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Created January 2018 wpsgha.litmos.com Page 1 of 19
Lakeland Medical Office Association Denials and How to Avoid Them!
Patient Eligibility • WPS GHA Portal User Manual https://www.wpsgha.com/wps/wcm/connect/mac/9916b093-2279-4d42-
955b-27e44f269c72/transactional-portal-user-
manual.pdf?MOD=AJPERES&CVID=lXtasMi&CVID=lC8JcHd&CVID=lC8JcHd
• Transactional Portal
• Requires sign in
• Requires MFA
o https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/multi-factor-
authentication-mfa/
o A second level of user authentication
• Information available
o Eligibility dates for both Part A and B
Can be different
o Medicare Advantage
Enrollment and termination dates
Contract name and address
o Home Health and Hospice
Start and end dates
Provider NPI
NPPES https://npiregistry.cms.hhs.gov/
Enter the Home Health or Hospice NPI and the screen will provide the name and address
Medicare Secondary Payer • Determine who is the primary payer
• Ask the patient
• Utilize a document to capture the necessary information
• Categories
o Working Aged
Patient and/or spouse has employment status
Employer provided coverage
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20 or more employees
o End-Stage Renal Disease (ESRD)
No employee number restriction
Applies to all services not just those ESRD related
30-month coordination period
Regular course of dialysis initiated
Self-dialysis training begins
Kidney transplant
Medicare pays as secondary during the 30 months
Medicare pays primary after the 30 months even if employer coverage continues
o Disabled beneficiaries under a large group health plan
100 or more employees
o Worker’s Compensation
o No-Fault Insurance
o Liability Insurance
Conditional primary payment
Timely Filing • Service must be submitted within one calendar year from the date of service
o Includes MSP claims
o Patient is not liable for charges
Only what would have been the 20% coinsurance
o Denials have no appeal rights
o Very rare to overturn
A Medicare administrative error
Rendering Physician Missing/Invalid • The rendering provider number must be present
• Rendering NPI must be matched to the billing NPI and Tax ID
• If they do not coordinate, the claim will deny
NOC Codes • NOC codes are used when a more specific code is not available
• Provider are required to provide a description of the service
o Can utilize item 19 or the electronic equivalent
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o Be prepared to provide documentation to show what was performed
• If we can find a code that matches the description, we will deny
o The claim will need to be recoded and resubmitted
• We could use a combination of procedure codes or other methods to pricing
SNF Consolidated Billing • Patient in a covered Part A stay
o Physical therapy exception
• Services considered technical are part of the SNF billing
o X-rays
o Laboratory testing
o Administration of injections
o Drugs and biologicals
• Excluded services
o When provided by a hospital or critical access hospital
• Charges go back to the SNF
• Cannot collect from the patient
• Common problems
o SNF fails to inform outside entity resident is in a covered Part A stay
o Valid payment contract was not arranged
o Beneficiary temporarily leaves SNF and obtains services subject to CB from another provider
Unprocessable • Each line of service must link a diagnosis code
o Services October 15, 2015 and after must use ICD-10
• Multiple units of service
o Must be able to determine specific dates
Example 3 units billed on 1/15/18
2 units billed on 1/15/18 and 1/16/18
o Cannot determine
Example 3 units billed with from date of 1/15/18 and to date of 1/20/18
o Utilize modifier if appropriate for same day
RT
LT
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E Modifiers
F Modifiers
• POS and procedure code match
o Professional and technical components billed in a facility
o Use of office E/M
• Codes
o ICD-10 codes are updated as of October
o Procedure codes updated as of January
Duplicate Denials • Claims processing time for clean claims is 14 days
• Payment will not be released prior to that date
• Before resubmitting a claim
o Look at the Remittance Advice
o Utilize the portal to determine status
Allowance went to deductible
Claim still in process
Determine if awaiting documentation
Claim denied
Determine denial
Correct claim
Appeal
• Duplicate elements include:
o Same HICN
o Same provider number
o Same type of service
o Same procedure code(s)
o Same place of service
o Same billed amount
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LCD • Policies affecting the WPS GHA processing center
• Defines reasonable and necessary for payment
• Evidence based process
• Requires public comments
• Reasons for LCD
o Use of new technology
o Services with abusive history
o Data driven
o Inconsistent provider billing
o High dollar
o High volume
• Reading LCDs
o Jurisdiction
o Effective dates
Original
Revisions
o Provides IOM references
• Coverage Guidance
o Medical necessity
o Documentation guidelines
o Coding information
Procedure codes
Diagnosis codes
o Additional coding or billing guideline
• Reconsideration process
o Provide information on why you believe a change is needed
o We will evaluate for appropriate request
o Will evaluate information for possible changes
Frequency of Services • LCD
• NCD
• CMS instructions
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• Services provided more frequently
o Denial
o Limitation of liability
o ABN
ABN • Provide protection for the patient
• Given prior to the service being performed
• Services denied for
o Medical necessity
o Frequency
• Modifiers
o GA – provided the ABN
Only if you are anticipating denial
o GZ – should have provided the ABN
o GX – voluntary usage for items never covered by Medicare
Modifier GY • Modifier used to tell Medicare to deny the claim
• Only used when the procedure code is payable, but the situation is not
o Cosmetic surgery
• Don’t use to by-pass Medicare rules
Telehealth • Patient is located a rural area
• Outside a MSA or
• In a HPSA
• Originating site is appropriate
o Originating site procedure code Q3014
• Practitioner is appropriate
• Utilize real-time interactive audio and video telecommunications
• Medicare has listing of procedure codes available for telehealth
• Place of service code 02 for performing provider
• Place of service is where patient is located for originating site
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• Modifier GT is no longer used
• Submit modifier GQ when service is “store and forward”
NCCI • Location - https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
o Purpose
To promote correct coding and submission of claims
Applies to Medicare Part A and Part B processing
o Information on the file
Procedure to Procedure Edits
MUE
Add-On codes
Quarterly Updates
How to use the tools
Correspondence manual
Use of Modifiers
59
XE
XP
XS
XU
Others
Address to submit request for updates
Global Surgery • E/M included in the payment for the procedure
• MPFSDB shows the global period for each procedure code
• The global period would include
o 00-day
o 10-day
o 90-day
o Other indications
• Items to think about
o Services by other members of the same group
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o Services by an NPP
o Treatment of infections are considered part of the global service
• Modifiers
o 24 – unrelated E/M during the postoperative period
Documentation would support unrelated service
Modifier usage beginning the day after the procedure
Modifier valid during the postoperative period
o 25 – Significant, separately identifiable service
Same day as the procedure
Significant – great amount of additional work, above and beyond what would normally be
performed
Separately identifiable – the documentation shows the separation
Evaluate documentation prior to adding modifier to service
Diagnosis does not determine usage
Not a decision for minor surgery
o 57 – Decision for major surgery
Day before or day of major (90 day) surgery
Documentation must determine when the decision for surgery was made
• Clearance for Surgery
o Generally performed by someone other than the surgeon
o Documentation must show medical necessity for separate service
o Notify patient if not separately payable
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New Medicare Cards • Formerly called the SSNRI (Social Security Number Removal Initiative)
CMS New Medicare Card Web Page • Access at https://www.cms.gov/medicare/new-medicare-card/nmc-home.html
Background • HICN contains SSN of primary beneficiary
– Prefix or suffix gives additional details
• New rules mandated by MACRA
• Decrease risk of identity theft
– Increase safety of program funds
• Unique numbers and redesigned cards
– Deceased, active and new beneficiaries
Transition Timeline • Systems ready by 4/1/18
• HICN or MBI
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During Transition • Message on eligibility response when new card sent
• Remittance Advice will include MBI if HICN was used
– Beginning 10/1/18
• Limited use of HICN after transition period
– Appeals, adjustments, etc.
CPO – Hospice • Place of service
• Procedure codes
o Supervision for hospice care (G0182)
• Monthly billing
o Date of service
• Complex and multi-disciplinary care modalities
• Attending physician
o Modifier GV
• Physician does not have relationship with hospice
o Relationship could include volunteer medical director
• Patient chooses attending physician
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Face-to-Face Requirements • An E/M within the previous 6 months
• Services provided incident to do not meet this requirement
• Special rules for Medicare Advantage patients
• Special rules for patients not eligible during the face-to-face encounter
• Services Included
o Regular physician development and/or revision of care plan
o Review of subsequent and ongoing reports of patient status
o Review of laboratory and other studies
o Communication with other health care professionals
o Integration of new information in the care plan
o Documentation of time
30 minutes of care
o Services not included in the time
Discussions with the patient, his/her family to adjust medications or treatments
Time spent by staff in getting or filing charts
Travel time
Telephoning prescriptions
Time spent by nursing staff or in discussions with nursing staff
Low intensity services as part of an E/M service
Who Can Perform • Physicians who are responsible for the patient’s care
• NPPs practicing with their scope of practice
• Patient has chosen practitioner as their attending physician
Attention Physicians! • Your medical record documentation and communication with a HHA helps determine payment of
agency care and services supplied to your patient
• Home Health Agency CERT
o 59 percent improper payment rate in 2015
o 42 percent improper payment rate in 2016
o Errors caused by:
Physician medical record documentation
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Orders
Certifications
Medicare Home Health Eligibility Criteria • A Medicare beneficiary must meet following 5 criteria:
o Be confined to home
o Need skilled services
o Be under care of physician
o Receive services under POC established and maintained by physician
o Have had a FTF encounter for their current diagnosis with physician or allowed NPP
Criteria 1: Confined to the Home • Individual considered “confined to the home” (homebound) and the following criteria are met
First Criteria One of the Following must be met:
Second Criteria Both of the following must be met:
Because of illness or injury, individual needs aid of supportive devices such as crutches, canes, wheelchairs, and walkers; use of special transportation; or assistance of another person to leave their place of residence
There must exist a normal inability to leave home
Have a condition such that leaving his or her home is medically contraindicated
Leaving home must require a considerable and taxing effort
Criteria 2: Need Skilled Service • Skilled nursing care on an intermittent basis
• Physical therapy
• Speech-language pathology
• Occupational therapy
Criteria 3: Be Under the Care of a Physician • Physician/patient encounter determines the need for home health care
• Patient is starting home health directly after discharge from an acute/post-acute care setting
o Certifying physician not following patient after discharge
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Certifying physician must identify community physician who will follow patient after discharge
Criteria 4: Plan of Care • Orders must include:
o Type of services to be provided to patient
o Professional who will provide them
o Nature of individual services
o Frequency of services
• Must contain all pertinent diagnoses, including:
o Patient’s mental status
o Types of services, supplies, and equipment required
o Frequency of visits to be made
o Prognosis
o Rehabilitation potential
o Functional limitations
o Activities permitted
o Nutritional requirements
o All medications and treatments
o Safety measures to protect against injury
o Instructions for timely discharge or referral
o Any additional items HHA or physician chooses to include
• Plan of care includes course of treatment for therapy services
o Course of therapy treatment must be established by physician
After any needed consultation with qualified therapist
o Plan must:
Include measurable therapy treatment goals
Pertain directly to patient’s illness or injury and resultant impairments
Include expected duration of therapy services
Describe course of treatment consistent with qualified therapist’s assessment of patient’s
function
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Criteria 5: Face-to-Face Encounter • No more than 90 days prior to start of home health care
o Or within 30 days after
• Related to primary reason patient requires home health services
• Performed by allowed provider type
• Certifying physician must document date of encounter
Certification • Statement from certifying physician acknowledging all 5 eligibility criteria have been met
• Dated signature o Below statement from certifying physician
• Date of face-to-face encounter
Recertification • Documentation to support initial certification
• Date of face-to-face encounter at time of initial certification
• Physician estimate regarding continued length of needed skilled services
• Statement acknowledging all 5 eligibility criteria continue to be met
• Dated signature o Below statement from recertifying physician
Physician Documentation and Collaboration • Documentation should be submitted to and/or shared with HHA
• Patient encounter could include office service, telehealth service, discharge management, etc.
• Medical record should include:
o Documentation to support need for home health care
o Diagnosis information pertaining to need for home health care
• Service submitted to Medicare under appropriate procedure code
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• Physicians can submit claims for:
Home Health Recertification
(G0179) Includes documentation showing patient’s continuing need for home health, any changes in plan, etc.
Home Health Certification
(G0180) Includes development of plan of care, sharing that information with HHA, and signing certification identifying need for Home Health care
Care Plan Oversight Services (G0181)
Require complex or multidisciplinary care modalities involving at least 30 minutes of care including:
• Regular physician development and/or revision of care plans • Review of subsequent reports of patient status • Review of related laboratory and other studies • Communication with other health professionals not employed in the
same practice who are involved in patient’s care • Integration of new information into medical treatment plan • Adjustment of medical therapy
• Physician claims for G0180 or G0179 will not be paid if HHA claim was non-covered
o Certification/recertification of eligibility not complete or insufficient documentation
Anesthesia Services • Medicare does not reimburse for topical, local, or patient controlled anesthesia
• Paid based on the allowable base unit and time units multiplied by an anesthesia conversion factor
specific to the location of the service.
• The evaluation and management (E/M) services provided within 5 days prior to or 5 days after the
surgical procedure are considered part of the anesthesia service and are not payable separately.
• Medicare will convert the number of minutes into the number of services payable by Medicare
• The time begins when the provider begins to prepare the patient for the anesthesia service
• The time ends when the provider is no longer furnishing anesthesia services to the patient and placed
patient in post-operative care
• Medical Record
o Clear indication of patient name, date of birth and date of service
o Documentation must support the diagnosis code billed
o Include documentation of the pre-anesthetic exam and evaluation
o Include intra-operative report with documentation of anesthesia time
o Should have a complete operative report
o Should include the post-anesthesia report.
• Transfer of care following surgery
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o Post-operative pain management could be a transfer of care
• Patients may have multiple surgical procedures during the same operative sessions.
o One procedure code for the highest base unit value for that day
o Appropriate minutes for the entire service.
• Modifiers
o AA – Anesthesia services performed personally by the anesthesiologist
o AD – Medical supervision by a physician; more than 4 concurrent anesthesia procedures
o G8 – Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive
surgical procedures
o G9 – Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition
o QK – Medical direction of two, three or four concurrent anesthesia procedures involving qualified
individuals
o QS – Monitored anesthesia care – This is placed in the second modifier field; the pricing anesthesia
modifier is placed in the first modifier field.
o QX – CRNA service; with medical direction by a physician
o QY – Medical direction of one certified registered nurse anesthetist by an anesthesiologist
o QZ – CRNA service; without medical direction by a physician
o GC – These services have been performed by a resident under the direction of the teaching
physician
o 23 – Unusual anesthesia
o P1- P6 – Physical status modifiers are not used for Medicare
Claims Denial Self-Service Tool • Instant information!
– Claim denial help any time of day
– Reduce phone calls
– Increase provider convenience
Enhanced Information • Displays
– Provider name and National Provider Identifier (NPI)
– Pay codes if present
– ANSI codes and narrative that appear on RA
• Window can be closed to view next line item
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Action Script • Description of claim denial
• Suggestions for correcting billing errors
• Possible claim actions
– File new claim
– Submit a clerical error reopening
Special Functions • Local Coverage Determinations (LCD)s, • Eligibility
• View another insurer
Overlap Claims
• We recently added inpatient overlap information to our denial self-service feature in the WPS GHA
Portal. Using the button, users can obtain information on overlapping inpatient hospital or Skilled Nursing Facility (SNF) claims.
Medicare Secondary Payer (MSP) Codes, Preventive Services Codes, and Qualified Medicare Beneficiary (QMB) Information
• The Portal now displays new MSP codes, preventive services code and QMB information available
E/M Documentation Requirements • Complete
• Each component must be met or exceeded
o History
o Exam
o Medical decision-making
• A new patient requires the code to be chosen based on three out of three
• An established patient code choice is based on two out of three
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Acronym Description
ABN Advance Beneficiary Notice of Non-Coverage
CB Consolidated Billing
CERT Comprehensive Error Rate Testing
CHIP Children’s Health Insurance Program
CMS The Centers for Medicare & Medicaid Services
CPO Care Plan Oversight
E/M Evaluation and Management Services
ESRD End-Stage Renal Disease
HICN Health Insurance Claim Number
HPSA Health Professional Shortage Area
IOM Internet-Only Manual
LCD Local Coverage Determination
MACRA Medicare Access & CHIP Reauthorization Act
MBI Medicare Beneficiary Identifier
MFA Multi-Factor Authentication
MPFSDB Medicare Physician Fee Schedule Data Base
MPFSRVF Medicare Physician Fee Schedule Relative Value File
MSA Metropolitan Statistical Area
MSP Medicare Secondary Payer
MUE Medically Unlikely Edits
NCCI National Correct Coding Initiative
NCD National Coverage Determinations
NPI National Provider Identifier
NPP Non-Physician Practitioner
NPPES National Plan and Provider Enumeration System
SNF Skilled Nursing Facility
SSN Social Security Number
SSNRI Social Security Number Removal Initiative
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Disclaimer
WPS GHA has produced this material as an informational reference. Every reasonable effort has been made to ensure the accuracy of this information at the time of publication, however, WPS GHA makes no guarantee that this information is error-free and bears no liability for the results or consequences of the misuse of this information. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov.