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MACtoberfest®
The information provided in this presentation was current as of November 7, 2018. Any changes or new information superseding the information in this presentation are provided in articles with publication dates after November 7, 2018 posted on our website at: www.PalmettoGBA.com/medicare
Disclaimer
2
CPT® only copyright 2017 American Medical Association.
All rights reserved.
The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2017 American Dental Association (ADA). All rights
reserved.
MACtoberfest®
Medicare Part B Billing and Clinical Updates
Presented by: Swandra Miller Senior Provider Relations Representative Paula Motes Senior Education Consultant Palmetto GBA
• Website Navigation
• Updates and Changes
• Hot Topics and Reminders
• Clinical Focus CERT Results
Medical Review Denials
Targeted Probe & Educate Reviews
Comparative Billing Reports
Advanced Communication Engine Edits
Agenda
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Website Navigation
News
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• MLN Connect Articles
• Special Editions
• Provider Enrollment Information
• Training and Holiday Closure Schedule
• D
Topics
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• Medicare Basics
• Appeals
• Fee Schedules
• E-mail Updates
• Denial Resolution
Self-Service Tools
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• Appeals Calculator
• CMS 1500 Claim Form
• eServices Portal
• Interactive ABN
• Forms
Upcoming JJ Education Events
Education
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Determinations/Policies
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• LCDs, NCDs, and Articles are housed on the CMS’ Coverage Database
• JJ and JM have identical LCDs
Updates and Changes
Top Inquiry Categories
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• Provided by CMS CMS MACRA web page
• Quality Payment Program (QPP) education: https://qpp.cms.gov/education
Medicare Access and CHIP Reauthorization (MACRA) Education
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Objectives
Allow Medicare beneficiary access to evidence-based diabetes prevention services
Lower the rate of progression to type 2 diabetes, improve overall health, and reduce spending
Expansion of the Diabetes Prevention Program (DPP) model test
Medicare Diabetes Prevention Program (MDPP) Expanded Model
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Coverage
Structured coaching sessions
Performance based payment
G-Codes
No referral required
Provider must enroll as a MDPP supplier
MDPP Supplier Road Map
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Hot Topics and Reminders
MSP Lookup Tool
Medicare Secondary Payer (MSP)
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• The MSP type entered on an electronic claim must correspond to the information Medicare has on file or the claim will be rejected
• Rejected claims: Do not have appeal rights Must be submitted as a new claim
MSP Claim Rejections
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Certain CPT/HCPCS codes and modifiers require additional documentation for claim adjudication. Providers can submit the additional documentation via:
• eServices – online portal where documents can be uploaded
• Fax – Claims Processing PWK Fax Cover Sheet
Submitting Additional Documentation
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Codes and Modifiers That Require Additional Documentation
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• Review and use the CPT and HCPCS Code Sets effective for the billed date of service
• Review the current CPT Coding Manual and CMS coverage guidelines to determine the qualifying service/procedure
• Review the CMS Medicare Learning Network Items and Services Not Covered Under Medicare Booklet
Denial Tips
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• Contact the patient or their responsible party for information regarding other insurance that may be liable for the charges related to the care provided
• Review the CMS Medicare Learning Network® Medicare Preventive Services Publication for a list of Medicare covered screening and preventive services along with any specific coverage and billing guidelines
Denial Tips
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• Eligibility Claims Status
eClaim Submissions
Clerical Error Claim
• Reopening Requests Remittances Online
eServices
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• Financial Forms Financial Information
Secure Forms • eDelivery
• eReview
• eServices User Guide
The Medicare Learning Network®
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Publications and Multimedia
News and Updates
Events and Training
Continuing Education
CMS 2018 MLN Matters® Articles
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS)
• Ask the Contractor Teleconferences (ACTs)
• Provider Outreach and Education Advisory Groups (POE-AGs)
• Webcasts
• Self-paced learning
• Videos
Education
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Part B Medicare Advisory
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Claims Payment Issues Log (CPIL)
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• IVR Flowchart
• Call Flowchart
• IVR Conversion Tool
• JJ Part B IVR Information
• JM Part B IVR Information
Interactive Voice Response (IVR)
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Contacts and Resources
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JJ Provider Contact
Center 877-567-7271
Jurisdiction J (JJ) Jurisdiction M (JM)
Palmetto GBA JJ and JM Part B
www.PalmettoGBA.com/JJB www.PalmettoGBA.com/JMB
Palmetto GBA E-Mail Updates
Select ‘Listservs’ from the top-right of your jurisdiction’s home page
Palmetto GBA eServices Select ‘eServices’ from the top navigation bar or select ‘eServices’ from the ‘Forms/Tools’ box in the center of your
jurisdiction’s homepage
CMS Website www.CMS.gov
JM Provider Contact
Center 855-696-0705
Social Networking
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How it Fits Together
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Comprehensive Error Rate Testing Program (CERT)
Service Type Improper Payment Rate Improper Payment Amount
Part A Providers 11.31% $18.24 B
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
44.60% $3.65 B
Hospital IPPS 3.91% $4.46 B
Part B Providers 10.16% $9.85 B
Overall 9.51% $36.21
CERT on the National Level
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CERT Jurisdiction J November 2017 Report
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CERT Comparison Part B JJ CERT Error Rate Increased
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• The reason for the improper payment determines the error category for the claim
• There are five major error categories: No Documentation
Insufficient Documentation
Medical Necessity
Incorrect Coding
Other
Part B CERT Errors
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JJ November 2017 Part B Error Rates (Projected)
CERT Error Rates by Type of Service
Type of Service JJ Projected Error Rate
JJ Projected Improper Payment
Overall-Part B 12.1% $841,177,563
Lab Tests-Other 37.3% $139,001,206
Other Drugs 15.1% $115,323,410
Ambulance 22.4% $94,641,516
Minor Procedures-Other 22.4% $61,220,151
Hospital Visit-Subsequent 14.6% $61,208,723
Hospital Visit-Initial 28.1% $60,201,065
Office Visit-Established 5.5% $57,398,629
Office Visit-New 20.5% $45,915,289
Hospital Visit-Critical Care 25.2% $16,071,438
Emergency Room Visit 9.8% $15,415,099
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• Make sure your contact information on file with CERT is up to date
• Submit documentation in a timely manner • Submit all requested documentation • Follow the instructions of the CERT additional
documentation request letter • Provide the exact documentation requested by CERT to
support the services billed and paid • Include the CERT barcode coversheet on top of each
medical record
Tips for Complying with the CERT Program
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• Maintain complete and accurate documentation
• Be sure the medical record supports the level of care billed
• Bill the appropriate code for the service that was provided
• Ensure the medical record is authenticated
• Obtain documentation housed by 3rd parties to support the billed service
Tips for Complying with the CERT Program
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If you receive a CERT error/denial
• Review the error
• Review the submitted documentation
• Appeal the denial and include any additional information that supports payment of the claim
Handling CERT Errors
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• Appeal
• CERT Redetermination Request Form
• Do not resubmit the claim Denial decision was based on review of medical records;
therefore, claims for these services may not be resubmitted, they may be appealed
Appeal CERT Denials
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• Providers have standard Medicare appeal rights
• Utilize the normal appeals process
• Redetermination requests must be submitted within 120 days
• Palmetto GBA appeals information
Appealing CERT Denials
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Medical Review
Part B Top Denials
Action Code
MR Comment
MR Comment Description Denied Amount
Number of Lines Denied
% of Lines Denied
F26 BILER Claim billed in error per provider 56,638 341 42.2%
529 NOTMN Information submitted does not support the medical necessity of services billed
44,968 217 26.9%
F10 NODOC Documentation for DOS not received or incomplete
10,095 86 10.6%
011 NOTIM Documentation lacks the necessary time component
7,800 37 4.6%
F06 NOSIG Documentation lacks the necessary provider signature
3,108 32 4.0%
F41 DNSRP Invalid/illegible provider signature
3,835 30 3.7%
015 EMCNM Documentation was not received or was incomplete
2,226 23 2.8%
JJ Top Medical Review Denials
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Action Code
MR Comment
MR Comment Description Denied Amount
Number of Lines Denied
% of Lines Denied
F12 WRONG Documentation contains incorrect/incomplete/invalid patient identification or date of service
2,033 17 2.1%
023 ALTMR Original medical record has been altered
1,105 11 1.4%
066 ISIGN Invalid/illegible provider signature 1,124 9 1.1%
093 ILDOC Information submitted deemed illegible
308 3 0.4%
F52 NOPSC Documentation not received/or incomplete
215 1 0.1%
528 NOTMN Information submitted does not support the medical necessity of services billed
223 1 0.1%
JJ Top Medical Review Denials
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• Up to three rounds of review
• Limited to 20 to 40 claims per round
• Rounds 2 and 3 will begin 45 – 56 days after the individual provider education is provided
• Discontinuation of review may occur if appropriate improvement and compliance is achieved during the review process
TPE
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• 99232-99233 (Subsequent Hospital Care)
• 99291-99292 (Critical Care)
• A0426/A0428/A0425 (Ambulance Services) Advanced life support, non-emergency
Basic life support, non-emergency
Ground mileage, per statute mile
Current MR TPE Reviews
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99232 • Subsequent hospital care,
per day, for the evaluation and management of a patient which requires at least 2 of these 3 key components:
• Expanded problem focused interval history
• Expanded problem focused examination
• Medical decision making of MODERATE complexity
Subsequent Hospital Care
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99233 • Subsequent hospital care,
per day, for the evaluation and management of a patient which requires at least 2 of these 3 key components:
• Detailed interval history • Detailed examination • Medical decision making
of HIGH complexity
• A physician cannot bill a subsequent hospital visit in addition to hospital discharge day management service on the same day
• Bill the appropriate level of service
• Documentation must support medical necessity and level of service billed
Subsequent Hospital Care
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99291
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
Critical Care
99292
Critical care, each additional 30 minutes, list separately in addition to code for primary service
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• Who qualifies as critically ill? Critical illness/critical injury impairs one or more vital organ
systems such as there is a high probability of imminent or life threatening deterioration in the patient’s condition
• Patient’s physical location in an intensive care/critical unit is not the defining factor
• Time based codes Documentation must support the time component Used to report the total amount of time the physician spends
providing critical care services
Total time <30 minutes, use other appropriate E/M code
Critical Care
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• Only one unit of 99291 may be billed by a physician for a patient per date of service
• Requires full attention of physician At bedside or on unit reviewing test results, imaging, etc.
• Physician must be immediately available to count time toward Critical Care codes
• Some otherwise separately reportable services are included in the Critical Care codes
Critical Care
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• A0426 – Ambulance service, advanced life support, non-emergency transport
• A0428 – Ambulance service, basic life support, non-emergency transport
• A0425 – Ambulance service, ground mileage, per statute mile
Ambulance Services A0426/A0428/A0425
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• Run report Must support the minimum Medicare Coverage Requirements for
the code billed
Include signatures
• Physician Certification Statement (non-emergent transports)
• Medical necessity
• Appropriate origin/destination modifiers
• Mileage Transport should be to closest facility that can provide the necessary
care
Ambulance Services
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Complete and accurate medical record documentation
• Must demonstrate medical necessity of the service AND
• Must demonstrate services were provided as billed
Avoiding Errors
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MLN Matters® Number: SE1237
• Medical records should be complete and legible
• Medical records should include the legible identity of the provider and the date of service
• Documents containing amendments, corrections, or delayed entries must employ widely accepted recordkeeping principles
• Adhere to Medicare signature requirements
Documentation
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SE1237
• Clinical Laboratory Services CERT – documentation issue
G0477 – G0483 (presumptive and definitive drug testing) • Local Coverage Determination: L35724 Controlled Substance Monitoring and
Drugs of Abuse Testing
• Established Patient Office Visits (99214-99215) • Other Drugs • Telehealth • Podiatry, Routine Foot Care Palmetto GBA enforces the supervisory physician requirement
Routine Foot Care LCD: L37643
Additional Error Prone Services
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• Respond to every medical record request
• Include progress notes or office notes that support the order and medical necessity of each test
• Physician order/intent to order
• Laboratory/test results or report
• Check for signatures
Laboratory Documentation Tips
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• If you bill laboratory or other diagnostic services to Medicare: You must obtain the treating physician’s signed order (or
progress note to support intent to order); and
Documentation to support medical necessity for the ordered service(s)
• Special Note: These records may be housed at another practitioner’s office or facility (for example, a nursing facility, hospital, or referring physician)
Billing Provider
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• Include the history that supports the need of the drug • Documentation should support the diagnosis of why the
patient is receiving the drug • Make sure documentation is for the right patient and the
right date of service • Check for signed and dated physician order • Follow the protocol when administering the drug • Document the drug name, dosage and method of
administration • Bill the correct number of units based on HCPCS code and
amount administered
Avoiding Drug and Biological Errors
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Comparative Billing Reports (CBRs)
What is a comparative billing report (CBR)?
• CBRs are reports that show providers how they rank against their peers in the state and nationally in billing for certain risk areas
• This report does not contain patient specific data
• The CBR applies to all provider types
• The CBR is not intended to be punitive or sent as an indication of fraud, it is intended to be proactive statements that will help the provider identify potential errors in their billing practice
Comparative Billing Reports
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• Prostate Pathology G0416
IHC Codes
• Optometry and Co-Management Services
JJ Part B CBRs
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If you receive a CBR:
• Evaluate your agency’s billing patterns to ensure the claims are billed accurately
• Examine the issue identified in the report to see if there are reasons your agency is an outlier in the data
• Evaluate the CPT/HCPCS/ICD-CM codes used related to the issue in the report to verify the most appropriate code is used
CBRs
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Tools to Use Advanced Communication
Engine Edits (ACE) eCBR
• Comprehensive suite of Medicare coding edits • Applied pre-adjudication at electronic claim and claim
line level • Delivered within the 277CA claim reports • Available to all submitters • No changes in electronic claims submission process • Integrates with clearinghouses • No downloads or software required • List of ACE edits on Palmetto GBA’s website
A-C-E: Advanced Communication Engine
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• Implemented July 2, 2018 DLP
mMOD
mMUE
mUN
mUO
• Palmetto GBA Smart Edit Listing: https://www.palmettogba.com/Palmetto/Providers.Nsf/files/EDI_277CA_Smart_Edits.pdf/$File/EDI_277CA_Smart_Edits.pdf
JJ First Set of ACE Edits
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JJ Most Recent Set of ACE Edits
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• Smart Edit Message will Inform providers that we’ve noticed a potential issue with their
billing pattern
Provide a link to eCBR and accompanying education material for more information on their billing pattern
• Sent back on 277CA report for each claim hitting the edit
• Educational only eCompare does not stop the claim from processing
eCompare Smart Edit
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• Limited topics available
• Data updated monthly
• Providers can pull for multiple time periods (last 3, 6, 12, or 18 months)
• Comparisons are made to the state and JJ for the specialty
eCBR
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• New Patient Office Visit (E/M) Services (CPT codes 99201-99205)
• Established Patient Office Visit (CPT codes 99211–99215)
Current eCBR Topics Available
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• Conduct self-audits
• Develop and utilize a checklist/audit/tracking tool to ensure compliance when responding to ADR request
• Pay close attention to your individual CBR report
• Check to ensure addresses on file are up-to-date
• Designate a contact for TPE
Be Proactive!
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MACtoberfest®
Questions?
