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TRANSCRIPT
Medicare Updates
Montgomery County Medical Society
Payor Conference
November 12, 2015
Disclaimer
All Current Procedural Terminology (CPT) only are copyright 2014 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 specific to providers in Medicare Administrative
Contractor Jurisdiction H (JH) include: Arkansas, Colorado,
Louisiana, Mississippi, New Mexico, Oklahoma, and Texas
Education specific to providers in Medicare Administrative
Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of
Columbia, Maryland, New Jersey, and Pennsylvania
This education contains specific contractor guidance
If you are not a provider in JL or JH, please contact your Medicare
contractor for specific guidance
Agenda
ICD-10 Assistance and Advice
Part A/B Updates
Preventive Services
Novitas Initiatives
Comprehensive Error Rate Testing (CERT) Program
Self Service Options
Objectives
Identify and understand the current Medicare changes
Learn how to apply the new guidelines
Identify and utilize the educational resources and information
Acronym List
Acronym Definition
CERT Comprehensive Error Rate Testing
CMS Centers of Medicare & Medicaid Services
EDI Electronic Data Interchange
ICD International Classification of Diseases, 10th Edition
IPPS Inpatient Prospective Payment System
LCD Local Coverage Determination
MLN Medicare Learning Network
NCD National Coverage Determination
OPPS Outpatient Prospective Payment System
ICD-10 Assistance and Advice
ICD-10 Tips
ICD-10 billing tips:
• Use ICD-10 codes with dates of service on and after October 1, 2015
• Use proper qualifiers on the proper codes- ICD-10 qualifiers (ABK/ABF)
• May not use ICD-9 codes with dates after 10/1/15
• Bill separate claims for September and October dates of service
CMS ICD-10 Implementation Page
• http://www.cms.gov/Medicare/Coding/ICD10/index.html
Flexibility to Coding Accuracy for
Physician
No medical review denials the first year related to coding errors as
long as the code is in the “appropriate family” of ICD-10 codes
• Applicable for services paid under the Medicare Fee-for-Service Part B
physician fee schedule
No grace period, codes must be valid, carried out to the highest
level of specificity
Claims subject to LCD/NCD guidelines may deny if not carried out to
the highest level of specificity
No penalties on 2015 quality reports
Reference
• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedicareProvi
derICD-10.pdf
• https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-
Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-
Announcement.pdf
Part B Appeal/Clerical Error and
Claim Process
No changes with the appeals/clerical error or claim process
• Denied claims continue to follow appeal process
Providers will continue to use the claims corrections line or the Novitasphere
portal to correct clerical errors
i.e. incorrect diagnosis code billed, incorrect units billed, wrong date of service,
incorrect modifier, etc.
Resubmitted claims will deny as duplicates
• Rejected claims need to be rebilled
CMS Communication and
Collaboration Center
Drawing from best practices of other technology implementation
• Monitor the implementation
• Quickly identify issues
• Initiate fixes
Check the validity of ICD-10 codes
• 2016 ICD-10 and GEMs (zip file titled “icd10cm_codes_2016.txt”)
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Code-
Descriptions-in-Tabular-Order.zip
Ombudsman
Ombudsman for physicians and other providers
• Located at the ICD-10 Coordination Center
• Triage and answer questions about claim submissions
• Ask coding questions
• Dr. William Rogers
AHA Central Office Coding
Questions
Free assistance and advice
• Providing ICD-10 and ICD-10-PCS coding advice
• Does not replace learning how to code
Questions should be submitted via www.codingclinicadvisor.com
• Not limited to AHA members, but registration required
• Review FAQ section for details on how to submit questions
Formulate coding question, not just “what is the code for XYZ”
Provide documentation
Specify whether inquiry refers to a certain setting
Cannot answer questions on payment/coverage
CMS Teleconferences and Videos
CMS sponsored ICD-10 teleconferences
• http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-
Teleconferences.html
MedScape modules
• http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
CMS has created “Road to 10” to help jump start the transition to
ICD-10
• http://www.roadto10.org/
CMS Tools and Fact Sheets
CMS ICD-10 Fact Sheets
• Intro Guide to ICD-10
• The ICD-10 Transition: An Introduction
• ICD-10 Basics for Medical Practices
• Talking to Your Vendors About ICD-10: Tips for Medical Practices
• ICD-10 and CMS eHealth: What’s the Connection?
• ICD-10 Basics for Small and Rural Practices
• Online ICD-10 Implementation Guide
ICD-10-CM/PCS Billing and Payment FAQs
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD-10BillingandPaymentFAQs.pdf
ICD-10 Quick Start Guide
ICD-10 Infographic
ICD-10 Website Wheel Educational Tool
Reference
• http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
CMS Resources
The CMS International Classification of Disease, Tenth Revision
(ICD-10) website
• http://www.cms.gov/icd10
Sign up for Centers and Medicare & Medicare Services (CMS) ICD-
10 Industry Email Updates
• http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-
10_Industry_Email_Updates.html
Subscribe to Latest New Page Watch
• https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_i
d=USCMS_609
Part B Updates
Sequestration Update
Mandatory Payment Reduction of 2% continues through March 31, 2016, for the Medicare Fee For Service Program
For more information• http://www.cms.gov/Outreach-and-
Education/Outreach/FFSProvPartProg/Downloads/2015-03-19-eNews.pdf
Frequently Asked Questions
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00007998
New and Revised Place of Service
Codes (POS) for Outpatient
Hospitals
Change Request # 9231
• Effective: January 1, 2016
• Implementation: January 4, 2016
Key Points
• POS 19 Off Campus-Outpatient Hospital
• POS 22 On Campus-Outpatient Hospital
• POS 17 Walk-in Retail Health Clinic
• POS 26 Military Treatment Facility
Reference
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf
Updates on the Therapy Cap
Exceptions to the therapy cap will remain in effect for claims with
dates of service through December 31, 2017
Hospital outpatient therapy claims will continue to apply to the
therapy cap through December 31, 2017
Suspension for therapy services that exceed $3,700 will remain in
effect for therapy services through December 31, 2017
https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?r
edirect=/TherapyServices
Preventive Services
Medicare Learning Network (MLN)
Products for Preventive Services
Help Keep Your Medicare Patients Healthy In 2015!
Ensure your patients take advantage of Medicare-covered
preventive services
Medicare covers a wide array of preventive services for eligible
beneficiaries, including cancer screenings, certain immunizations,
among others
The Medicare Learning Network (MLN) Preventive Services
Educational Products Web Page provides descriptions and ordering
information for MLN preventive services educational products and
resources for health care professionals and their staff
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/PreventiveServices.html
Preventive Services and Screenings
Covered by Medicare
Abdominal Aortic Aneurysm Screening
Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care
Annual Wellness Visit (Including Personalized Prevention Plan Services)
Bone Mass Measurements
Cancer Screenings o Breast Cancer (mammograms and clinical
breast exam)
o Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])
o Colorectal Cancer Fecal Occult Blood Test
Flexible Sigmoidoscopy
Colonoscopy
Barium Enema
o Prostate (Prostate Specific Antigen blood test and Digital Rectal Exam)
Cardiovascular Disease Screening
Depression Screening in Adults
Diabetes Screening
Diabetes Self-Management Training
Glaucoma Screening
Hepatitis C Screening
Human Immunodeficiency Virus (HIV) Screening
Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)
Intensive Behavioral Therapy for Cardiovascular Disease
Intensive Behavioral Therapy for Obesity
Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs
Tobacco-Use Cessation Counseling
Influenza Vaccine Payment Allowances-
Annual Update 2015-2016 Season
Change Request #9299
• Effective Date: August 1, 2015
• Implementation : No later than November 24, 2015
Key Points
• These payment allowances are updated on an annual basis
• The pending payment allowances will be updated in the influenza
vaccine pricing webpage
• Providers may visit the webpage for the updated prices
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-
Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html
Reference
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/MM9299.pdf
Preventive Services Resources
Quick Reference Chart for Medicare Preventive Services
o https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads
/MPS_QuickReferenceChart_1.pdf
Improve Your Patients’ Health with the Initial Preventive Physical
Examination (IPPE) and Annual Wellness Visit (AWV)
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/SE1338.pdf
Novitas Initiatives
Increasing Your Bottom Line: How
Much Does Rework Cost?
Cost savings for providers by reducing the need for Clerical Error
Reopening requests:
• Correct minor errors
• Omissions of claim specific information
Education Initiatives:
• Articles published to assist with proper use of specific modifiers
New Web page dedicated to help you reduce rework and increase
your bottom line:
• JL
http://www.novitas-
solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00092539
What is Novitasphere?
Free web-based Portal which allow enrolled users access to
Eligibility, Claim Information and Remittance Advice, Claim
Submission with File Status, Electronic Remittance Advice (ERA),
Claim Correction, and a Mail Box
Available to JH and JL Part B providers, billing services and
clearinghouses servicing Part B practitioners
For demonstrations and more information on Novitasphere visit:
• JL providers:
http://www.novitas-
solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000
24648
Novitasphere Claim Correction
Feature
Common clerical errors can be corrected on finalized claims:
• Number of services or units
• Diagnosis code (Primary)
• Eligible modifiers
• Procedure code
• Date of service
• Place of service
• Billed amount
JL Novitasphere Claims Correction Guide:
• http://novitas-
solutions.com/cs/idcplg?IdcService=GET_FILE&RevisionSelectionMeth
od=LatestReleased&dDocName=00086496&allowInterrupt=1
Novitasphere Help Desk
1-855-880-8424
Comprehensive Error Rate Testing
(CERT) Program
Comprehensive Error Rate Testing
(CERT)
Program developed by Centers for Medicare & Medicaid Services
(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
JL CERT page
• http://www.novitas-solutions.com/webcenter/spaces/CERT_JL
Part B Common Errors
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:
• Evaluation and Management (E/M) codes
• Critical care, discharge day management, physical therapy
• Units of medication/infusion services
• Laboratory services
Self-Service Options
Customer Contact Information
Jurisdiction L Providers:
• 1-877-235-8073
• JL Self-Service Tools:
http://www.novitas-
solutions.com/webcenter/portal/CustomerServiceCenter_JL/Self-
Service+Tools
Telecommunication Devices for the Deaf:
• 1-877-235-8074
Patient / Medicare Beneficiary:
• 1-800-MEDICARE (1-800-633-4227)
http://www.medicare.gov/index.html
Centers for Medicare & Medicaid
Services (CMS)
The CMS website offers valuable resources such as
• CMS Internet Only Manuals (IOMs)
• Medicare Learning Network (MLN) Matters Articles
• Open Door Forum
• http://www.cms.gov/
Stay Up-to-Date
Electronic Mailing List
• Daily E-mail of the latest Medicare Updates
• Subscribe
• http://www.novitas-
solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
=00007968
Podcast
• Podcast of the latest Medicare Updates and other informative topics
http://www.novitas-
solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000
08119
Educational Videos and Tutorials
http://www.novitas-
solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000
82787
Summary
Discussed the current change requests, giving key points and links
Reviewed the Novitas tools that are needed to keep providers
updated
Gave valuable resources from the CMS and Novitas websites
Thank You For Attending
Questions