Thank you for your participation in this session!

Novitas Solutions, Inc. Medicare Part A & B Presents:

Welcome and

Navigating the Medicare Compliance Programs with Novitas

JH Fall 2013 Symposium

Disclaimer • All Current Procedural Terminology (CPT) only copyright 2012 American Medical Association (AMA). All rights

reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

• 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.

Novitas Solutions, Inc. Novitas = “Newness”

Formerly known as Highmark Medicare Services Inc.

Wholly-owned subsidiary of Diversified Service Options, Inc. (DSO), a subsidiary of Blue Cross Blue Shield of Florida (BCBSF)

DSO - established in 1998 for fee-for-service government business

Includes Novitas, First Coast Service Options, and 50% ownership in Tri-Centurion

Medicare contractor since the inception of the Medicare Program

Novitas currently serves as the Medicare Administrative Contractor (MAC) for JL (PA, NJ, MD, DE, and DC) and JH (AR, CO, LA, MS, NM, OK, and TX)

Nationwide Section 1011 contract for Federal Reimbursement of Emergency Services Provided to Undocumented Aliens

Novitas Solutions, Inc.

• Contracts o JH MAC (OK, TX,

NM, CO, AR, LA, MS (VA and Indian Health Services)

o JL MAC (PA, NJ, MD, DE, and DC)

o Section 1011 Contract

A/B Medicare Administrative Contractors (MAC)

Novitas Fun Facts DETAIL JURISDICTION

H JURISDICTION

L Traditional Medicare Providers

155,000

158,000

Average Claims Processed Annually

165 million

121 million

Total Medicare Payments Annually

$49 billion

$35 billion

Agenda

• Medicare Compliance • Fraud and Abuse • Medicare Regulations • Reporting Suspected Fraud • Medicare Integrity Programs and Medicare

Audit Programs • Medicare Audit Findings • Resources • Self Service Options

Objectives

• Encourage an environment of self-monitoring, detection, and resolution of problems

• Encourage developing a culture of integrity and transparency

• Encourage development and revision of policies and procedures to enhance compliance

Medicare Compliance

Medicare Compliance is… • Compliance is defined as:

o A state of being in accordance with established guidelines, specifications or legislation, or the process of becoming so

• Safeguarding the Medicare Trust Fund

• Identifying program weaknesses and vulnerabilities to

help prevent fraud, waste and abuse

• Improving quality of care in the Medicare program

Medicare Compliance Initiatives

• Ensure providers have an understanding of the importance of being compliant by: o Documenting their services correctly o Filing claims properly with the correct information o Adhering to program guidelines and coverage

policies (for example: proper modifiers, diagnosis codes, etc.)

• Paying It Right the First Time, Every Time!

Fraud and Abuse

How Much Fraud?

• The Centers for Medicare & Medicaid Services estimates that as much as 10% of Medicare costs are inappropriately spent due to fraud and abuse incidents.

Fraud and Abuse

• Benefit Integrity Contractor • Focus resources to detect and deter fraud

and abuse in the Medicare Program o Eliminate potential fraud, waste and abuse in the

Medicare Program o Maintain the integrity of the Medicare Trust Fund http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/pim83c04.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c04.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c04.pdf

Fraud

• Fraud Defined o Intentional deception or misrepresentation

that an individual makes, knowing it to be false and that could result in some unauthorized benefit to them Most frequent kind of fraud arises from a false

statement or misrepresentation that is material to entitlement or payment under the Medicare program

Examples of Fraud

• Examples include: o Incorrect reporting of diagnoses or procedures to

maximize payments;

o Billing for services not furnished and/or supplies not provided;

o Altering claim forms, electronic claim records, medical documentation, etc. to obtain a higher payment amount

Abuse

• Abuse Defined o Incidents or practices that may, directly or indirectly,

result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or that are medically unnecessary

o Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and intentionally misrepresented facts to obtain payment

Examples of Abuse

• Examples include: o Providing medically unnecessary services or services that do

not meet professionally recognized standards; o Submitting bills to Medicare that are the responsibility of

other insurers under the Medicare Secondary Payer (MSP) regulation

• Office of Inspector General (OIG) Fraud and Abuse Hotline o 1-800-HHS-TIPS (1-800-447-8477)

• Fraud and Abuse Brochure

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

Stop Medicare Fraud!

http://www.stopmedicarefraud.gov/index.html

http://www.stopmedicarefraud.gov/index.html

Beware of Sanctioned Providers! • https://oig.hhs.gov/exclusions/exclusions_list.asp • http://exclusions.oig.hhs.gov/

https://oig.hhs.gov/exclusions/exclusions_list.asphttp://exclusions.oig.hhs.gov/

Office of Inspector General’s Most Wanted Fugitives

• http://oig.hhs.gov/fraud/fugitives/index.asp

http://oig.hhs.gov/fraud/fugitives/index.asp

Compliance Program

• Internal monitoring and auditing • Compliance and practice standards • Compliance officer or contact • Training and education • Response to detected offenses and

corrective actions • Open lines of communication with employees • Enforce disciplinary standards through well-

publicized guidelines

Tips for Avoiding Fraud and Abuse

• Accurate coding and billing • Accurate and complete medical records

and documentation • Knowledge of Medicare rules and

regulations • Response to Medicare inquiries • Good business sense

It’s the Law!

Centers for Medicare & Medicaid Services (CMS) Regulations

False Claims Act (FCA)

•31 United State Code Sections 3729-3733 •Protects the government •Imposes civil liability on a person who knows they submit a fraudulent claim

•Criminal penalties include fines, imprisonment or both

Anti-Kickback Statute

• 42 United State Code Section 1320 a-7b(b)

• Criminal offense to knowingly and willingly reward referrals o Fines, imprisonment, or both

• Safe harbor regulations: Code of Federal Regulations, Section 1001.952

Physician Self-Referral Law (Stark Law)

• 42 United States Code Section 1395nn • Prohibits a physician from making a

referral to entities with ownership or investment interest

• Fines and exclusion from participation in all Federal health care programs

Criminal Healthcare Fraud Statute

• 18 United States Code 1347

• Prohibits knowingly and willfully defrauding any health care benefit program

• Penalties include fine and/or imprisonment

Exclusions

• 42 United States Code Section 1320a-7 • Requires exclusion from participation when

convicted of: o Medicare fraud o Patient abuse or neglect o Felony convictions for other healthcare related

fraud, theft, or other financial misconduct o Felony convictions for unlawful manufacture,

distribution, prescription, or dispensing of controlled substances

Civil Monetary Penalties

• 42 United States Code 1320a-7a • Range from $10,000 to $50,000 per

violation • Up to three times the amount of

remuneration offered, paid, solicited, or received

Reporting Suspected Fraud

Medicare Providers • Office of Inspector General (OIG) Hotline

o Phone: 1-800-HHS-TIPS (1-800-447-8477) • Fax: 1-800-223-8164 • E-mail:

o [email protected] • TTY: 1-800-377-4950 • https://forms.oig.hhs.gov/hotlineoperations/ • Mail: Office of Inspector General

U.S. Department of Health & Human Services Attn: Hotline P.O. Box 23489 Washington, DC 20026

https://forms.oig.hhs.gov/hotlineoperations/

Beneficiaries • For any complaints:

o The Centers for Medicare & Medicaid Services

(CMS) Hotline: 1-800-MEDICARE (1-800-633-4227) or TTY 1-800-

486-2048

OR o For Medicare Managed Care or Prescription

Drugs: 1-877-7SafeRx (1-877-772-3379)

Contact Novitas Solutions

• Novitas Solutions Attention: Benefit Integrity 2020 Technology Parkway Mechanicsburg, PA 17050

• Customer Contact Center

o JH Providers: 1-855-252-8782

Medicare Integrity Program (MIP)

Overview- History • Medicare Integrity Program (MIP) created by Health

Insurance Portability & Accountability Act (HIPAA) of 1996 Section 202 (section 1893 of the Social Security Act) o Specialized contracts with entities other Medicare claims processors o 12 organizations - Program Safeguard Contractors (PSCs), (also

known as Benefit Integrity Support Centers (BISCs) • Medicare Modernization Act of 2003 created Medicare

Administrative Contractors (MACs) o Streamlines and regionalizes claims processing functions across

the country. o Aligns program integrity efforts with the new MAC claims processing

jurisdictions, o Centers for Medicare & Medicaid Services (CMS) established Zone

Program Integrity Contractors (ZPICs) which, beginning in 2009, replaces the PSCs/BISCs

Program Safeguard Contractors (PSCs)/Benefit Integrity Support Centers (BISCs) and Zone Program Integrity Contractors (ZPICs)

• Seven (7) ZPIC jurisdictions (zones)

• One ZPIC zone (Zone 6) not transitioned yet (benefit integrity functions are still the responsibility of PSCs/BISCs)

• Benefit integrity activities may include the following: o Investigation of healthcare fraud and abuse o Data analysis to identify potential fraud and abuse o Medical record reviews in support of benefit integrity

activities o Cost report audits in support of benefit integrity activities o Education related to benefit integrity activities o Support federal law enforcement in the investigation and

prosecution of fraud cases.

Zone Program Integrity Contractors (ZPIC)

Novitas Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs) • AdvanceMed Zone 5 ZPIC

o ZPIC for the Jurisdiction H (JH) Part A and Part B providers in states of Arkansas, Louisiana, and Mississippi

o http://nciinc.com/

• Health Integrity, LLC Zone 4 ZPIC o ZPIC for the JH Part A and Part B providers in the states of

Colorado, New Mexico, Oklahoma and Texas o http://www.healthintegrity.org/contracts/zpic-4

• Note: For contact information for these contractors

see the links provided in Chapter 21 of the A/B Reference Manual o https://www.novitas-solutions.com/refman/chapter-21.html

http://nciinc.com/http://www.healthintegrity.org/contracts/zpic-4https://www.novitas-solutions.com/refman/chapter-21.html

Medicare Integrity Program (MIP) Specialty Contractors

• Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs) o Expertise to develop cases o Conduct data analysis o Audit o Perform medical review and other tasks to

detect and deter fraud, waste, and abuse

Program Safeguard Contractor (PSC)/ Zone Program Integrity Contractor (ZPIC) Responsibilities

• Identify and deter Medicare fraud and abuse • Develop cases for referral to the Office of Inspector General

(OIG) • Respond to requests for Medicare data and support from law

enforcement • Identify and report program • Refer recommendations for a corrective actions (including

provider education, overpayment recovery, licensure considerations)

• Develop and validate methodologies for the early detection and prevention of fraud schemes and abusive billing

Medicare Administrative Contractor (MAC) Medical Review (MR) Program

Medicare Administrative Contractors (MACs) Involvement

• Program and fiscal integrity oversight: o Medical review/probe analysis/medical policy o Claims processing o Provider/supplier education o Beneficiary services including complaint

screening o Referral of potential fraud to the Zone

Program Integrity Contractors (ZPICs)/Benefit Integrity Support Centers (BISCs)

Medicare Administrative Contractors (MACs) Identify Fraud or Abuse

• Medical Review • Data Analysis • Financial • Enrollment

Medical Review (MR)

• One component of the Medicare Integrity Program (MIP) • Works with other MIP Contractors to minimize potential

future losses to the Medicare Trust Fund • Support s the primary goal of the MIP

o Pay claims correctly o Reduce the claims payment error rate

• Aggressively pursues Progressive Corrective Action (PCA) to process claims in the right amount for covered, medically necessary, and correctly coded services rendered to eligible beneficiaries by legitimate providers

Medical Review (MR) Strategy

• Medicare Administrative Contractors (MACs) develop an annual MR Strategy to identify problem areas: o The Strategy is updated every six months o Problem areas are based on data analyses Error rates produced by the Comprehensive Error Rate

Testing (CERT) program Vulnerabilities identified through the Recovery Audit

(RA) program Analysis of claims data/aberrancies in billing patterns Evaluation of other information (complaints)

Additional Documentation Requests (ADRs) • When a coverage or coding determination cannot be made

based on the information provided on a claim, the Medicare Administrative Contractor (MAC) may ask for additional documentation by issuing an ADR

• ADRs are typically driven by standardized code sets: o Diagnostic Related Groups (DRGs) o Current Procedural Terminology (CPT) o Healthcare Common Procedure Coding System (HCPCS) o Resource Utilization Groups (RUGs)

• 45 days to respond or may be denied • Internet Only Manual 100-8; Chapter 3, Section 3.2.3.8:

o http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf

http://www.cms.gov/Reg

JH Part B Fall Symposium Handout: 'Hot Medicare Topics'...Jul 01, 2013 · All JL should be using...

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Transcript of JH Part B Fall Symposium Handout: 'Hot Medicare Topics'...Jul 01, 2013 · All JL should be using...