gulf coast hfma meeting: medicare part a updates€¦ · january 2017 update of the hospital opps...

Gulf Coast HFMA Meeting:

Medicare Part A Updates

February 16, 2017

Disclaimer

All Current Procedural Terminology (CPT) only are copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.

Novitas Solutions does not permit videotaping or audio recording of training events.

Novitas Solutions Education

This education contains specific contractor guidance for providers in

Medicare Administrative Contractor (MAC):

• Jurisdiction H (JH) includes: Arkansas, Colorado, Louisiana, Mississippi,

New Mexico, Oklahoma, and Texas

Acronym List

Acronym Definition

CERT Comprehensive Error Rate Testing

CMS Centers for Medicare & Medicaid Services

CR Change Request

EDI Electronic Data Interchange

HIPAA Health Insurance Portability and Accountability Act

MBI Medicare Beneficiary Identifier

MLN Medicare Learning Network

NPI National Provider Identifier

PHI Personal Health Information

SSNRI Social Security Number Removal Initiative

Today’s Presentation

Agenda:

• Issue of Concern: Credit Balance Reporting

• Comprehensive Error Rate Testing (CERT) Program

• Quarterly Updates

• Novitas Initiatives

• Self-Service Options

Objectives:

• Know when and where to submit the credit balance report

• Understand how to avoid common documentation errors based on the

Comprehensive Error Rate Testing program findings

• Identify and understand the current Medicare changes

• Identify and utilize the educational resources and information

Medicare Credit Balance

Reporting – Issue of Concern

What is a Medicare Credit Balance?

Overpayments for Medicare services

Duplicate payments

Payment received for services not performed

Payment received for non-covered services

Payment received for outpatient services that should have been

bundled to inpatient

Overpayment due to deductible or coinsurance miscalculations

Medicare Credit Balance Report

Due Dates

Quarter End Medicare Credit

Balance Report

Due

Warning Letter

Mailed

Placed on 100%

Payment Withhold

March 31 April 30 May 15 June 03

June 30 July 30 August 15 September 03

September 30 October 30 November 15 December 03

December 31 January 30 February 15 March 03


CMS-838 Form Page 1


CMS-838 Form Page 2

Credit Balance Reporting Errors

Summary of Credit Balance Errors

Certification page errors:

• Invalid PTANs:

Using National Provider Identification (NPI)

Enter only 4 – 5 digits

• Blocks at the bottom of the Certification Page not checked:

Largest error on the Certification Page for the quarter

Detail page errors:

• Column 11 – Method of payment

• Column 13 – Reason for credit balance

• Column 14 – Value Code

• Column 15 – Billing name and address

Invalid Medicare Credit Balance Form (CMS-838):

• The correct form number is 0938-0600:

https://www.cms.gov/Medicare/CMS-Forms/CMS-

Forms/downloads/CMS838.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS838.pdf

Fax Errors

Multiple facilities on one fax:

• One facility one fax

Faxing separate Part A and Part B of A credit balances with separate

Certification Page:

• Providers are also not separating Part A from Part B of A

Faxing Credit Balance Reports when paying by check:

• When paying by check the Credit Balance Report must be mailed

Providers are faxing and mailing Credit Balance Report:

• Fax or mail not both

Medicare Credit Balance Status

Tool

Check the status of your quarterly reports by using the Medicare

Credit Balance Status Tool:

• Allow 2 – 3 days for zero balance certifications

• Allow up to 2 weeks for credit balance to be added

JH Providers:

• http://www.novitas-

solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId

=00024444

http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00024444

Medicare Credit Balance Status

Tool Results

Comprehensive Error Rate Testing

(CERT) Program

CERT Program

Program developed by CMS to monitor the accuracy of claims

processing

Designed to protect the Medicare trust fund and determine error

rates nationally and regionally

Random audits conducted on a monthly basis:

• AdvanceMed request medical records for claims selected as part of the

monthly random sample

• Medical record documentation supporting claim must be returned in

designated time frame

JH CERT page:

• http://www.novitas-solutions.com/webcenter/portal/CERT_JH/CERT

http://www.novitas-solutions.com/webcenter/portal/CERT_JH/CERT

Trending Errors- Part A

Insufficient documentation:

• Procedure/service billed

• Missing or illegible documentation and/or physician signature

• No valid physician’s order

• No physical therapy certified plan of care/treatment plan

Incorrect coding errors:

• Incorrect Diagnosis Related Group (DRG) billed

• Laboratory services

• Discharge disposition code

• Resource Utilization Group (RUG)

Medical Record Signature

Reminders

Categorized as “Insufficient Documentation” errors:

• Missing signatures

• Illegible handwritten signatures

• Electronic signatures not dated

• Attestation statements do not match the date of service

Records must be signed and dated

Include signature logs to determine handwritten signatures

Complete attestation statements when records are not signed

Do not add late signatures

CMS Complying with Medicare Signature Requirements:

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-

MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_I

CN905364.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

CERT Identification Online Tool

Provides status information for sampled claims using the Claim

Identification Number (CID) where a decision has been made by the

CERT contractor:

• Claim in Error- CERT error was assessed or not

• Status Date- last date that CERT updated/reviewed the case

• Status Decision- where the claim is with the CERT Review Contractor

• Appealed- if an appeal was initiated and the appeal status

• Error Code- errors assessed

Quarterly Updates

January 2017 Update of the

Hospital OPPS

Change Request # 9930:• Effective: January 1, 2017

• Implementation: January 3, 2017

Key Points:• New Device Pass-Through Policies

• Device Intensive Procedures

• Expiration of modifier “L1” for unrelated lab testes in the OPPS

• Conditional packaging change to apply at claim level

• Exception for laboratory packaging in the OPPS for Advanced Diagnostic Laboratory Tests (ADLTs)

• FX Modifier (X-ray Taken Using Film)

• CT Modifier

• Billing for Items and Services Furnished at Off-Campus Hospital Outpatient Departments

• Partial Hospitalization Program

• Drugs, Biologicals, and Radiopharmaceuticals

• Changes to OPPS Pricer Logic

• Update the Outpatient Provider Specific File (OPSF)

Reference:• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/downloads/R3685CP.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3685CP.pdf

Medicare Deductible, Coinsurance

and Premium Rates for 2017

Change Request # 9902:

• Effective: January 1, 2017


Key Points:

• 2017 Part A – Hospital Insurance:

Deductible: $1,316.00

Coinsurance:

$329.00 a day for 61st-90th day

$658.00 a day for 91st-150th day (lifetime reserve days)

$164.50 a day for 21st-100th day (Skilled Nursing Facility coinsurance)

• 2017 Part B –Medical Insurance:

Deductible: $183.00 a year

Coinsurance: 20 percent

Reference:

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9902.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9902.pdf

2017 Amounts in Controversy

JH Providers: http://www.novitas-

solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00002671

Appeal Level Time Limit for Filing

Appeal

Amount in

Controversy

Redetermination 120 days $0.00

Reconsideration 180 days $0.00

Administrative Law

Judge (ALJ) Hearing

60 days $150.00 for 2016

$160.00 for 2017

Medicare Appeals

Council of the

Departmental Appeals

Board (DAB)

60 days $0.00

Judicial Review in

Federal District Court

60 days $1,500.00 for 2016

$1,560.00 for 2017

http://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00002671

Medicare Outpatient Observation

Notice (MOON)

MOON is a standardized notice to inform beneficiaries they are:

• An outpatient receiving observation services

• Not an inpatient of the hospital or critical access hospital (CAH)

Federal Notice of Observation Treatment and Implication for Care

Eligibility ACT (NOTICE Act) passed August 6, 2015:

• NOTICE Act requires all hospitals and CAHs to provide written and oral

notification under specified guidelines

Form and instructions are located under the downloads section at:

• https://www.cms.gov/Regulations-and-

Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-

Items/CMS-10611.html

All hospitals and CAHs are required to provide the MOON beginning

no later than March 8, 2017

https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html

JW Modifier: Drug Amount

Discarded/Not Administered to Any

Patient




Key Points:

• Use of the JW modifier is required to identify unused drugs or

biologicals that are appropriately discarded

• Providers are required to document the discarded drug or biological in

the patient's medical record

Reference:


Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf


Therapy Cap Values for Calendar

Year (CY) 2017




Key Points:

• Outpatient therapy limits for:

Physical Therapy (PT) and Speech-Language Pathology (SLP) combined is

$1,980

Occupational Therapy (OT) is $1,980

Reference:




2017 Annual Update to the Therapy

Code List




Key Points:

• 2017 updates to the therapy code list are adding eight “always therapy”

codes:

97161 – 97168 for PT and OT evaluative procedures

• This update will delete the four codes currently used to report these

services (97001 – 97004)

Reference:



Current Procedural Terminology (CPT) only copyright 2016 American Medical Association. All rights reserved.


Updates to ESRD for Home and Self-

Dialysis Training, Retraining, and

Nocturnal Hemodialysis


• Effective: January 1, April 1, or July 1, 2017

• Implementation: January 3, April 3, or July 3, 2017

Key Points:

• New CC 87 is to be entered on 72X TOB to indicate dialysis patient is receiving a retraining treatment

• New modifier UJ is entered to show the provision of nocturnal hemodialysis:

Performed either at home or dialysis facility while patient is sleeping

• Home and self-dialysis training cap:

Patient should not receive more than 25 hemodialysis training treatments

CAPD and CCPD should not receive no more than 15 training sessions

Reference:

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9609.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9609.pdf

Medicare Coverage of Diagnostic

Testing for Zika Virus

Special Edition Article SE1615:

Key Points:

• Medicare Part B pays for clinical diagnostic laboratory tests for

diagnosis and treatment of a person’s illness or injury

• No specific HCPCS code for testing Zika virus

• Provide resources and cost information as requested by MAC to

establish appropriate payment amounts for the tests

Reference:


Network-MLN/MLNMattersArticles/Downloads/SE1615.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1615.pdf

Social Security Number Removal

Initiative

The Medicare Access and CHIP Reauthorization Act of 2015

(MACRA) requires CMS to remove Social Security Numbers (SSNs)

from all Medicare cards by April 2019

Medicare Beneficiary Identifier (MBI) will replace the SSN-based

Health Insurance Claim Number (HICN) on the new Medicare cards:

• 11-characters in length

• Made up only of numbers and uppercase letters (no special characters)

Transition period:

• Will begin no earlier than April 1, 2018 and run through December 31,

2019:

Either the HICN or the MBI can be used

Use the MBI or the HICN to check Medicare eligibility, after transition period

ends use only the MBI

Use the beneficiary identifier (MBI or HICN) you used to submit the claim

that’s under appeal, even after the transition period

What Providers Need to Know on

The Social Security Number

Removal Initiative

How will providers get MBIs?:

• During the transition period, the MBI will be on the remittance advice

when you submit a claim using your patient’s HICN

• In the message field on the eligibility transaction responses it will let you

know when a new Medicare card has been mailed to each person with

Medicare

• Your systems must be ready to accept the MBI by April 2018:

No earlier than April 2018 Medicare cards will be sent, people new to

Medicare will only be assigned an MBI

Claim forms:

• Not changing:

During the transition period, you can use either the HICN or the MBI

Once the transition period ends, you must use the MBI

Get more information about the SSNRI:

• https://www.cms.gov/Medicare/SSNRI/Index.html

https://www.cms.gov/Medicare/SSNRI/Index.html

Timely Reporting of Provider

Enrollment Information Changes

Special Edition Article SE1617

Key Points:

• All physician and non-physician practitioners and physician and non-

physician organizations must report the following changes within 30 days:

A change of ownership

An adverse legal action

A change in practice location

• All other changes must be reported to your MAC within 90 days of the

change

• Changes can be reported via the Internet-based Provider Enrollment, Chain

and Ownership System (PECOS) or the CMS 855 paper enrollment

application

Reference:

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/SE1617.pdf


Provider Enrollment Revalidation –

Cycle 2

Special Edition Article SE1605

Key Points:

• Requires all providers/suppliers to resubmit and recertify the accuracy

of their enrollment information

• All providers/suppliers must be revalidated under the new enrollment

screening criteria

Revalidation Cycle 2 expectations:

• CMS and MACs to streamline the process

• More standardized process across all MACs

• Reduce provider/supplier burden

Reference:


Network-MLN/MLNMattersArticles/Downloads/SE1605.pdf


CMS Look Up Tool for Provider

Enrollment Revalidation – Cycle 2

Due Dates are posted to CMS look up tool:

• Lookup tool will display all currently enrolled providers/suppliers by

either:

Due Date

TBD (To be determined)

• Posted up to 6 months before revalidation due date

• MACs will continue to issue revalidation notices in addition to the CMS

posted list

Avoid Deactivation:

• Submit a complete application to Novitas and include all active practice

locations and reassignments by the requested due date

Reference:

• https://data.cms.gov/revalidation

https://data.cms.gov/revalidation

Sequestration Update

Mandatory Payment Reduction of 2% continues until further notice for

the Medicare Fee For Service Program

For more information:

• https://www.cms.gov/Outreach-and-

Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-

Archive-Items/2016-03-03-Enews.html

Frequently Asked Questions:

• JH Providers:

http://www.novitas-

solutions.com/webcenter/portal/MedicareJH/page/pagebyid?contentId=00106

360

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2016-03-03-Enews.html

http://www.novitas-solutions.com/webcenter/portal/MedicareJH/page/pagebyid?contentId=00106360

Part A Quarterly/Annual Updates

Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) 2017:


Fiscal Year (FY) 2017 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes:


January 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.0:


2017 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update:






More Part A Quarterly/Annual

Updates

Quarterly Update to the Correct Coding Initiative (CCI) Edits,

Version 23.0, Effective January 1, 2017:



January 2017- Quarterly Average Sales Price (ASP) Medicare Part

B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files:



Influenza Vaccine Payment Allowances - Annual Update for 2016-

2017 Season:






Novitas Initiatives

Novitas Medicare Learning Center

Features:

• Create an individualized education account

• Register for webinars, teleconferences, and workshops

• Download your Continuing Education Unit (CEU) Certificates

• Be placed on a waitlist if the educational event you register for is closed

Benefits:

• Centralized location for all educational materials

• Track all of the educational events you’ve attended

• Access Medicare education 24 hours a day, 7 days a week with web-

based training modules

JH Providers:



812


Novitasphere

Free Web-based portal

Part A – Access to Eligibility, Medical Review Record Submission, ,

Claim Submission with File Status, and Audit and Reimbursement

Cost Reports Submission

Part B - Access to Eligibility, Claim Information and Remittance

Advice, Claim Submission with File Status, Electronic Remittance

Advice (ERA), Claim Correction, Secure Messaging and a MailBox

Live Chat feature

Dedicated Help Desk- 1-855-880-8424

For demonstrations and more information:

• JH Providers:

http://www.novitas-solutions.com/webcenter/portal/Novitasphere_JH/

http://www.novitas-solutions.com/webcenter/portal/Novitasphere_JH/

Website Satisfaction Surveys

Join Our Email List Today

Stay current with Medicare by receiving emails twice a week

Available email lists (not all-inclusive):

• Jurisdiction L

• Jurisdiction H

• Part B Electronic Billing

• Novitasphere Portal

• ABILITY| PC-ACE

• Medicare Remit Easy Print (MREP) Users

JH Providers join using:



968


Part A Publications

Latest Part A News & Web Site Updates

News Bulletins & Articles

Monthly Medicare Part A Newsletters

Novitas Solutions e-News

Novitas Educational Tips and Tools (NETTs)

Reference Manual

JH Providers:


solutions.com/webcenter/portal/Bulletins_JH/Publications

http://www.novitas-solutions.com/webcenter/portal/Bulletins_JH/Publications

On-Demand Education

Frequently Asked Questions

Novitas Educational Tips and Tools (NETTs)

Podcasts

Educational Videos and Tutorials:

• Watch and learn about the Medicare program and our website's

features

• JH Providers:

http://www.novitas-


http://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00082787

Provider Specialties / Services

One stop shop to direct access to consolidate information for certain

provider specialties and other specific services:

• Ambulance

• End Stage Renal Disease

• Federally Qualified Health Centers

• Medicare Secondary Payer

• Observation

• Rural Health Centers

• Skilled Nursing Facilities

• Therapy

• Inpatient Perspective Payment System

• And many more

JH provider specialty search:




Summary

Gave key points and references to the latest quarterly updates

Stay up to date with the latest Medicare changes by visiting the

Novitas Solutions website

Be aware of CERT documentation request and respond

appropriately

Complete the Credit Balance Report accurately and timely

Take advantage of the various self service options available to the

provider community

JH Customer Contact Information

Providers are required to use the IVR unit to obtain:

• Claim Status

• Patient Eligibility

• Check/Earning

• Remittance inquiries

Customer Contact Center- 1-855-252-8782

Provider Teletypewriter- 1-855-498-2447

JH Self-Service Tools:


solutions.com/webcenter/portal/CustomerServiceCenter_JH/Self-

Service+Tools

Patient / Medicare Beneficiary:

• 1-800-MEDICARE (1-800-633-4227)

• http://www.medicare.gov/index.html

http://www.novitas-solutions.com/webcenter/portal/CustomerServiceCenter_JH/Self-Service+Tools

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

Important Contacts

Denise Church

Manager Provider Outreach and Education

412-802-1739

[email protected]

Gregory Hart

Supervisor Provider Outreach and Education

501-690-2931

[email protected]

mailto:[email protected]

mailto:[email protected]

Thank you

gulf coast hfma meeting: medicare part a updates€¦ · january 2017 update of the hospital opps...

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