July 14, 2017

MAMES Excellence in HME Conference

Medicare Updates Session

October 4, 2017

July 14, 2017

Terri Shoup JB POE Senior Analyst Community Coach for MN, WI

July 14, 2017

Disclaimer The presentations herein were current at the time they were published or uploaded onto the Web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. The presentations herein were prepared as tools to assist providers and are 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.

The Centers for Medicare & Medicaid Services (CMS) employees and agents, including CGS and its 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 publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. Official Medicare Program provisions are contained in relevant laws, regulations, and rulings.

July 14, 2017

Agenda Acronyms

New Medicare Card Project

Advance Beneficiary Notice of Noncoverage

Voluntary Refunds

Condition of Payment Prior Authorization

Updates/Clarifications

Targeted Probe and Educate

MLN Updates

Resources and Self-Service Tools

July 14, 2017

5EO Five Element Order

ABN Advance Beneficiary Notice of Noncoverage

ACA Affordable Care Act

ACT Ask-the-Contractor Teleconference

ADMC Advanced Determination of Medicare Coverage

ADR Additional Documentation Request

CERT Comprehensive Error Rate Testing

CMS Center for Medicare & Medicaid Services

DME MAC Durable Medical Equipment Medicare Administrative Contractor

DMEPOS Durable Medical Equipment, Prosthetics, Orthotics and Supplies

DWO Detailed Written Order

esMD Electronic Submission of Medical Documentation

HCPCS Healthcare Common Procedure Coding System

5

Acronyms

July 14, 2017

IVR Interactive Voice Response

IOM Internet Only Manual

JA Jurisdiction A

JB Jurisdiction B

JC Jurisdiction C

JD Jurisdiction D

LCD Local Coverage Determination

MAC Medicare Administrative Contractor

MBI Medicare Beneficiary Identifier

MLN Medicare Learning Network

NCD National Coverage Determination

NPI National Practitioner Identifier

NPWT Negative Pressure Wound Therapy

6

Acronyms

July 14, 2017

NSC National Supplier Clearinghouse

PA Policy Article

PAP Positive Airway Pressure

PAR Prior Authorization Request

PIM Program Integrity Manual

POE Provide Outreach and Education

SSN Social Security Number

SSNRI Social Security Number Removal Initiative

TPE Targeted Probe and Educate

UTN Unique Tracking Number

WOPD Written Order Prior to Delivery

7

Acronyms

July 14, 2017

New Medicare Card Project

July 14, 2017

New Medicare Card Project • Formerly known as the Social Security Number Removal

Initiative (SSNRI)

• Requires the removal of Social Security Numbers from Medicare cards by April 2019

• Replaced with a Medicare Beneficiary Identifier (MBI)

• 11 characters in length

• Randomly generated for member, spouse, & dependents

• Made up only of numbers and uppercase letters

• Distribution of new cards will begin April 2018

• Transition period April 1, 2018 – December 31, 2019

July 14, 2017

New Medicare Card Project • During transition period, you can use either the HICN or MBI on

all transactions

• You cannot submit both numbers on the same transaction

• Use the CGS secure web portal myCGS to look up an MBI number starting June 2018

• You must have the beneficiary’s firs/last name, date of birth, SSN

• If the beneficiary doesn’t want to provide their SSN, they can log into www.mymedicare.gov to get their MBI

• Beginning October 2018 and through the transition period, when you submit a claim using a valid and active HICN, CGS will return both the HICN and the MBI on every remittance advice

July 14, 2017

New Medicare Card Project • End-to-end testing with Medicare is not necessary as you’ll be

able to use either HICNs or MBIs to submit claims during the transition period.

• Use the transition period as a live test and make adjustments as necessary

• CMS is planning a wide-scale outreach and education campaign aimed at beneficiaries which will begin with the mailing of the Medicare handbook in September 2017 and continue through April 2019

• We are working closely with other payers, state Medicaid agencies, and supplemental insurers to make sure the crossover claims process will still work like it does now

July 14, 2017

New Medicare Cards Gender and signature line won’t appear on new Medicare

cards

All cards will be printed on white paper

Smaller size to match the size of a standard credit card

© 2017 Copyright, CGS Administrators, LLC. 12

July 14, 2017

CMS Resources • New Medicare Card Web Page

• https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

• Questions related to New Medicare Card Project

• SSNRemoval@cms.hhs.gov

• Open Door Forums

• June 8, 2017 - https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/Downloads/06082017SSNRITranscriptandAutoFile.zip

July 14, 2017

CGS Resources • New Medicare Card Project Webinars

• Latest information on timelines, the transition period, and resources will be provided

• Webinars will be held monthly through 2018

• October 19 – 2:30p.m. ET

• Ask-the-Contractor Teleconferences (ACTs)

• Update on project will be given with majority of time dedicated to attendee questions

• October 10 – 2:00p.m. ET

• ListServ/Social Media

• Partnerships with State Associations

July 14, 2017

Advance Beneficiary Notice of Noncoverage

July 14, 2017

ABN • New ABN form CMS-R-131

(03/2020)

• Mandatory as of June 21, 2017

• Special guidance for non-assigned claims requiring an ABN

July 14, 2017

Blank G, Option 1

© 2017 Copyright, CGS Administrators, LLC. 17

• Draw a single line through the last sentence

• No CMS requirement to initial or date the stricken sentence

• If changes are completed prior to issuing the ABN to the beneficiary

July 14, 2017

Blank H Additional Information

© 2017 Copyright, CGS Administrators, LLC. 18 May 19

• Must add the below statements to Section H

July 14, 2017

ABN Resources Supplier Manual Chapter 3

• https://cgsmedicare.com/jb/pubs/pdf/chpt3.pdf

Assignment agreement

• CMS Internet Only Manual (IOM)100-04, Chapter 1, Section 30.3.2

Enrollment

• Participating / Non-Participating

• Social Security Act Section 1842(h); 42 U.S.C. Section 1395u (h); 42 C.F.R. Sections 400.202, 424.55 (1999)

ABN Instructions

• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-Instructions.pdf

July 14, 2017

Voluntary Refunds

July 14, 2017

Voluntary Check Refunds • Submit refunds to the correct PO Box

• Jurisdiction B and C refunds should not be combined on one check

• Always separate checks, correspondence and any information you are submitting to CGS that is for both JB and JC

Jurisdiction B Refunds: Jurisdiction C Refunds:

CGS DME MAC Jurisdiction B PO Box 953479 St. Louis, MO 63195-3479

CGS DME MAC Jurisdiction C PO Box 955152 St. Louis, MO 63195-5152

July 14, 2017

Condition of Payment Prior Authorization

July 14, 2017

Overview – Phase 1 Began accepting Prior Authorization Requests on March 6, 2017

Effective for dates of service March 20, 2017 and after

Affected Codes

– K0856: power wheelchair, group 3 standard, single power option

– K0861: power wheelchair, group 3 standard, multiple power option

Affected States

– Jurisdiction A - New York

– Jurisdiction B - Illinois

– Jurisdiction C - West Virginia

– Jurisdiction D - Missouri

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July 14, 2017

Overview – Phase 2 Nationwide for dates of service/delivery on or after July 17,

2017, for all claims for K0856 and K0861

Began accepting Prior Authorization Requests on July 03, 2017

Must have prior authorization before delivery

• If prior authorization is not submitted, the claim will be denied as prior authorization is a condition of payment

© 2017 Copyright, CGS Administrators, LLC 24

July 14, 2017

Exclusions • The following claim types are excluded from any PA program

described in the operational guide:

• Veterans Affairs

• Indian Health Services

• Medicare Advantage

• Part A and Part B Demonstrations

• The Advanced Determination of Medicare Coverage (ADMC) process is available (K0856 and K0861) when applicable for excluded beneficiaries

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July 14, 2017

Documentation Requirements • NCD and LCD coverage are unchanged

• Documentation requirements are unchanged

• The program does NOT create any new documentation requirements

• Requires the information be submitted earlier in the claims process

© 2017 Copyright, CGS Administrators, LLC 26

July 14, 2017

Submitting Prior Authorization Requests • Suppliers or beneficiaries may submit the PAR

• Utilize the following options to submit a PAR to the DME MACs:

• Mail

• Fax

• Electronic Submission of Medical Documentation (esMD)

» http://www.cms.gov/esMD

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Jurisdiction B

Fax 1.615.660.5992

Mail CGS – JUR B DME Medical Review – Condition of Payment Program PO Box 23110 Nashville, TN 37202-4890

July 14, 2017

Timeframes • Initial Request

• Decision letters will be sent with the Unique Tracking Number (UTN) within 10 business days

• Resubmitted Requests

• Decision letters will be sent with the UTN within 20 business days

• Expedited Requests

• Based on the DME MAC determination that delays in review and response could jeopardize the life or health of the beneficiary

• DME MAC will attempt to review and communicate a decision within 2 business days

© 2017 Copyright, CGS Administrators, LLC 28

July 14, 2017

Resources

• CMS • https://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Process-for-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items.html

• CGS • http://www.cgsmedicare.com/jb/mr/k0856.html

© 2017 Copyright, CGS Administrators, LLC 29

July 14, 2017

Updates/Clarifications

July 14, 2017

Updates/Clarifications • NPWT

• As of May 25, 2017, Negative Pressure Wound Therapy (NPWT) removed from ACA list

• WOPD requirement removed from LCD and PA and replaced with DWO

• Request for Refill • As of June 1, 2017, request for refill information added to Standard

Documentation Language

• Deleted policy specific refill requirements that were located in the applicable LCDs

• Center Mount Elevating Leg Rest • HCPCS K0040 is separately payable when provided initially with leg rests

coded as E1012

• HCPCS K0108 will be denied as unbundling when billed in conjunction with E1012

• Clarified in August 10th article published by all DME MACs

July 14, 2017

Updates/Clarifications • Urological Supplies

• SpeediCath® Flex Coudé Catheter is classified as a straight catheter, even though coudé is part of the name

• Should be billed with HCPCS A4351

• Clarified in August 24th article published by all DME MACs

• Power Mobility Devices • Revised to include PMD codes for which E2397 (lithium based battery)

may be used

• Revised article published September 21st by all DME MACs

• Knee Orthoses • LCD will be updated on October 16, 2017 to include new ICD-10 codes

• S76.111, S76.112, S76.121 and S76.122 added to Group 2 and 4

July 14, 2017

5EO Change for ACA • Date stamp no longer required

• Encouraged to have a date stamp or equivalent to document the 5EO receipt date by the supplier

• Reminders:

• Must be completed within six months after the required ACA 6407 face-to-face examination

• Must be received by supplier prior to delivery

Note: CGS reviewers will utilize the physician’s signature date to ensure the order was received prior to delivery

July 14, 2017

Targeted Probe and Educate (TPE)

July 14, 2017

Overview • Pilot program began July 3, 2017 for Jurisdictions B and D

• Goal is to improve claims payment error rate, reduce volume of appeals through claim review and education

• Will utilize existing data analysis processes to determine the item(s) and suppliers to review

• Claims will be selected that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate

• Suppliers who have the highest claim error rates or billing practices that vary significantly from their peers as determined through data analysis will be the focus

• As of October, in effect for all DME MACs

July 14, 2017

TPE Process • Suppliers identified for TPE will receive written notification

• Process includes a review of 20-40 claims followed by one-on-one education to address errors

• Up to three rounds of supplier-specific prepayment probe reviews • Suppliers with moderate and high error rates in the first round of

reviews will continue on to a second round of reviews and education

• Suppliers with high error rates after round two will continue to a third and final round of reviews and education

• Suppliers with continued high error rates after three rounds may be referred to CMS for additional action

• Suppliers may be removed from the process after any of the three rounds of probe review and education

July 14, 2017

Resources • CGS

• ListServ/Web article published on CGS website on June 27

• https://www.cgsmedicare.com/jb/pubs/news/2017/06/cope3647.html?wb48617274=04C09B97

• CMS

• TPE Webpage

• https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

• Flow Chart

• https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-Pilot-Flow-chart06-20-17v9-final.pdf

July 14, 2017

MLN Updates

September

© 2016 Copyright, CGS Administrators, LLC 38

July 14, 2017

MLN Matters MM9986 • “DMEPOS Order Requirements for Changing Suppliers” • A new supplier may use a valid order obtained from a previous

supplier

• As a reminder, new orders are required:

• There is a change in the order for the accessory, supply, drug, and so forth

• On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy.

• When an item is replaced.

• When there is a change in the supplier, if the recipient supplier did not obtain a valid order for the DMEPOS item from the transferring supplier.

July 14, 2017

MLN Matters MM9904 • “Guidance on Implementing System Edits for Certain

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)”

• The following entities must show evidence of accreditation as of July 1, 2017:

• DME

• Medical supplies

• Home dialysis supplies and equipment

• Therapeutic shoes

• Parenteral and enteral nutrient, equipment and supplies

• Transfusion medicine

• Devices, prosthetics, and orthotics

July 14, 2017

MLN Matters SE17010 • “Improvements to the Adjudication Process of Serial

Claims” • Effective date is April 7, 2017

• Identify other claims in the same series • Denied for same or similar reasons

• Within 1 year of initial determination date

• Prevent future claims from unnecessarily entering the appeals process

• Ensures decision is applied to other claims in series

• CGS will re-open these claims

• Suppliers do not need to take any actions

• Suppliers need to follow the normal appeals process and timeliness guidelines

July 14, 2017

MLN Matters MM9968 • “Extension of the Transition to the Fully Adjusted

DMEPOS Payment Rates Under Section 16007 of the 21st Century Cures Act”

• DME MACs began adjustments in July and completed them in September

• Remittance code N689 identified these adjustments

• Notification sent advising suppliers can submit reopening requests to add KE modifier to applicable claims

• Up to 250 per request

• Fax requests related to the KE modifier to Written Reopenings

• JB Written Reopenings Fax: 615-660-5978

July 14, 2017

Resources and Self-Service Tools

July 14, 2017

Just completed 2017 Workshops • Indianapolis

• Cleveland

• Chicago

2018 Workshops • Coming to a city near you in 2018

• Planning to host a workshop in each of the seven JB states

• Survey will be sent to all JB suppliers later this year

• More details will be released via the ListServ and Website in the first quarter or 2018

Workshops

July 14, 2017

Upcoming Webinars October 5 Diabetic Shoes

October 6 Diabetic Shoes LiveLine Plus

October 10 Documentation Requirements - Principles

October 11 Oxygen

October 12 TENS Unit

October 13 Oxygen LiveLine Plus

October 17 Documentation Requirements – Orders and CMNs

October 18 Medicare 101

October 20 Spinal Orthoses

October 24 Documentation Requirements – Refill and Delivery

October 25 Medicare 102

October 27 Reopenings and Redeterminations

July 14, 2017

CGS WIZARD MR WIZARD is now CGS WIZARD!

Contains valuable information such as:

• Processed claim details for all JB/JC claims

• ADR status

• Medical Review decisions

• Resources directly from our website

Detailed descriptions of denial codes provided

Same information provided as myCGS and CGS GO Mobile

Available 24/7 with no registration needed

July 14, 2017

myCGS Web Portal MyCGS provides access to beneficiary

eligibility, claim status, claim denial information, and much more.

The myCGS portal mirrors all of the functionality currently contained in the Interactive Voice Response (IVR) unit.

MyCGS includes several additional and more detailed features than the IVR can provide.

FAQs, Registration Guides, and User Manuals are available.

• To learn more, visit: http://www.cgsmedicare.com, select JB DME or JC DME, then select the myCGS link from the left navigation menu.

• Register today!

July 14, 2017

CGS Connect Jurisdiction B CGS ConnectTM is a unique concierge-level

service for suppliers seeking professional review and evaluation of pre-claim documentation before submitting an initial claim to Medicare.

• Clinical Reviews

– Urological Supplies (A4353)

– PAP (E0601)

– Oxygen and Oxygen Equipment (E1390)

– Manual Wheelchairs (K0004)

– Hospital Beds and Accessories (E0260/E0394/ E0301/E0303/E0912)

Estimated MR Response Times: 10-15 days

• Routine Reviews

– Glucose Monitors (A4253/E0607NU)

– Nebulizers (E0570)

– Oxygen and Oxygen Equipment (E1390)

– Knee Orthoses (K0901)

– Knee Orthoses (L1832/L1833/L1843

July 14, 2017

GO Mobile CGS GO MOBILE IS KEEPING YOU CONNECTED!

CGS Go Mobile works on Apple and Android phones and tablets!

The download is free!

Access and share important CGS Medicare information from the convenience of your mobile device!

http://www.cgsmedicare.com/jb/onlinetools/gomobile.html

July 14, 2017

ForeSee Satisfaction Website Survey When visiting http://www.cgsmedicare.com

and you see the survey, please take a moment to provide feedback.

• Use ForeSee to give us your thoughts about the CGS website.

• Website enhancements are based on your requests.

Once you complete a survey, you will not be asked again for 14 days. Complete a survey then complete another in a few months to let us know changes have been made.

July 14, 2017

Find Us on Facebook® and Twitter®! Find the CGS DME MAC POE page

on Facebook®.

• Like our page and get all of the latest DME MAC POE information and more on the CGS DME POE Facebook® page at: http://www.facebook.com/CGSadminDME

Provider Outreach and Education is now on Twitter®.

• Search “@JBDMEPOE” on your Twitter account to follow us.

• Our tweets will include reminders about Medicare requirements, helpful tips, and POE events.

July 14, 2017

CGS ListServ Stay updated on DME MAC Jurisdiction B news!

Sign up for the DME MAC Jurisdiction B ListServ: http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

• Enter your name, location, email address, and company

• Choose the contract and/or specialty information that fits your business

• Click “Submit”

July 14, 2017

Jurisdiction B Resources Interactive Voice Response (IVR) Unit Phone: 1.877.299.7900

Customer Service Phone: Hours of Operation:

1.866.590.6727 Monday – Friday, 8:00 a.m. – 5:00 p.m. ET

Telephone Re-openings Phone: Hours of Operation:

1.844.240.7490 Monday – Friday, 8:00 a.m. – 5:00 p.m. ET

Paper Claim Submission Address: CGS PO Box 20013 Nashville, TN 37202

Adjustment Requests (Reopenings), EFT Form Submission, and Written Inquiries

Address: CGS PO Box 20007 Nashville, TN 37202

Redetermination Requests

Fax:

Address:

1.615.660.5976

CGS PO Box 20007 Nashville, TN 37202

Also accepted through esMD

Overpayment Appeals Fax:

Address:

1.615.782.4514

CGS Overpayment Appeals PO Box 23070 Nashville, TN 37202

July 14, 2017

Jurisdiction B Resources Supplier Manual

• http://www.cgsmedicare.com/jb/pubs/supman/index.html

Local Coverage Determinations

• http://www.cgsmedicare.com/jb/coverage/lcdinfo.html

Medical Review Resources

• http://www.cgsmedicare.com/jb/mr/resources.html

Online Tools

• http://www.cgsmedicare.com/jb/help/tools.html

July 14, 2017

Questions