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JM HHH MEDICARE ADVISORY Latest Medicare News for JM Home Health & Hospice

What’s Inside... MLN Connects ..............................................................................................................2

Weekly Articles .......................................................................................................2 Special Edition Articles ..........................................................................................3 CMS Proposes 5 Rules Affecting FY20 Payment & Quality Programs ..................3

Home Health and Hospice Information......................................................................7KEPRO’s Patient Navigation Program.....................................................................7July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files ...................................7Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment ...............................................................................9

Documentation Requests (eMDR) for Registered Providers via the ElectronicSubmission of Medical Documentation (esMD) System.......................................11

Implementation to Exchange the List of Enrollment in Electronic Medical

Medicare Beneficiary Identifier (MBI) Look-up Tool............................................17 Get Your Medicare News Electronically ................................................................19 Medicare Learning Network® (MLN) ...................................................................19

Appeals Information...................................................................................................21Pub. 100-04, Chapter 29 – Appeals of Claims Decisions - Revisions ...................21

Audit and Reimbursement Information ...................................................................23 Unsolicited Voluntary Refunds...............................................................................23

Learning and Education Information.......................................................................23April 25, 2019, Ask the Contractor Teleconference (ACT) Rescheduled to May 2, 2019........................................................................................................232019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule ........................................................................................24 2019 Jurisdiction M (JM) Home Health Medicare Workshop Series ....................242019 Jurisdiction M (JM) Hospice Medicare Workshop Series.............................26Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA................................................................................................28

Medical Policy Information .......................................................................................29HHH Local Coverage Determinations (LCDs) Updates........................................29

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The JM HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction M HHH. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM HHH Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/Medicare.

CPT only copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable 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 rec-ommending 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 Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved.

May 2019 Volume 2019, Issue 05

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2 05/2019

CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data con-tained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Tools That You Can Use..............................................................................................31 Limitations on the Recoupment of Medicare OverpaymentsWeb Based Training ...............................................................................................31New Medicare Card Information ...........................................................................32

Helpful Information....................................................................................................33Contact Information for Palmetto GBA Home Health and Hospice ......................33

Upcoming Home Health and Hospice Educational Events

April 25, 2019, Ask the Contractor Teleconference (ACT) Rescheduled to May 2, 2019 The date of the Palmetto GBA Jurisdiction M HHH ACT changed from Thursday, April 25, 2019, to Thursday, May 2, 2019. The May 2, 2019 ACT will be held on 2 p.m. ET.

2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2019. These calls are open to all providers.

2019 Jurisdiction M (JM) Home Health Medicare Workshop SeriesPalmetto GBA is pleased to announce our 2019 Home Health Workshop Series. These workshops are designed for home health providers and their staffs to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

2019 Jurisdiction M (JM) Hospice Medicare Workshop Series Palmetto GBA is pleased to announce our 2019 Hospice Workshop Series. These workshops are designed for hos-pice providers and their staffs to equip them with the tools they need to be successful with Medicare billing, cover-age and documentation requirements.

For more information and registration instructions to attend these education sessions, please go to Page 3 of this issue.

MLN CONNECTS

MLN Connects will contain Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recent issues, please copy and paste the following links into your Web browser:

Weekly Articles

April 25, 2019 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-04-25-eNews. pdf


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-04-25-eNews.pdfhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-04-18-eNews.pdf




March 28, 2019 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-03-28-eNews. pdf

Special Edition Articles

CMS Proposes 5 Rules Affecting FY20 Payment & Quality Programs

Provider Education Message:

• Proposed FY 2020 IPPS and LTCH PPS Address Rural Health & Medical Innovation

• IRF: FY 2020 Proposed Payment and Policy Changes

• IPF: FY 2020 Proposed Payment and Quality Reporting Updates

• SNF: FY 2020 Proposed Payment and Policy Changes

• Hospice: FY 2020 Proposed Payment Rate Update

Proposed FY 2020 IPPS and LTCH PPS Address Rural Health & Medical Innovation On April 23, the Trump Administration proposed changes that build on the progress made over the last two years and further the agency’s priority to transform the health care delivery system through competition and innovation while providing patients with better value and results. The proposed rule would update Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for FY 2020 and advances two key CMS priorities, “Rethinking Rural Health” and “Unleashing Innovation,” by proposing historic changes to the way Medicare pays hospitals.

3 05/2019

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-04-11-eNews.pdfhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-04-04-eNews.pdfhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-03-28-eNews.pdf

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“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s health care system,” said CMS Administrator Seema Verma. “Rural Americans face many obstacles as the result of our fragmented health care system, including living in communities with disproportionally higher poverty rates, more chronic conditions, and more uninsured or underinsured individuals. The Trump administration is committed to addressing inequities in health care, which is why we are proposing historic Medicare payment changes that will help bring stability to rural hospitals and improve patients’ access to quality health care.”

In last year’s proposed rule, CMS invited comments on changes to the Medicare inpatient hospital wage index. Many responses reflected a common concern that the current wage index system makes the disparities between high and low wage index hospitals worse. To address these disparities, we are proposing to increase the wage index of low wage index hospitals. This change would ensure that people living in rural areas have access to high quality, affordable health care. We are considering several ways to implement this change, and the agency looks forward to comments on the different approaches.

We are also announcing proposals that would ensure Medicare beneficiaries have access to a world-class health care system by unleashing innovation in medical technology and removing potential barriers to innovation and competition in order to expedite access to novel medical technology.

“Transformative technologies are coming to the private market, but Medicare’s antiquated payment systems have not contemplated these technologies,” said CMS Administrator Seema Verma. “I am particularly concerned about cases that have been reported to the agency in which Medicare’s inadequate payment has led hospitals to curtail access to needed therapies. We must continually update our policies in response to the rapid pace of advancement in medical science.”

To ensure that Medicare payment supports broad access to transformative technologies, we are proposing several payment policy changes. These include proposing to increase the new technology add-on payment, which provides hospitals with additional payments for cases with high costs involving new technologies, including potentially new antimicrobial therapies. The increase would apply to all technologies receiving add-on payments starting on October 1, so that when a physician determines that a patient needs a qualifying new therapy, the hospital at which the therapy is administered would be able to more completely cover its costs. This change would promote patient access and reduce the uncertainty that innovators face regarding payment for new medical technologies for Medicare beneficiaries.

We are also proposing to modernize payment policies for medical devices that meet the Food and Drug Administration’s (FDA’s) Breakthrough Devices designation. For devices granted this expedited FDA approval, real-world data regarding outcomes for the devices in different patient populations is often limited. At the time of approval, it can be challenging for innovators to meet the requirement for evidence demonstrating “substantial clinical improvement” in order to qualify for new technology add-on payments.

Therefore, we are proposing to waive for two years the requirement for evidence that these devices represent a “substantial clinical improvement.” Waiving this requirement would provide additional Medicare payment for the technologies for a period of time while real-world evidence is emerging, so Medicare beneficiaries do not have to wait for access to the latest innovations. In the proposed rule, we highlight the unique challenges associated with paying for CAR-T technology in particular, the first-ever gene therapy to treat certain forms of cancer for which no other treatment options exist.


For More Information:

• Proposed Rule (https://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the)

• Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute), includes proposed changes to payment rates and quality programs

See the full text of this excerpted CMS Press Release (https://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovation) (issued April 23).

IRF: FY 2020 Proposed Payment and Policy Changes On April 17, CMS proposed a rule that would update Medicare payment policies for facilities under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the Inpatient Rehabilitation Quality Reporting Program for FY 2020.We are proposing to update IRF PPS payment rates using the most recent data to reflect an estimated 2.5 percent increase factor (reflecting an IRF-specific market basket estimate of 3.0 percent increase factor, reduced by a 0.5 percentage point multifactor productivity adjustment). We are proposing that if more recent data becomes available, we would use the more recent estimates to determine the FY 2020 market basket update and multi-factor productivity adjustment in the final rule. Accounting for an additional update to the outlier threshold so that estimated outlier payments remain at 3.0 percent of total payments, we project that IRF payments will increase by 2.3 percent (or $195 million) for FY 2020, relative to payments in FY 2019.

The proposed rule also includes:

• Proposed case-mix group revisions (using FY 2017 and FY 2018 data)

• Proposal to rebase and revise the IRF market basket

• Ensuring quality and safety/interoperability

CMS will accept comments on the proposed rule (https://www.federalregister.gov/ documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscal) until June 17. See the full text of this excerpted CMS Fact Sheet (https:// www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilities) (issued April 18).

IPF: FY 2020 Proposed Payment and Quality Reporting Updates On April 18, CMS proposed a rule that would update Medicare payment policies and rates for the Inpatient Psychiatric Facility (IPF) Prospective Payment System and the IPF Quality Reporting Program for FY 2020. We estimate total IPF payments to increase by 1.7 percent or $75 million in FY 2020. The IPF market basket update, which is used to update IPF payment rates, is 3.1 percent. After adjusting that 3.1 percent by two reductions required by law (the productivity adjustment of 0.5 percentage point and a 0.75 percentage point reduction), the net market basket update to IPF payment rates is 1.85 percent. Additionally, estimated payments to IPFs are reduced by 0.15 percentage point due to updating the threshold amount used in calculating outlier payments. For FY 2020, we are proposing to rebase and revise the IPF market basket to reflect a 2016 base year from a 2012 base year.

5 05/2019

https://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-thehttps://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-thehttps://www.federalregister.gov/documents/2019/05/03/2019-08330/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-thehttps://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acutehttps://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acutehttps://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acutehttps://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovationhttps://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovationhttps://www.cms.gov/newsroom/press-releases/cms-advances-agenda-re-think-rural-health-and-unleash-medical-innovationhttps://www.federalregister.gov/documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscalhttps://www.federalregister.gov/documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscalhttps://www.federalregister.gov/documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscalhttps://www.federalregister.gov/documents/2019/04/24/2019-07885/medicare-program-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal-fiscalhttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilitieshttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilitieshttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilitieshttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilities

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CMS will accept comments on the proposed rule (https://www.federalregister.gov/ documents/2019/04/23/2019-07884/medicare-program-fy-2020-inpatient-psychiatric-facilities-prospective-payment-system-and-quality) until June 17. See the full text of this excerpted CMS Fact Sheet (https:// www.cms.gov/newsroom/fact-sheets/fy-2020-proposed-medicare-payment-and-quality-reporting-updates-inpatient-psychiatric-facilities-cms) (issued April 18).

SNF: FY 2020 Proposed Payment and Policy Changes On April 19, CMS issued a proposed rule for FY 2020 that updates the Medicare payment rates and the quality programs for Skilled Nursing Facilities (SNFs). Effective October 1, we will begin using a new case-mix model, the Patient Driven Payment Model (PDPM). The PDPM focuses on the patient’s condition and resulting care needs, rather than on the amount of care provided, in order to determine Medicare payment.

We project that aggregate payments to SNFs will increase by $887 million, or 2.5 percent, for FY 2020 compared to FY 2019. We attribute this estimated increase to a 3.0 percent market basket increase factor with a 0.5 percentage point reduction for multifactor productivity adjustment.

The proposed rule also includes:

• Sub-regulatory process for ICD-10 code revisions for PDPM

• Aligning SNF PPS group therapy definitions with other post-acute care settings

CMS will accept comments on the proposed rule (https://www.federalregister.gov/ documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities) until June 18. See the full text of this excerpted CMS Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1718-p) (issued April 19).

Hospice: FY 2020 Proposed Payment Rate Update On April 19, CMS issued a proposed rule that would update the hospice payment rates, wage index, and cap amount for FY 2020. This rule also:

• Proposes to rebase the continuous home care, general inpatient care, and inpatient respite care per diem payment rates in a budget-neutral manner

• Proposes to modify the election statement requirements to require the hospice to include additional information aimed at increasing coverage transparency for patients that elect hospice

• Solicits comments on the interaction of the hospice benefit and various alternative care delivery models

As proposed, hospice payment rates are updated by 2.7 percent ($540 million increase in their payments) for FY 2020. This is based on the proposed FY 2020 hospital market basket increase of 3.2 percent reduced by the multifactor productivity adjustment of 0.5 percentage point, resulting in a proposed 2.7 percent increase in hospice payment rates for FY 2020. Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual market basket update for the year.

https://www.federalregister.gov/documents/2019/04/23/2019-07884/medicare-program-fy-2020-inpatient-psychiatric-facilities-prospective-payment-system-and-qualityhttps://www.federalregister.gov/documents/2019/04/23/2019-07884/medicare-program-fy-2020-inpatient-psychiatric-facilities-prospective-payment-system-and-qualityhttps://www.federalregister.gov/documents/2019/04/23/2019-07884/medicare-program-fy-2020-inpatient-psychiatric-facilities-prospective-payment-system-and-qualityhttps://www.federalregister.gov/documents/2019/04/23/2019-07884/medicare-program-fy-2020-inpatient-psychiatric-facilities-prospective-payment-system-and-qualityhttps://www.cms.gov/newsroom/fact-sheets/fy-2020-proposed-medicare-payment-and-quality-reporting-updates-inpatient-psychiatric-facilities-cmshttps://www.cms.gov/newsroom/fact-sheets/fy-2020-proposed-medicare-payment-and-quality-reporting-updates-inpatient-psychiatric-facilities-cmshttps://www.cms.gov/newsroom/fact-sheets/fy-2020-proposed-medicare-payment-and-quality-reporting-updates-inpatient-psychiatric-facilities-cmshttps://www.cms.gov/newsroom/fact-sheets/fy-2020-proposed-medicare-payment-and-quality-reporting-updates-inpatient-psychiatric-facilities-cmshttps://www.federalregister.gov/documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilitieshttps://www.federalregister.gov/documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilitieshttps://www.federalregister.gov/documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilitieshttps://www.federalregister.gov/documents/2019/04/25/2019-08108/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilitieshttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1718-phttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1718-phttps://www.cms.gov/newsroom/fact-sheets/proposed-fiscal-year-2020-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1718-p


The hospice payment system includes a statutory aggregate cap. The aggregate cap limits the overall payments per patient made to a hospice annually. The proposed hospice cap amount for the FY 2020 cap year will be $29,993.99, which is equal to the FY 2019 cap amount ($29,205.44) updated by the proposed FY 2020 hospice payment update percentage of 2.7 percent.

CMS will accept comments on the proposed rule (https://www.federalregister.gov/ documents/2019/04/25/2019-08143/medicare-program-fiscal-year-2020-hospice-wage-index-and-payment-rate-update-and-hospice-quality) until June 18. See the full text of this excerpted CMS Fact Sheet (https:// www.cms.gov/newsroom/fact-sheets/fiscal-year-2020-hospice-payment-rate-update-proposed-rule-cms-1714-p) (issued April 19).

HOME HEALTH AND HOSPICE INFORMATION

KEPRO’s Patient Navigation Program

KEPRO began a Patient Navigation program in fall 2017 as part of its Person and Family Engagement project with the Centers for Medicare & Medicaid Services (CMS). The program has helped over 14,000 Medicare beneficiaries transition from one care setting to another. As a result of KEPRO’s current contract with CMS coming to a close, the Patient Navigation program will be ending. KEPRO is not able to continue enrolling Medicare beneficiaries into the Patient Navigation program but will continue providing service to beneficiaries already enrolled in the program through April 30, 2019, to ensure all of their needs are met.

It is KEPRO’s understanding that CMS has future plans to implement another Patient Navigation program. KEPRO does not have any further details at this time.

Please contact the KEPRO Outreach Specialist for your state (https://www.keproqio.com/partners/ frmSpeaker.aspx) with any questions or for further assistance.

July 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

MLN Matters Number: MM11225 Related CR Release Date: March 22, 2019 Related CR Transmittal Number: R4264CP Related Change Request (CR) Number: 11225 Effective Date: July 1, 2019 Implementation Date: July 1, 2019

7 05/2019

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8 05/2019


Provider Type Affected This MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries.

Provider Action Needed CR 11225 provides the quarterly update for Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) Medicare Part B Drug Pricing Files and Revisions to the prior quarterly pricing files. CR11225 instructs MACs to download and implement the July 2019 and, if released, the revised April 2019, January 2019, October 2018, and July 2018 files. Make sure your billing staffs are aware of these updates.

Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are in chapter 4, section 50 of the Medicare Claims Processing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c04.pdf. Make sure that your billing staffs are aware of these changes.

Background The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply the MACs with the ASP and ASP NOC drug pricing files for Medicare Part B drugs on a quarterly basis. CR 11225 addresses the following pricing files:

• File: July 2019 ASP and ASP NOC -- Effective Dates of Service: July 1, 2019, through September 30, 2019

• File: April 2019 ASP and ASP NOC -- Effective Dates of Service: April 1, 2019, throughJune 30, 2019

• File: January 2019 ASP and ASP NOC -- Effective Dates of Service: January 1, 2019,through March 31, 2019

• File: October 2018 ASP and ASP NOC -- Effective Dates of Service: October 1, 2018,through December 31, 2018

• File: July 2018 ASP and ASP NOC -- Effective Dates of Service: July 1, 2018, throughSeptember 30, 2018

For any drug or biological not listed in the ASP or NOC drug pricing files, your MACs will determine the payment allowance limits in accordance with the policy in the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c17.pdf.

For any drug or biological not listed in the ASP or NOC drug pricing files that is billed with the KD modifier, MACs will determine the payment allowance limits in accordance with instructions for pricing and payment changes for infusion drugs furnished through an item of Durable Medical Equipment (DME) on or after January 1, 2017, associated with the passage of the 21st Century Cures Act which is available at https://www.gpo.gov/fdsys/pkg/PLAW-114publ255/pdf/PLAW-114publ255.pdf.

Note: MACs will not search and adjust claims that they already processed unless you bring such claims to their attention.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdfhttps://www.gpo.gov/fdsys/pkg/PLAW-114publ255/pdf/PLAW-114publ255.pdf


Additional Information The official instruction, CR11225, issued to your MAC regarding this change is available at https://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4264CP.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/ MAC-website-list.

Document History

Date of Change Description March 26, 2019 Initial article released.

Evaluation and Management (E/M) When Performed with Superficial Radiation Treatment

MLN Matters Number: MM11137 Revised Related CR Release Date: March 27, 2019 Related CR Transmittal Number: R4267CP Related Change Request (CR) Number: 11137 Effective Date: January 1, 2019 Implementation Date: March 25, 2019

Note: We revised this article on March 28, 2019, to reflect the revised CR 11137 that CMS posted on March 27. CMS revised the CR to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401. We revised the article to show that change. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information is unchanged.

Provider Types Affected This MLN Matters Article is for physicians and other providers billing Medicare Administrative Contractors (MACs) for Evaluation and Management (E/M) related to radiation services provided to Medicare beneficiaries.

Provider Action Needed CR11137 revises Chapter 13 of the Medicare Claims Processing Manual to allow providers to bill E/M codes 99211, 99212, and 99213 for Levels I through III, when performed with superficial radiation treatment delivery (up to 200 kV), when performed for the purpose of reporting physician work associated with:

• Radiation therapy planning

• Radiation treatment device construction

• Radiation treatment management when performed on the same date of service as superficial radiation treatment delivery

9 05/2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4264CP.pdf

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Make sure your billing staffs are aware of these revisions.

Background Radiation treatment delivery codes recognize technical-only services and contain no physician work, while providers should use treatment management codes to report the professional component. According to Current Procedural Terminology (CPT) guidance, providers should not report superficial radiation (up to 200 kV) with CPT codes for planning and management. Providers should report the professional component associated with this service with the appropriate E/M codes. According to Chapter 13 of the Medicare Claims Processing Manual,

Medicare does not make separate payment for E/M services for established patients.

CR11137 revises Chapter 13 of the Manual to allow providers to bill E/M codes 99211, 99212, and 99213 for Levels I through III when performed for the purpose of reporting physician work associated with:

• Radiation therapy planning (including, but not limited to, clinical treatment planning, isodose planning, and physics consultation)

• Radiation treatment device construction

• Radiation treatment management when performed on the same date of service as superficial radiation treatment delivery

Billing of these E/M codes with modifier 25 may be necessary if National Correct Coding Initiative (NCCI) edits apply.

Note: MACs will not search their files for claims already paid or to retroactively pay claims. However, MACs will adjust affected claims that you bring to their attention.



https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4267CP.pdfhttp://go.cms.gov/MAC-website-list


Document History

Date of Change Description March 28, 2019 We revised this article to reflect the revised CR 11137 that CMS posted

on March 27. CMS revised the CR to clarify that providers need to bill the 25 modifier when performing E/M services with CPT code 77401. We revised the article to show that change. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information is unchanged.

March 1, 2019 We revised this article to correct an E/M code on page 2 of this article, which should have been E/M codes 99211.

February 25, 2019 Initial article released.

Implementation to Exchange the List of Enrollment in Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

MLN Matters Number: MM11003 Reissued Related CR Release Date: April 16, 2019 Related CR Transmittal Number: R2281OTN Related Change Request (CR) Number: 11003 Effective Date: July 1, 2019 Implementation Date: July 1, 2019

Note: We reissued this article on April 19, 2019, to reflect an updated CR that added an MLN article attachment. We reissued this article to cover the CR in its entirety. We also revised the CR release date, transmittal number and the link to the transmittal.

Provider Types Affected This MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11003 introduced the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler (https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/ Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html). Make sure your billing staffs are aware of these changes.

Background In response to a number of requests from Medicare providers, the Centers for Medicare & Medicaid Services (CMS) is adding the functionality to send ADR letters electronically. CMS conducted a pilot

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https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.htmlhttps://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html

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supporting the electronic version of the ADR letter known as Electronic Medical Documentation Request (eMDR) via the esMD system. Since the eMDRs may contain Protected Health Information (PHI) data being sent to the prospective provider, CMS will require a valid consent from the authorized individual representing the provider along with the destination details including any delegation to their associated or representing organizations such as Health Information Handlers (HIHs).

The article published as a part of CR 11003 (which follows) will educate providers on the steps to be performed in order to receive the ADR letter electronically as an eMDR.

MLN Article Information Attached to CR 11003

Terminology

• NPPES: National Plan and Provider Enumeration System

• eMDR: Electronic Medical Documentation Request. (Electronic form of ADR)

• esMD: Electronic Submission of Medical Documentation

• HIH: Health Information Handler

• RC: Review Contractor

• ADR: Additional Documentation Request

Timeline

• July 2019 - Providers can register to give their consent that an HIH of their choice can receive transactions on their behalf.

• January 2020 - Providers can receive eMDR (Pre or Post Pay) through their HIH and process the data systematically.

• April 2020 - Providers can receive the list of ‘Requested Documents for an ADR’ along with eMDR through their HIH.

CMS requires its review contractors to support sending ADR letters electronically as eMDRs. The following contractors are exempted from participation in the eMDR process:

• Payment Error Rate Measurement (PERM) contractors

• The Comprehensive Error Rate Testing (CERT) contractors (can opt to participate in the eMDR process)

• Quality Improvement Organizations (QIO) (can opt to participate in the eMDR process)

• Unified Program Integrity Contractor (UPIC)


CMS is implementing systematic changes to esMD, for the providers to receive ADR letters (Pre/Post) electronically as eMDR. Advantages for the provider to receive eMDRs include:

• ADR letter data in an electronic format (eMDR) provides structured data that can be used for system processing

• Electronic ADR letter (as eMDR) reaches the provider faster and brings traceability to the exchange

• ADRs received electronically makes for efficient management of ADR requests and responses

Registration To receive the ADRs electronically as an eMDR via the esMD system:

• Provider must ensure that they have a Business Associate Agreement (BAA) in place with an HIH of their choice

• Provider must update the NPPES system to authorize their HIH to receive electronic transactions on their behalf (details mentioned below)

• HIH must complete additional processing steps after which the provider will receive eMDR

Points to Note for Registered Providers

1. eMDR (ADR letters sent via esMD) may have PHI data and requires:

• Consent from authorized individual to receive electronically

• Endpoint information where the eMDR has to be sent

• Active agreements between Provider and HIH, covering security and privacy requirements to handle PHI data

2. eMDR enrollment must use NPPES system to gather provider consent and endpoint information (only provider’s authorized individual has access to NPPES).

3. A provider (by NPI) must have an active agreement with one HIH at a time to send/receive data via esMD for all supported Lines of Businesses (LOBs).

4. A provider (by NPI) enrolling and registering for eMDR will receive ADR letters electronically via esMD from all RCs sending out ADR letters. CMS exempts PERM, CERT, UPIC, and QIO contractors from sending eMDRs.

5. A provider (by NPI) enrolling for eMDR is applicable to all its PTANs.

6. HIH shall complete additional processing steps after which provider receives eMDR (after January 2020).

7. The eMDR registration process (new, HIH change or removal) is not effective until all process steps are completed without any discrepancies.

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8. Provider is responsible to update NPPES with the latest HIH details.

9. A provider registering for the first time to receive eMDR will receive both electronically and by mail for the first three ADRs as a transition step.

10. A provider enrollment for MAC portals and DDE (Part A) are separate from eMDR enrollment and registration.

Update ‘Endpoint’ information in NPPES

Provider Profile in NPPES (to be updated by the provider’s authorized person)

Step 1: Navigate to the main page after logging in. (https://nppes.cms.hhs.gov)

Step 2: Scroll down and click on the edit icon under the ‘Action’ column.

https://nppes.cms.hhs.gov


Step 3: Proceed to the ‘Other Identifiers’ section.

Step 4: Scroll down to ‘End Point (optional)’ section and fill out the details as mentioned below the screen shot.

Provider shall enter the following information in NPPES:

• Endpoint Type: ‘Connect URL’

• Endpoint: [Connect URL of the HIH] (to be provided by HIH)

• Endpoint Description: [HIH OID] (to be provided by HIH)

• Endpoint Use: ‘Other’

• Other Endpoint Use: ‘CMS esMD eMDR’

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Is this Endpoint affiliated to another Organization? (Here provider shall choose ‘Yes’ and enter all the details of the HIH)

• Affiliation: [Enter the HIH Organization Name] (to be provided by HIH)

• Endpoint location: [Enter the HIH address] (to be provided by HIH)

Use cases

1. A new enrollment and registration request.

• Provider - Provider shall enter an agreement with an HIH to accept eMDR on their behalf. An authorized user of the provider shall update the NPPES system with the HIH details.

• HIH - HIHs after getting a confirmation of the NPPES update shall send an eMDR enrollment request to esMD.

2. Removal of an eMDR registered provider (does not want ADRs electronically any more).

• Provider - An authorized user of the provider shall remove the HIH details from the NPPES system.

• HIH - HIHs after getting a confirmation of the NPPES deletion, shall send an eMDR remove request to esMD.

3. Change from one HIH to the other (HIH1 to HIH2)

• Provider - An authorized user of the provider shall remove HIH1 and add HIH2 details in the NPPES system.

• HIH1 - HIH1 after getting a confirmation of the NPPES deletion, shall send an eMDR remove request to esMD.

• HIH2 - HIH2 after getting a confirmation of the NPPES update shall send an eMDR enrollment request to esMD.

Additional Information The official instruction, CR11003, issued to your MAC regarding this change is available at https://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2281OTN.pdf. A detailed provider education document is attached to CR11003.

CMS will notify providers via MLN Matters articles If there are any changes to the process of registration.


For more information on esMD visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2281OTN.pdfhttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.htmlhttps://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html


Document History

Date of Change Description April 19, 2019 We reissued this article to reflect an updated CR that added an MLN

article attachment. The article is reissued to include the CR attachment (MLN article) in its entirety. We also changed the CR release date, transmittal number, and link to the transmittal.

February 1, 2019 Initial article released.

Medicare Beneficiary Identifier (MBI) Look-up Tool

The Medicare Beneficiary Identifier (MBI) Lookup tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. If you do not already have access, sign up (https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do) now for access to eServices to use the tool.

As background, the New Medicare Card Project was established in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which mandates the removal of the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) from Medicare cards by April, 2019. CMS began mailing new Medicare cards with the MBI on April 2, 2018.

From April 1, 2018, to December 31, 2019, CMS will offer a transition period during which the system will accept both HICNs and MBIs on Medicare transactions (including eligibility requests and claims) for beneficiaries in the Medicare program prior to April 1, 2018 (i.e., those who received an HICN on their Medicare card). The transition period ensures your Medicare patients continue to get care by allowing you to use either the HICN or the MBI for all Medicare transactions. Note: Providers should not submit both numbers on the same transaction.

Beginning in January, 2020, providers may only use MBIs, with limited exceptions,

To submit an inquiry you must do the following:

• Once logged into eServices, click on the MBI LOOKUP tab located in the header of the portal

• Complete the required* fields:

o Beneficiary’s Last Name

o First Name

o Date of Birth

o Social Security Number (Note: the social security number must be in the XXX-XX-XXXX format)

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https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do

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• To meet our CAPTCHA requirements, you must select the I’M NOT A ROBOT checkbox

• Click SUBMIT INQUIRY

Figure 1: MBI Lookup Tab

Lookup Tool Status Results If the inquiry successfully returns an MBI, the screen will refresh with the data at the bottom.

Figure 2: MBI Lookup Successful Response Screenshot


In the event that your MBI Lookup request does not result in a successful response, eServices will display an error message to assist you. If any required fields are left blank or are not in a proper format, a message will appear advising you which fields to correct.

Figure 3: MBI Lookup Unsuccessful Response Screenshot

Check the CMS New Medicare Card Project Outreach & Education (https://www.cms.gov/Medicare/ New-Medicare-Card/Outreach-and-Education/Outreach-and-education.html) webpage and the Medicare Beneficiary Identifier (MBI) Lookup Tool Clarification article (https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdf) for additional information.

Get Your Medicare News Electronically

The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about:

• Medicare incentive programs • Fee Schedule changes • New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv:

Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

Medicare Learning Network® (MLN)

Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

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https://www.cms.gov/Medicare/New-Medicare-Card/Outreach-and-Education/Outreach-and-education.htmlhttps://www.cms.gov/Medicare/New-Medicare-Card/Outreach-and-Education/Outreach-and-education.htmlhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdfhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdfhttp://tinyurl.com/PalmettoGBAListserv

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The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index. html

• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”

• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources: • MLN Publications List: contains the electronic versions of the downloadable publications. These

products are available to you for free. To access the MLN Publications go to: https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service:

1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or Unsubscribe’ link under the ‘Options’ tab on the right side of the page.

2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-lmailto:[email protected]


APPEALS INFORMATION

Pub. 100-04, Chapter 29 – Appeals of Claims Decisions - Revisions

MLN Matters Number: MM11042 Related CR Release Date: April 12, 2019 Related CR Transmittal Number: R4278CP Related Change Request (CR) Number: 11042 Effective Date: June 13, 2019 Implementation Date: June 13, 2019

Provider Type Affected This MLN Matters® Article is for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs and Home Health and Hospices (HH&H) MACs for services provided to Medicare beneficiaries.

Provider Action Needed CR11042 incorporates the following policy updates to the Medicare Claims Processing Manual:

• The policy on use of electronic signatures

• Timing of signatures on transfer of appeal rights and the appointment of representative forms

• Tolling an adjudication timeframe when trying to cure a defective appointment form

• Limiting scope of redetermination review in certain instances

• Application of good cause for late filing involving beneficiary accessibility

• Application of good cause where there is a declared disaster

Key Points CR11042 revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 (Appeals of Claims Decisions)) and adds various policy clarifications regarding appeals of claims decisions. The CR includes the revised manual section.

Key revisions of interest to providers include the following:

1. The CR adds the terms Medicare number, Medicare Beneficiary Identifier (MBI), and attorney adjudicator to the Glossary.

2. The inclusion throughout the manual chapter of the Medicare number which incorporates both the Health Insurance Claim Number (HICN) and the new non-SSN based MBI.

3. Section 240.1 (Good Cause) - MACs will document when the MAC finds good cause for late filing on the appeal decision letter or the appeal case file.

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4. 240.4 (Good Cause - Administrative Relief Following a Disaster) - MACs will observe the addition of procedures to follow for appeals when a natural or man-made disaster occurs. When a disaster occurs, whether natural or man-made, MACs can expect an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks. For appeals purposes, as defined in this IOM, a ‘disaster area’ is one that the Federal Emergency Management Agency (FEMA) declares. When a Presidential declaration occurs, the HHS Secretary may, under Section 319 of the Public Health Service Act, declare that a Public Health Emergency (PHE) exists in the affected State. Once the Secretary declares a PHE, Section 1135 of the Social Security Act authorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements as determined necessary by CMS.

5. 270.1.2 (How to Make and Revoke an Appointment) – MACs will observe the amendments to accepted forms of signatures, which state that all signatures may be handwritten or electronic, digital, and/or digitized. Electronic, digital, and/or digitized signatures are acceptable for appointment of representative instruments providers submit via mail, facsimile, or a CMS-approved secure Internet portal/application.

6. 270.1.6 - Curing a Defective Appointment of Representative – MACs will observe tolling of timeframe when attempting to cure a defective appointment instrument. Where an adjudication time frame applies, the time from the later of the date that a defective appointment of representative was filed or the current appeal request was filed by the prospective appointed representative, to the date when the defect was cured, the party notifies the adjudicator that he or she will proceed with the appeal without a representative, or the 30-day deadline for curing the defect has elapsed with no response, does not count towards the adjudication time frame.

7. 270.1.7 (Incapacitation or Death of Beneficiary) – MACs will observe enhanced guidance to determine proper parties to appeals. MACs must follow state law when determining proper parties to initial determinations and appeals. Legal representatives of deceased beneficiaries can be proper parties to initial determinations and appeals. In order to verify that the requester is the proper representative, MACs must be aware of the current state laws in their jurisdictions and must accept any documentation acceptable by the appropriate state. The documentation must be sufficient to verify that the individual making the request is a proper and valid representative for purposes of initial determinations and appeals under 42 CFR Part 405. The revised manual section gives examples of proper documentation.


If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list

Date of Change Description April 12, 2019 Initial article released.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4278CP.pdfhttp://go.cms.gov/MAC-website-list


AUDIT AND REIMBURSEMENT INFORMATION

Unsolicited Voluntary Refunds

The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

LEARNING AND EDUCATION INFORMATION

April 25, 2019, Ask the Contractor Teleconference (ACT) Rescheduled to May 2, 2019

The date of the Palmetto GBA Jurisdiction M HHH ACT changed from Thursday, April 25, 2019, to Thursday, May 2, 2019. The May 2, 2019 ACT will be held on 2 p.m. ET.

The topics for this ACT are:

• Targeted Probe and Educate (TPE) Resources/Reminders

• Review Choice Demonstration (RCD) for Home Health Services

• Redesign of Hospice Periods – Additional Requirements

• Medicare Beneficiary Identifier (MBI) Updates

• eServices Online Provider Portal Updates

The Call-in Number is 800-374-0740 and the Passcode is 4875753

ACTs are intended to open the communication channels between providers and Palmetto GBA, which allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference. To help ensure your access to this conference call, we ask that you dial in 5 to 10 minutes prior to the scheduled start time.

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We encourage you to submit questions prior to the call. All questions must be received at least five business days prior to the teleconference. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form (https://palmettogba.com/palmetto/Mforms.nsf/files/PO-HHH-A-5008.pdf/$File/PO-HHH-A-5008.pdf?Open&). Once the form is completed, please fax it to (803) 935-0140, Attention: HHH Ask-the-Contractor Teleconference.

2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule

Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2019. These calls are open to all providers. Please mark your calendars to join our Medical Review Subject Matter Experts as they discuss and answer your questions concerning current TPE process.

Medical Review Hot Topic Targeted Probe and Educate Teleconference Date June 3, 2019 September 3, 2019 December 2, 2019

Time 2:00 p.m. -3:00 p.m. ET 2:00 p.m. -3:00 p.m. ET

2:00 p.m. -3:00 p.m. ET

Participation Number (877) 789-3907 (877) 789-3907 (877) 789-3907

Confirmation ID Number 1291838 5369828 6879568

This schedule is also available on the Palmetto GBA Event Registration Portal at https://www.palmettogba. com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304

2019 Jurisdiction M (JM) Home Health Medicare Workshop Series

Palmetto GBA is pleased to announce our 2019 Home Health Workshop Series. These workshops are designed for home health providers and their staffs to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

These workshops will provide insight for home health agency staff at all levels; however, we suggest that providers who are new to Medicare, or have new staff members, attend our Online learning courses for beginners at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section (https://tinyurl.com/y6mfg8ff) by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices.

https://palmettogba.com/palmetto/Mforms.nsf/files/PO-HHH-A-5008.pdf/$File/PO-HHH-A-5008.pdf?Open&https://palmettogba.com/palmetto/Mforms.nsf/files/PO-HHH-A-5008.pdf/$File/PO-HHH-A-5008.pdf?Open&https://palmettogba.com/palmetto/Mforms.nsf/files/PO-HHH-A-5008.pdf/$File/PO-HHH-A-5008.pdf?Open&https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304http://www.PalmettoGBA.com/hhhhttps://tinyurl.com/y6mfg8ff


To register for a 2019 Home Health Workshop session, please go to Event Registration Portal at https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B8QMKB7306 on the Palmetto GBA website.

The following topics will be covered during the workshop:

Part I:

1. Top Denials

a. Certification/Plan of Care

b. Face-to-Face Encounter

c. Medical Necessity

d. 56900

2. Teaching and Training

3. Screening and Documentation – Cardiovascular Patient

4. Medication Reconciliation

Part II:

5. What You Need to Know for 2019

a. 2019 Home Health Final Rule

b. Targeted Probe and Educate (TPE)

i. Responding to a TPE Additional Documentation Request (ADR)

c. Misuse of Requests for Anticipated Payments (RAPs)

i. eCBR - Home Health RAP Cancellations

d. Enhancing the Verification Process of Common Working File (CWF) Part A Provider Inquiries

e. Medicare Beneficiary Identifier (MBI) Updates

6. Data Driven Topics

a. Reason Code 37253 – Why Did My Claim Return?

7. eServices Online Portal

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8. Reminders

a. CERT Program

b. Provider Enrollment Revalidation

9. Provider Resources/Self Service Tools

a. Palmetto GBA Resources

b. CMS Resources

c. Top Links

d. Social Media

e. Education/Events

2019 Jurisdiction M (JM) Hospice Medicare Workshop Series

Palmetto GBA is pleased to announce our 2019 Hospice Workshop Series. These workshops are designed for hospice providers and their staffs to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

These workshops will provide insight for hospice agency staff at all levels; however, we suggest that providers who are new to Medicare, or have new staff members, attend Online learning courses for beginners offered at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section (https://tinyurl.com/y6mfg8ff) by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices.

To register for a 2019 Hospice Workshop session, please go to Event Registration Portal at https:// www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B8QKZE1474 on the Palmetto GBA website.

The following topics will be covered during the workshop:

Part I:

1. Utilization

a. Length of Stay

http://www.PalmettoGBA.com/hhhhttps://tinyurl.com/y6mfg8ffhttps://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B8QKZE1474https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B8QKZE1474


b. Medicare Spending

2. Improper Payments

3. Continuous Home Care

4. Effective Documentation of Certification of Terminal Illness

5. Documentation for the End Stage Renal Patient

Part II:

• What You Need to Know for 2019

• 2019 Final Rule

• Targeted Probe and Educate (TPE)

• Medicare Beneficiary Identifier (MBI) Updates

• Improvements in Hospice Billing and Claims Processing

• Data Driven Topics

• Election Statement Requirements

• Hospice Transfers

• eServices Online Portal

• Reminders

• CERT Program

• Provider Enrollment Revalidation

• Provider Resources/Self Service Tools

• Palmetto GBA Resources

• CMS Resources

• Top Links

• Social Media

• Education/Events

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28 05/2019


Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA

Don’t Miss this Wonderful Opportunity! If you are in search of an opportunity to interact with and get answers to your Medicare billing, coverage and documentation questions from Palmetto GBA’s Provider Outreach and Education (POE) department, please see these educational offerings which have a question and answer session.

To access the following information, go to: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/ JM-Home-Health-and-Hospice~AH2JQU8321

Quarterly Ask ACTs are intended to open the communication channels between providers the Contractor and Palmetto GBA, which allows for timely identification of problems Teleconferences and information-sharing in an informal and interactive atmosphere. These (ACTs) teleconferences will be held at least quarterly via teleconference.

Preceding the presentation, providers are given an opportunity to ask questions both on the topics discussed as well as any other question they may have. While we encourage providers to submit questions prior to the call, this is not required. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form). Once the form is completed, please fax it to (803) 935-0140, Attention: Ask-the-Contractor Teleconference

Quarterly Updates The Quarterly Update Webcasts are intended to provide ongoing, scheduled Webcasts opportunities for providers to stay up to date on Medicare requirements.

Providers are able to type a question and have it responded to by the POE department throughout the webcast. At the end of the presentation the moderator will also read and respond to questions submitted by attendees in order to share the responses with the group at large.

Event Registration Portal

Visit our Event Registration Portal to find information on upcoming educational events and seminars.

This is a complete listing of both our face-to-face outreach opportunities as well as our teleconference and webcast listings. Providers are able to dialogue with POE and get answers to their questions at all of these educational events.

If you have a question that you need an answer to today or a claims specific question which requires the disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at 1-855-696-0705.

https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/JM-Home-Health-and-Hospice~AH2JQU8321


MEDICAL POLICY INFORMATION

HHH Local Coverage Determinations (LCDs) Updates

Revised ICD-10 LCDs The table below provides a summary of recent HHH ICD-10 LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/hhh/lcd. Select “Active LCD Policies under the Medical Policies” section. Make sure “Active LCDs” is selected under the “Select LCD Types(s)” section. Then select the “Submit” button.

Title LCD ID Number Revision Number

Changes/Additions/Deletions Effective Date

HH Speech Language Pathology LCD Number: L34563 Revision Number: 12

Under Coverage Indications, Limitations and/or Medical Necessity removed all quoted Internet Only Manual (IOM) text from the first paragraph and changed verbiage to read “Coverage of therapy services, including speech-language pathology services, is based on an individual’s need for skilled care as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Home Health Services, Chapter 7, §40.2.3”. Under subheading Maintenance Program removed all quoted IOM text and changed verbiage to read “Coverage of therapy services, including speech-language pathology services, for a maintenance program is based on the individual’s need for skilled care in that maintenance program as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Home Health Services, Chapter 7, §40.2.1”. Under subheading Re-evaluation removed all quoted IOM text and changed verbiage to read “A re-evaluation would be considered reasonable and necessary for indications described by the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Home Health Services, Chapter 7, §40.2.3”. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. CPT® was inserted throughout the LCD where applicable.

04/04/2019

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http://www.PalmettoGBA.com/hhh/lcd

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This advisory should be shared with all health care practitioners and managerial members of the provider/ supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www. PalmettoGBA.com/hhh.

Address Changes

Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the CMS website. To obtain the hard copy form plus information on how to complete and submit it, visit the Palmetto GBA website (www.PalmettoGBA.com/hhh).

http://www.PalmettoGBA.com/hhhhttp://www.PalmettoGBA.com/hhhhttps://pecos.cms.hhs.govhttp://www.PalmettoGBA.com/hhh


TOOLS THAT YOU CAN USE

Limitations on the Recoupment of Medicare Overpayments Web Based Training

To access this module and other online training courses, please go to the Self-Paced Learning Section (https://www.palmgba.com/elearn/limits_on_recoups/ie7/index.html?dhtmlActivation=inplace) of the JJM HHH website.

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https://www.palmgba.com/elearn/limits_on_recoups/ie7/index.html?dhtmlActivation=inplace

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CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data con-ta