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10/10/2019
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Medicare Updates and What’s
Trending for 2019
Arkansas Chapter Healthcare Financial Management Association Conference
October 18, 2019
Disclaimer
All Current Procedural Terminology (CPT) only are copyright 2019 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.
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Subscribe to Novitas eNews!
Receive current updates via email directly from Novitas Solutions:
• Part A and Part B News
• Issued every Tuesday and Friday
• CMS MLN Connects issued Thursdays
• Subscribing is quick and easy:• Click the Join E-Mail List from our website tool bar
Acronym List
Acronym Definition
APC Ambulatory Payment Classification
CC Condition Code
CMS Centers for Medicare & Medicaid Services
CPT Current Procedure Terminology
ED Emergency Department
FAQ Frequently Asked Question
FISS Fiscal Intermediary Standard System
HCPCS Healthcare Common Procedure Code System
IOM Internet Only Manual
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Today’s Presentation
Agenda:
• Medicare Updates and Reminders
• Provider Enrollment Basics
• Methods of Enrollment Application Submission
• Overview of Critical Access Hospitals (CAH)
Objectives:
• Provide billing and documentation guidance for Medicare Part A providers
• Review basic information for Medicare enrollment
• Provide an understanding of the CAH background and designation
• Provide references and resources for future utilization
Medicare Updates and Reminders
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July 2019 Update of the Hospital
Outpatient Prospective Payment
System (OPPS)
MM11318:• Effective: July 1, 2019• Implementation: July 1, 2019
Key Points:• Changes to and billing instructions for various payment policies for OPPS providers• Summary of modifications:
New Temporary C-Code Established Effective July 1, 2019 New CPT Category III Codes Effective July 1, 2019 CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2019 Myocardial Imaging by Magnetocardiography (MCG) Drugs, Biologicals, and Radiopharmaceuticals:
New HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals
New Established HCPCS Codes for Separately Payable Drugs and Biologicals as of July 1, 2019
Descriptor Change for the HCPCS code J9355, Effective July 1, 2019 Drugs and Biologicals with Payments Based on Average Sales Price (ASP)
Reassignment of Skin Substitute Products from the Low Cost Group to the High Cost Group
New CPT Category I Vaccine Code Effective July 1, 2019 Status Indicator Revision for CPT Code 90689 Status Indicator Revision for HCPCS Code A4563
New Waived Tests
MM11231:
• Effective: July 1, 2019
• Implementation: July 1, 2019
Key Points:
• List of newly approved tests by the Food and Drug Administration (FDA) as waived tests under the Clinical Laboratory Improvement Amendments (CLIA)
Reference:
• Medicare Claims Processing Manual, Pub. 100-04, Chapter 16 –Clinical Laboratory Improvement Amendment (CLIA) Requirements Section 70.8 Certificate of Waiver
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Remittance Advice Updated Codes
CR11252:
• Effective: October 1, 2019
• Implementation: October 7, 2019
Key Points:
• This Change Request (CR) provides notification indicating updates to Claim Adjustment Reason Codes (CARC) and Reason and Remark Code (RARC) lists which are available on the Washington Publishing Company website
• This recurring update notification applies to Medicare Claims Processing Manual chapter 22, sections 40.5, 60.1, and 60.2 of Pub. 100-04
October 2019 - Quarterly Average
Sales Price (ASP)
CR11343:
• Effective: October 1, 2019
• Implementation: October 7, 2019
Key Points:
• October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
• CMS will supply the contractors with the ASP and not otherwise classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis.
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ICD-10 and Other Coding
Revisions to NCDs
MM11392:
• Effective: January 1, 2020
• Implementation: January 6, 2020
Key Point:
• Maintenance update of ICD-10 and other coding updates to NCDs due to newly available codes:
NCD20.7 Percutaneous Transluminal Angioplasty
NCD110.18 Aprepitant
NCD110.23 Stem Cell Transplantation
NCD150.3 Bone Mineral Density Studies
NCD220.4 Mammography
NCD220.13 Percutaneous Image-Guided Breast Biopsy
NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds
Medicare Beneficiary Identifier
(MBI) Updates
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MBI is coming! Are you ready?
Effective January 1, 2020, claims submitted to Medicare will require the beneficiary’s MBI number
Is your office or facility prepared for the MBI transition?
Use MBI now for all Medicare transactions
3 ways to get the MBI:
• Ask your patient for their card
• Use your Medicare Administrative Contractor’s look up tool: Sign up for the Portal to use the tool
• Check the remittance advice: MBI is returned on the remittance advice if a valid and active Health Insurance
Claim Number is submitted
Get Your New Medicare Card
Beneficiaries who did not receive their card can:
• Sign into MyMedicare.gov:
• Call 1-800-MEDICARE (1-800-633-4227) for assistance
• TTY users can call 1-877-486-2048
JH Part A Claims Submitted With MBI
August 2019
JH Region Total % of Claims Submitted with MBI
Arkansas 84.00%
Colorado 80.70%
Louisiana 76.00%
Mississippi 77.00%
New Mexico 82.40%
Oklahoma 85.20%
Texas 77.30%
Monthly Average 80.37%
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JH Part B Claims Submitted With MBI
August 2019
JH Region Total % of Claims Submitted with MBI
Arkansas 85.27 %
Colorado 79.30%
Louisiana 76.90 %
Mississippi 81.26%
New Mexico 75.94%
Oklahoma 83.44 %
Texas 74.96 %
Monthly Average 79.58%
Is Your Vendor/Clearinghouse
Submitting Your Claims With the MBI?
If you send the MBI to your vendor/clearinghouse on your Medicare claim for payment, but you see both the Health Insurance Claim Number and the MBI on your remittance advice:
• Your vendor/clearinghouse is not using the MBI to submit your claims
• Contact your vendor/clearinghouse today and ask about their process to submit Medicare claims
Starting January 1, 2020, Medicare will reject claims with the Health insurance Claim Number, with a few exceptions
For more information, see the MLN Matters Article
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Provider Enrollment Basics
What is Provider Enrollment?
Definition:
• Process of credentialing a provider/supplier into the Medicare program
Purpose:
• Assures only qualified and eligible providers/suppliers enroll in the Medicare program through validation and screening of the Medicare enrollment application and other supporting documentation
• Enrolling in Medicare with the MAC only includes enrollment into the traditional Part A and B Medicare Program
• Providers/suppliers must be enrolled in Medicare to render services to beneficiaries and receive reimbursement
Provider Enrollment guidelines and regulations to follow:
• Medicare Program Integrity Manual, Pub. 100-8, Chapter 15 - Medicare Enrollment
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National Provider Identifier (NPI)
Background:
• The NPI Final Rule, published on January 23, 2004, establishes that all health care providers covered under Health Insurance Portability and Accountability Act (HIPAA) obtain a National Provider Identifier and must comply with the requirements set forth within the statute
Definition:
• Unique identification number assigned to health care providers
Purpose:
• The NPI serves as the identification number assigned to health care providers for billing purposes
Obtaining an NPI
Providers must apply for a National Provider Identifier (NPI) prior to requesting enrollment with Medicare through the National Plan and Provider Enumeration System (NPPES):
CMS encourages providers to obtain NPIs based on a one-to-one relationship:
One NPI per PTAN/CCN
NPI Helpdesk:
• Phone:
1-800-465-3203 (NPI Toll-Free)
• Email:
National Plan & Provider Enumeration System
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Application Fee
Application Fee:
• Application Fee Requirements Chart
• 2019 Application Fee of $586.00 must be paid prior to submitting the application dependent on your supplier provider/supplier type:
Fee amounts are subject to change each calendar year
Fee may be applied to certain provider types only:
• Initial Enrollment
• Revalidation
• Addition of Practice Location
Fee can be paid using PECOS or Pay.gov
Application Fee Requirement Chart
This is not the full Application Fee Requirement Chart.
Provider/
Supplier
Type
Initial
Enrollment
Revalidation Change of
Ownership
Change of
Information
Addition of
Practice
Location
Clinic/ Group
Practice
No No No No No
Critical Access
Hospital
Yes Yes No No Yes
Physician No No No No No
Skilled
Nursing
Facility
Yes Yes No No Yes
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Methods of Enrollment
Application Submission
Submission Methods
There are two ways for providers/suppliers to enroll in the Medicare program:
• Paper applications
• Provider Enrollment, Chain, and Ownership System
Efficient – faster than completing and submitting a paper enrollment application
Secure – handled through a secure environment that meets all required government security standards
Easy – built in front-end editing and help screens
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Internet-Based PECOS
Definition:
• Provider Enrollment, Chain, and Ownership System (PECOS) is a CMS established internet-based system online enrollment process
Purpose:
• Allows physicians, non-physician practitioners, and provider and supplier organizations/facilities the option of enrolling, making a change in their Medicare enrollment information, or tracking the status of their Medicare enrollment applications throughout the Internet submission process
Providers must have a web user account (user ID/password) established in the Identity and Access System
Physicians, Non-Physician practitioners, or users on their behalf will access the Internet-based PECOS with the same user ID and password that is utilized for NPI Registry
Benefits of using PECOS
Advantages of using PECOS include:
• Completely paperless process, including electronic signature and Digital Documentation Repository:
Supporting Documentation
• Faster processing time than paper-based enrollment
• Tailored application process, only supply information relevant to the application and specialty
• More control over enrollment information, including reassignments
• Easy to check and update your information for accuracy
• Less staff time and administrative costs to complete and submit enrollment to Medicare
• Check pending Revalidation due date
• Receive approval letter when application gets approved in PECOS
We encourage you to use PECOS instead of paper Medicare enrollment applications
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Paper Applications
Definition:
• Paper applications are downloaded into hardcopy form, completed and mailed to the contractor in order to facilitate the enrollment process
Purpose:
• Enrollment can be facilitated through the submission of CMS-855 Medicare enrollment applications:
Applications are available on Novitas Solutions or CMS website
It is recommended applications be:
• Typed
• Legibly written with ink
Mail all hardcopy applications along with any supporting documentation:
• It is recommended that you retain a copy of the application and supporting documentation for your records
Signatures must be handwritten when mailing in paper applications
Eligible Providers to Enroll in
Medicare
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Part A Medicare Eligible
Organizations
Community Mental Health Center
Comprehensive Outpatient Rehabilitation Facility
Critical Access Hospital
End-Stage Renal Disease Facility
Federally Qualified Health Center
Histocompatibility Laboratory
Home Health Agency
Hospice
Indian Health Services Facility
Organ Procurement Organization
Outpatient Physical Therapy/ Occupational Therapy/ Speech Pathology Services
Religious Non-Medical Health Care Institution
Rural Health Clinic
Skilled Nursing Facility
Part A Medicare Eligible Hospital
Subgroups and Units
Hospital- General
Hospital- Acute Care
Hospital- Children’s
Hospital- Long-Term
Hospital- Psychiatric
Hospital- Rehabilitation
Hospital- Short-Term
Hospital- Swing-Bed approved
Hospital- Psychiatric Unit
Hospital- Rehabilitation Unit
Hospital- Specialty Hospital(cardiac, orthopedic, or surgical)
Other (Specify): ______
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CMS-855A Guidelines
Purpose:
• Complete this application if you are a health care organization and plan to bill Medicare for Part A medical services
Use this form for:
• Initial enrollment
• Reporting a change to Medicare information
• Change of Ownership
• Revalidation
• Termination of Medicare enrollment
EIN and Type 2 NPI must be reported on application
Make sure to include supporting documentation with enrollment package
CMS-855A Tutorial
CMS-855A Practice Locations
SE18023:
• Article Release Date: October 12, 2018
Background:
• Hospitals can operate an off-campus, outpatient, provider-based department of a hospital
• These additional locations can possibly be in a different locality than the main provider
• The service facility address of the off-campus, outpatient, provider-based department is used to determine the locality in these cases
Purpose:
• In accordance with the Social Security Act, non-excepted services provided at an off-campus, outpatient, provider-based department of a hospital were required to be identified
• Medicare systems will validate service facility location to ensure services are being provided in a Medicare enrolled location
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National Edit Testing
Purpose:
• CMS performed a national trial activation of Fiscal Intermediary Standard System (FISS) Edits 34977 and 34978 in production environments
• The testing was transparent to providers as most claims impacted by the test were suspended for one billing cycle and then editing was turned off so the claim could process as normal
Conclusion:
• Many providers were not sending the correct, exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into PECOS for their off-campus provider departments
Provider/Supplier Actions
Providers/suppliers need to make sure all practice locations listed on the enrollment file with Medicare, including off-campus, outpatient, and provider-based department locations:
• Access this information:
PECOS
Call Provider Enrollment Customer Service Representatives:
Must be an authorized/delegated official or contact person on the group’s enrollment file
Direct Data Entry (DDE) (projected for April 2019)
Add/change any practice locations (if applicable) through:
• PECOS
• Paper Application- CMS-855A
When submitting claims, make sure the location listed on the claim matches the enrollment file location exactly
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CMS-588 Electronic Funds
Transfer
Purpose:
• Used to have your Medicare payments deposited directly into your bank account
Required for all individuals/groups who plan to bill Medicare for services
Use this application for initial enrollment and change of information
Submit one supporting document:
• Voided Check
• Bank Letterhead:
Name on account
Account number
Routing number
Account type
Bank officer’s name and signature
CMS-588 Tutorial
Timely Reporting of Provider
Enrollment Information Changes
All physicians, non-physicians, physician and non-physician organizations and IDTFs must report the following changes within 30 days:
• Change of ownership
• Change of adverse legal action
• Change in practice location
• Change in general supervision (IDTF specific):
All other changes must be reported to your MAC within 90 days of the change
All providers and suppliers not previously identified above must report the following changes within 30 days:
• Change of ownership- including change in authorized/delegated officials:
All other informational changes must be reported within 90 days
Changes can be reported via the Internet-based PECOS or the CMS-855 paper enrollment application
Failure to do so could result in the revocation or deactivation of your Medicare billing privileges or payment suspension
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Processing CMS Applications
Application Overview
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Receipt/Initial Screening
Receipt date is the date we receive your Medicare application
Once uploaded into our system, you will receive a DCN
Enrollment Status Tool
Application Inquires
Throughout the course of application processing and once finalized, CMS authorizes the release of enrollment-related information to the following individuals listed on the application:
• Provider/Supplier
• Authorized Official
• Delegated Official
• Contact Person:
No limit on the amount of contacts per file
If you have multiple contacts and want to designate a primary contact for the application, please provide that on application
Contact us:
• 1-855-252-8782
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Review/Development
CMS requires that all MAC contractors review each enrollment application in accordance with the Medicare Program Integrity Manual
During review process:
• Development:
Fax
• Site Visit (if applicable)
• Fingerprint Background Check (if applicable)
Note: all development returned to Novitas must be accompanied with a newly signed and dated signature page, with the exception of supporting documentation:
• PECOS signature- electronic signature/upload signature/fax signature
• Paper application signature- mail signature/fax signature
Data Entered/ Issuance of
Notification
Once all needed information is received and complete, we document the application information in PECOS:
• Certified Providers / Suppliers:
If you are enrolling in Part B as a state certified ASC or PXS, or if you are enrolling as a Part A provider, we are required to forward your application to the state survey agency / CMS Regional Office for final approval
Information is then exported to our claims processing system
Once enrollment information has been exported from PECOS and received in the claims processing system, supplementary information is added to the file to ensure claims process accurately
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Update Medicare System/
Finalization
Mailed approval notification letter should be received within 7 to 10 business days after your information finalizes in PECOS:
• Provide valuable information regarding the steps you need to take to begin submitting Medicare claims
• Approval letters will be mailed to the Contact Person’s (Section 13) address
If PECOS application was utilized, an approval letter will be emailed upon finalization and mailed to the contact person
Processing Timeframes
Type of Enrollment Paper Applications Internet Based Pecos
Initial Enrollments,
Revalidations and
Reactivations
Note: Processing
timeframes may vary
60-210 calendar days from
receipt
80 percent of applications
will be processed within 60 –
80 calendar days
45-120 calendar days from
receipt
80 percent of applications
will be processed within 45 –
80 calendar days
Reassignments/
Change Requests
Note: Processing
timeframes may vary
60-120 calendar days from
receipt
80 percent of applications
will be processed within 60
calendar days
45-90 calendar days from
receipt
90 percent of applications
will be processed within 45
calendar days
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Cycle 2 Revalidation
Due Dates in Cycle 2
Due dates for Revalidations are displayed on the revalidation lookup tool, if due within six months:
• “TBD” (To Be Determined) displayed in the due date field for all other providers/suppliers:
Unsolicited revalidation submissions will be returned
• No extensions of the due date
Providers/suppliers who are within two months of their listed due date, but have not received a revalidation letter are encouraged to submit their revalidation application
Revalidation Notices sent via mail:
• Novitas Solutions will send a revalidation notice three to four months prior to your revalidation due date to at least two of your reported addresses:
Correspondence, special payments and/or your primary practice address
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Medicare Revalidation Lookup
Tool
Medicare Revalidation Lookup Tool:
• Lookup tool for revalidation due dates
Gap in Coverage
Failure to respond to revalidation request by due date or development request within 30 days:
• There will be a gap in coverage (no payments) between the date of deactivation and the new Medicare effective date:
Providers/suppliers will maintain their original PTAN
Reactivation date after period of deactivation will be based on the receipt date of the new, full, and complete application
Following the Medicare effective date guidelines, retroactive billing privileges can be granted
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Critical Access Hospital (CAH)
Overview
Critical Access Hospital
CAH Definition:
• A designation given to eligible rural hospitals by the CMS
• CAH program is a federal program established in 1997 as part of the Balanced Budget Act
CAH Purpose:
• CAHs aim to offer small hospitals in rural areas to serve residents that would otherwise be a long distance from emergency care
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CAH Overview
24-hour emergency care services, 7-days a week
Using either on-site or on-call staff, with specific on-site response timeframes for on-call staff
Maintain no more than 25 beds for inpatient beds or swing bed care
May operate rehabilitation and psychiatric distinct parts of up to 10 beds each
Provide acute inpatient care for a period that does not exceed, as determined on an annual average basis, 96 hours per patient
Coverage of inpatient and outpatient services is the same for CAHs and PPS hospitals:
• The only difference is CAHs are cost-reimbursed
Medicare Part A and Part B deductible and coinsurance apply
Outpatient split bill at calendar year end
CAH Split Billing
Definition:
• There are times when an outpatient claim may cross over the provider’s fiscal year end, the federal fiscal year end, or calendar year end
A calendar year is the one-year period that begins on January 1 and ends on December 31
Outpatient split billing is only required for services that span the calendar year end
Outpatient split billing is not required for services that span the provider or federal fiscal year end
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Distinct Part Units and
Reimbursement
Definition:
• Psychiatric and rehabilitation distinct part units within the CAH
Must meet conditions of participation requirements for hospitals and all requirements for acute care hospitals
10 bed limit for each distinct unit:
• Beds are excluded from the 25 inpatient and swing bed count limit for CAHs
Payment for rehabilitation units is under the Inpatient Rehabilitation Facility (IRF) PPS
Payment for psychiatric units is under the Inpatient Psychiatric Facility (IPF) PPS
MM3399 – “Further Information Related to Change Request 3175, Distinct Part Units of Critical Access Hospitals”
CAH Swing Bed Definition
Definition:
• A swing bed hospital is a hospital or CAH participating in Medicare that has CMS approval to provide post-hospital SNF care and meets certain requirements
• Medicare Part A (the hospital insurance program) covers post-hospital extended care services furnished in a swing bed hospital
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CAH Swing Bed Coverage
CAHs approved to furnish swing bed services may use their beds as needed to furnish either acute or post-hospital SNF-level care:
• Included in 25 bed limit
• Paid at 101 percent of reasonable costs
• Exempt from SNF-PPS
• Three-day qualifying hospital stay
• SNF-PPS Consolidated Billing provisions do not apply
• Split billing required for provider fiscal year and calendar year end
• Ancillary hospital services provided during skilled Part A stay included on swing bed claim
• Swing bed patients revert to being inpatient hospital Part B patients when not eligible for Part A services:
Drop below skilled level of care
Exhaust Part A benefits
No qualifying hospital stay
Bundling
Definition:
• Bundling of payments for services provided to outpatients who later are admitted as inpatients
CAHs are exempt from the one and three-day bundling window provisions that apply to PPS hospitals:
• Unless the CAH is wholly owned or operated by a non-CAH hospital
Outpatient CAH services are billed and paid separately from inpatient services
Outpatient services provided to a beneficiary who then becomes an inpatient are not bundled to the inpatient bill, even if they are provided during same encounter
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Inpatient CAH Services
Definition:• Inpatient care is medical treatment administered to a patient whose
condition requires treatment in a hospital or other health care facility, and the patient is formally admitted to the facility by a doctor
Physician order and certification for inpatient admission in accordance to regulations:
• Certification begins with order for admission
• Expected to be discharged or transferred within 96 hours
Payment made at 101 percent of reasonable costs
Payment for inpatient CAH services are subject to Part A deductible and coinsurance
Benefit periods apply to Part A services
Facility charges billed to Part A on a UB-04 or the electronic equivalent
Professional services billed to Part B on the CMS-1500 Claim Form or the electronic equivalent
Split billing is required for provider fiscal year end
Method I Overview
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Method I: Outpatient
Definition:
• A CAH that elects Method I bills the MAC for facility services only
• Facility outpatient charges billed to Part A on a UB-04 or the electronic equivalent:
Reimbursed at 101 percent of reasonable cost minus Part B deductible and coinsurance provisions
Except for CRNA Pass-Through
• Professional services billed to Part B on the CMS-1500 Claim Form or the electronic equivalent:
Reimbursed under the MPFS minus Part B deductible and coinsurance provisions
Method I: CRNA Pass-Through
Definition:• A CRNA is a licensed professional nurse who is licensed by the state in
which the nurse practices and provides anesthesia/related services
Qualifying CAHs providing low number of surgical procedures can apply for CRNA pass-through exemption:
• Hospital performed 800 or fewer surgical procedures• CRNA worked no more than 2080 hours for hospital
Pass-through applies to inpatient and outpatient Billing CRNA pass-through:
• Revenue code 037X for CRNA technical services • Revenue code 0964 for professional services • Apply appropriate HCPCS
CRNA pass-through exemption set up in Medicare Provider-Specific files will determine payment calculation:
• CRNA can only be paid on one methodology either Method II or Pass-through
Provider chooses to keep the exemption or relinquish
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Method II Overview
Method II Election
Definition:
• Method II includes payment for professional services at 115 percent of what would otherwise be paid under the MPFS
Method II only applies to outpatient services
New elections:
• Must be made in writing
• At least 30 days in advance of beginning of affected cost-report period
• Submit list of practitioners by specialty
Practitioners rendering services at a Method II CAH, may elect to reassign their billing rights to that CAH:
• Under this election, a CAH will receive payment from the Part A MAC for professional services furnished in the their outpatient department
• The individual practitioner must complete and submit the CMS-855R –“Reassignment of Medicare Benefits” form to reassign their billing rights
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Maintaining Method II Election
Method II remains in place until election is terminated
No annual updates
Notice to terminate must be made in writing at least 30 days prior to beginning of cost reporting period
CAHs need to submit the CMS-855R – “Reassignment of Medicare Benefits” for new physicians electing Method II:
• Include specialty information
References:
• Completing the Reassignment of Medicare Benefits (CMS-855R) Form Tutorial
• Medicare Enrollment Forms
Method II: Practitioner Election
Definition:
• Practitioners rendering services at a Method II CAH, may elect to reassign their billing rights to that CAH
Not all practitioners have to reassign benefits in order for the hospital to become a Method II CAH
Practitioner types eligible to reassign billing rights to the CAH:
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Method II: Practitioner Attestation
Definition:
• For each physician or practitioner who agrees to be included under the Optional Payment Method (Method II) and reassigns benefits accordingly
Practitioners choosing to reassign benefits to hospital must sign attestation:
• States that practitioner will not bill Part B for any services provided to hospital outpatients
• Attestation remains on file at CAH:
No standard form, CAH will need to create attestation
Method II: Outpatient
Definition:
• A CAH that elects Method II bills the MAC for both facility services and professional services furnished to its outpatients by a physician or practitioner who has reassigned his or her billing rights to the CAH
Include professional fees for outpatient hospital services on the UB-04 or the electronic equivalent
Professional services are reimbursed at 115 percent of the MPFS
NPP services are reimbursed at 115 percent of allowed percentage
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CAH Specialty Services and
Billing
CAH Ambulance Services
Definition:• For a CAH or a CAH-owned and operated entity to be paid 101 percent of
reasonable costs for its ambulance services, there can be no other provider or supplier of ambulance services located within a 35-mile drive of the CAH
CAH ambulance paid under ambulance fee schedule or at 101 percent of cost, depending on ambulance location in relation to CAH and other ambulance providers:
• If another ambulance is within 35 miles of CAH, CAH ambulance paid on ambulance fee schedule
If CAH-based ambulance and non-CAH ambulance are both beyond 35 miles from hospital, payment rate is determined by which is closer:
• CAH-based ambulance closer to CAH = 101 percent of reasonable cost
• Non-CAH-based ambulance closer to CAH = ambulance fee schedule
Use condition code B2 (CAH ambulance attestation) to indicate CAH ambulance meets fee schedule exemption criteria to receive cost reimbursement
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CAH Laboratory Services
Definition:
• A clinical diagnostic test
Patient is considered to be receiving services from the CAH if:
• Individual must either be receiving outpatient services in the CAH on the same day the specimen is collected, or
• Specimen must be collected by an employee of the CAH
Laboratory billing:
• Bill tests that meet definition of hospital outpatient with TOB 85X
• Non-patient (reference) tests are to be billed with TOB 14X
SNF labs:
• Lab services billed by SNF if patient is in Part A SNF stay
• CAH may bill Medicare directly for Part B SNF patients:
TOB 85X if hospital employee draws lab specimen or if SNF is hospital-based
TOB 14X if non-hospital based or if SNF employee draws specimen
CAH Observation Services
Definition:
• Observation care is a well-defined set of specific, clinically appropriate services, which includes ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital
Medicare Claims Processing Manual, Pub. 100-04, Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS), Section 290 – "Outpatient Observation Services"
Must be patient specific and not part of CAH internal protocol:
• Including same day surgical procedures
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CAH Observation Time
Begins at clock time documented in patient’s record in accordance with physician’s order
Ends when patient is discharged or admitted:
• May include medically necessary services and follow-up care provided after physician writes discharge order
• Inpatient status begins with the time of the physician order
Report units by rounding to nearest hour
CAH Observation Billing
TOB: 85X
Revenue code: 0762
HCPCS: G0378 (Hospital Observation Services, Per Hour)
All hours of observation billed on single line item using beginning date as line item date of service
All services related to episode of care must be on same claim
Current Procedural Terminology (CPT) only copyright 2018 American Medical Association. All rights reserved.
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Medicare Outpatient Observation
Notice (MOON) Instructions
Definition:• Issued to inform Medicare beneficiaries (including health plan enrollees)
that they are outpatients receiving observation services and are not inpatients of a hospital or CAH
MM9935:• Effective: February 21, 2017
• Implementation: February 21, 2017
Key Points:• Alterations to the MOON is prohibited, it must remain two pages:
May add logos, but cannot move text to another page
• Must add: Patients name
Patients number
Reason patient is in observation
• Retain the original signed MOON in the beneficiary’s medical record
Hospital Delivery of the MOON
Must use the Office of Management and Budget (OMB)-approved MOON:
• CMS-10611
Provide both standardized written, as well as oral notification
Must include the reason the individual is receiving observation services
Hospitals or CAHs must obtain the signature of the individual or an individual acting on behalf of the patient:
• Electronic issuance is permitted
• A paper copy of the MOON must be given regardless if paper or electronic issuance
Beneficiary refusal to sign:• Staff member who presented the written notification will sign and give
the date and time of refusal (date of notice receipt)
MOON FAQs
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References and Resources
General Resources
CMS CAH Fact Sheet:
• Booklet reviews and defines several CAH topics
CMS CAH Webpage:
• Provides basic information about being certified as a CAH provider
State Operation Manual, Chapter 2 – The Certification Process:
• CAH certification information
Novitas CAH Specialty Page:
• Central location for all CAH links, resources and references
MM7404 – CAH Optional Method Election for Outpatient Services:
• Information for CAHs electing Method II
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Summary
Reviewed the enrollment process from start to finish
Provided an understanding of the CAH background and designation
Identified the difference between Method I and Method II billing methods
Discussed specialty services and billing
Provided references and resources for future utilization
Thank You for Attending
Contact Information:
• Teresa Tatum
Education Specialist
Phone: (717) 526-6357
• Stephanie Portzline
Manager, Provider Engagement
Phone: (717) 526-6317
• Janice Mumma
Supervisor Provider Outreach and Education
717-526-6406
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Thank You for Attending
The information enclosed was current at the time it was provided. 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.
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