silverdale aapc chapter meeting january 10, 2013 medicare updates for 2013 medicare part b provider...

Silverdale AAPC Chapter MeetingJanuary 10, 2013

Silverdale AAPC Chapter MeetingJanuary 10, 2013

Medicare Updates for 2013Medicare Part B

Provider Outreach and Education (POE)

DISCLAIMER

This information release is the property of Noridian Administrative Services, LLC (NAS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by NAS and CMS. The most current edition of the information contained in this release can be found on the NAS website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

January 2013 NAS, LLC Proprietary 2

http://www.noridianmedicare.com/

http://www.noridianmedicare.com/

http://www.cms.gov/

http://www.cms.gov/

AgendaAgenda

• Medicare Updates

• Medicare Initiatives and Incentive Programs

• Audit Programs

• Contractor Updates

January 2013 3NAS, LLC Proprietary

2013 Deductible, Coinsurance and Premium Rates2013 Deductible, Coinsurance and Premium Rates

2013 Medicare Part B Rates

Standard Premium $104.90 a month

Deductible $147.00 a year

Coinsurance 20%


2013 Conversion Factor 2013 Conversion Factor

• 2013 conversion factor is $34.0230

• 2012 conversion factor is $34.0376


President Obama Signs the American Taxpayer Relief Act of 2012 President Obama Signs the American Taxpayer Relief Act of 2012

• Section 601 - Medicare physician payment update • Section 602 - Extension of Medicare physician work

geographic adjustment floor • Section 603 - Extension related to payments for

Medicare outpatient therapy services • Section 604 - Extension of ambulance add-on payments • Section 605 - Extension of Medicare inpatient hospital

payment adjustment for low-volume hospitals

• Section 606 - Extension of the Medicare-Dependent

Hospital (MDH) Program


Section 602 - Extension of Medicare Physician Work Geographic Adjustment Floor

Section 602 - Extension of Medicare Physician Work Geographic Adjustment Floor

• The 2012 1.0 floor on the physician work geographic practice cost index is extended through December 31, 2013. As with the physician payment update, this extension will be reflected in the revised 2013 MPFS.


Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services

Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services

• $1900 therapy and speech-language therapy combined

• $1900 for occupational• Extension of the KX modifier until 12/31/13• 3700 threshold • Critical Access Hospital are included • http://www.cms.gov/manuals/downloads/clm

104c05.pdf.


http://www.cms.gov/manuals/downloads/clm104c05.pdf

http://www.cms.gov/manuals/downloads/clm104c05.pdf

Claims-Based Data Collection for Outpatient Therapy Services (CR 8005)

Claims-Based Data Collection for Outpatient Therapy Services (CR 8005)

• 42 new non-payable functional G-codes– G8978-G9174– Status Code “Q”

• 7 new modifiers

• System to include– Data by therapy providers and practitioners

furnishing therapy services– Collection of data by the contractors

NAS, LLC Proprietary 9January 2013

Severity ModifiersSeverity Modifiers


Reporting Functional G-Code RequirementsReporting Functional G-Code Requirements

• Severity Modifier CH-CN

• Therapy modifier-GP,GO or GN

• Date of the billable service

• Nominal charge– Penny- for institutional claims– Zero charge is acceptable for professional

claims


Application of New Coding RequirementsApplication of New Coding Requirements

• Effective January 1, 2013

• Testing period 1/1/2013 through June 30, 2013

• Separate CR will be issued regarding the editing

• Claims will be rejected and returned after July 1, 2013


Section 604 - Extension of Ambulance Add-On PaymentsSection 604 - Extension of Ambulance Add-On Payments

• Extends the three Job Creation Act provisions

• 3% for originating rural ground. • 2% for originating urban ground• Continuation of the “super rural” bonus for

originating transports in the lowest 25th percentile of all rural areas.

• Rural Air is extended until 6/30/13January 2013 13NAS, LLC Proprietary

New Waive Tests New Waive Tests

• Effective date: January 1, 2013

• 36 newly added waived tests • New CPT code 86803QS • Assigned for hepatitis C

antibody test • https://www.noridianmedicare

.com/provider/updates/docs/mm8054_new_waived_tests.pdf

CPT CODE

86803GW

87809QW

81003QW

86294QW

82055QW

G0434QW

83036QW

87880QW

87880QW

G0433QW

January 201314 NAS, LLC Proprietary

https://www.noridianmedicare.com/provider/updates/docs/mm8054_new_waived_tests.pdf




New Non-Physician Specialty Code for Centralized Flu New Non-Physician Specialty Code for Centralized Flu


• New non-physician practitioner specialty code for Centralized Flu –C1

• Only applicable to CMS-855B enrollment application

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7884.pdf.


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7884.pdf



National Correct Coding Initiative Associated Modifier ChangesNational Correct Coding Initiative Associated Modifier Changes

• Change Request #8111 • Key Points :• Additional modifiers shall be added to the list of

NCCI-associated modifiers that will allow an edit with modifier indicator of ”1” to be bypassed when the modifier is utilized.


National Correct Coding Initiative Associated Modifier Changes 2

National Correct Coding Initiative Associated Modifier Changes 2

• These modifiers are LM (left main coronary artery), RI (ramus intermedius), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery)


New Multiple Procedure Payment Reductions (MPPR) New Multiple Procedure Payment Reductions (MPPR)

• Change Request #7848• Key Points:• New Payment reduction for the technical

component (TC) of diagnostic cardiovascular and ophthalmology procedures

• Applies when multiple procedures are furnished to the same patient on the same date of service

• Does not apply to the professional component( PC)


MPPRs Application to TC Services for Cardiovascular and Ophthalmology MPPRs Application to TC Services for Cardiovascular and Ophthalmology

• CR 7848 –• The MPPRs apply to TC-only services, and to the TC of global

services. • For cardiovascular services, full payment is made for the TC

service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.

• For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day.


Examples of Payment Reductions Examples of Payment Reductions


CY 2013 Proposed CPT Changes CY 2013 Proposed CPT Changes

• Telehealth Expansion– Alcohol and/or other substance abuse assessments

(G0396 – G0443)– Depression screening (G0444, G0445)– Behavioral counseling (G0446, G0447)

• Individual Psychotherapy (90832, 90833, 90834, 90836, 90837, 90838) – Replaces 90804 – 90809

• Psychiatric Diagnostic Exam (90791/ 90792) – Replaces 90801


Update To Publication 100-04, Chapter 12, Non-Physician Practitioners (NPPs) Update To Publication 100-04, Chapter 12, Non-Physician Practitioners (NPPs)

• Effective 2/19/2013

• Must have their own “nonphysician practitioner” NPI number

• NPP assistant-at-surgery services bill with "AS" modifier only

• Physicians use 80, 81, 82, only

• Modifiers eliminated: QB, QU, AH, AJ


Provider Open Enrollment Extension Provider Open Enrollment Extension

• CR 8055

• The deadline has been extended from 12/31/12 to 02/15/13 due to the MPFS has been updated.

• Open enrollment information can be located at:

• https://www.noridianmedicare.com/partb/enroll/participation/open_enrollment.html%3f,


CHANGE REQUESTS OF INTERESTCHANGE REQUESTS OF INTEREST

24January 2013 NAS, LLC Proprietary

Balance Billing ProhibitedBalance Billing Prohibited

• SE1128 Prohibition on Balance Billing for Qualified Medicare Beneficiary (QMB)

• At state’s discretion, Medicaid may pay part of Part A, B or C Advantage premiums

• http://www.ssa.gov/OP_Home/ssact/title19/1902.htm


Crossover Claim AddressCrossover Claim Address

• SE1245 states ongoing problem of Medicare crossover claims failing HIPAA compliance with Coordination of Benefits Contractor (COBC) – Due to P.O. Box or Lock Box within PECOS

• 2010AA N301 and N302 segments


Crossover Claim Address 2Crossover Claim Address 2

• EDI Technical Report Type 3 (TR-3) Guides prohibit inclusion of P.O. Box or Lock Box Address– Within provider address

• Any health care claims exchanged electronically between HIPAA “covered entities”– Includes providers, health plans and

clearinghouses January 2013 27NAS, LLC Proprietary

Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies

Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies

• Change Request # 7834 • Key Point(s):• In order to be granted a timely filing extension,

the provider, supplier, or beneficiary must furnish an official letter from the Social Security Administration (SSA) that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service


Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies 2

Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies 2

• If an official SSA letter to the beneficiary is not submitted, Medicare contractors must check the Common Working File (CWF) database


Termination of Common Working File (CWF) ELGB Provider QueryTermination of Common Working File (CWF) ELGB Provider Query

• CR8086 – Effective April 1, 2013

• CMS required by HIPAA to use proper format when exchanging information

• PPTN users no longer able to access ELGB (eligibility) query

• Users can access HIPAA Eligibility Transaction System (HETS), IVR or Endeavor


Miscellaneous Change RequestsMiscellaneous Change Requests

• CR 8007 - Beneficiary incarcerated DOS– Partially/fully overlap when beneficiary

incarcerated– Medicare will generally not pay for

items/services • Medicare creating new IUR process to identify

previously paid claims


New from CMS Medicare Learning Network (MLN) New from CMS Medicare Learning Network (MLN)

• “HIPPA Eligibility Transaction System (HETS) to Replace Common Working File (CWF) Medicare Beneficiary Health Insurance Eligibility Queries” MLN Matters® Article - Released

• “Important Reminder for Providers and Suppliers Who Provide Services and Items Ordered or Referred by Other Providers and Suppliers” MLN Matters® Article - Revised

• Subscribe to the MLN Educational Products and MLN Matters Electronic Mailing Lists

• Submit Feedback on MLN Educational Products


New from CMS MLN 2 New from CMS MLN 2

• “Implementation of Provider Enrollment Provisions in CMS-6028-FC” MLN Matters® Article – Revised

• “Further Details on the Revalidation of Provider Enrollment Information” MLN Matters® Special Edition Article – Revised

• “Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange (EDI) Standards” Web-Based Training Course – Reminder


New from CMS MLN 3New from CMS MLN 3

• “The National Provider Identifier (NPI): What You Need to Know” Booklet – Revised

• “Mass Immunizers and Roster Billing” Fact Sheet – Revised

• “Federally Qualified Health Center” Fact Sheet – Revised

• “Phase 2 of Ordering/Referring Requirement “MLN Matters® Article - Revised


New from CMS MLN 4New from CMS MLN 4

• “Prescription Drug Monitoring Programs: A Resource to Help Address Prescription Drug Abuse and Diversion” MLN Matters® Article – Released

• New MLN Provider Compliance Fast Fact


RECOVERY AUDITOR, CERT AND OIG UPDATES RECOVERY AUDITOR, CERT AND OIG UPDATES

36January 2013 NAS, LLC Proprietary

Comprehensive Error Rate Testing (CERT) Comprehensive Error Rate Testing (CERT)

• National Claim Paid Error Rate: 9.2 % Physician/Lab /Ambulance

• Impacts all providers submitting Fee for Service claims

• Limited random claim sample • Record requests must be received within

30 days from the initial CERT letter • Right to Appeal? Yes January 2013 37NAS, LLC Proprietary

Recovery Audit Program MythsRecovery Audit Program Myths

• Published 12/17/12• Provide correct information about the

Medicare Fee-for-Service Recovery Audit Program

• Further questions can be directed to CMS at [email protected]

• http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/index.html?redirect=/RAC/


Compliance - SignaturesCompliance - Signatures

• Signature Requirements Fact Sheet– 5 pages total– CERT error driven– http://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

– http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Basic_Booklet.pdf


CMS Provider Compliance Resources CMS Provider Compliance Resources

• http://www.cms.gov/MLNProducts/45_ProviderCompliance.asp

– MLN Catalog of Products• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf – MLN Product Ordering Page

• http://cms.meridianksi.com/kc/pfs/pfs_lnkfrm_fl.asp?lgnfrm=reqprod&function=pfs

– MLN Publications List• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/MLN-Publications.html – MLN Provider Compliance Products

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


Office of the Inspector Generals (OIG) 2013 Work Plan Office of the Inspector Generals (OIG) 2013 Work Plan

• On-Site Visits for Enrollment and Reenrollment.

• Claims Submitted by Error Prone Providers.

• Payments for Immunosuppressive Drugs.

• Anesthesia Services. • High-Cost Diagnostic

Radiology Tests.

• High Cumulative Part B Payments.

• Independent Therapists• Anesthesia Services• Electrodiagnostic Testing• High-Cost Diagnostic

Radiology Tests.• Incident-To Services

Performed by Non-Physicians.


CONTRACTOR UPDATES CONTRACTOR UPDATES


Left-hand Navigation RevisedLeft-hand Navigation Revised

• Part B Home Page • Allows providers to view

most frequently accessed website– Categories/ subcategories

• Selecting (+) symbol expands view – Displays most commonly

viewed subcategories • Selecting another

category or (–) symbol – Will collapse view


Sign Up to Get Medicare News Now!Sign Up to Get Medicare News Now!

• Receive the most recent NAS and CMS news and information– Regulation and policy

updates – Payment and

reimbursement updates – Workshop and

educational event notices

– NAS hours of availability and related notifications


Foresee Survey – We Want to Hear From You. Foresee Survey – We Want to Hear From You.


NAS Single Toll- Free Customer Service Line Effective March 1, 2013NAS Single Toll- Free Customer Service Line Effective March 1, 2013

• One number for all inquiries to offer the best service possible

• Unify customer service and simplify provider contact

• Watch NAS’s “What’s New/Latest Updates” webpage and e-mails for new phone number and additional information


Single Toll Free Customer Service Line for JF MAC – 1-877-908-8431 Single Toll Free Customer Service Line for JF MAC – 1-877-908-8431

• Purpose of consolidation – Better customer service

• Departments affected– General Inquiries, Phone Reopenings, EDI,

Enrollment, User Security

• Hours of operation – 8 a.m. to 4 p.m. in respective time zone


Reminder from Medical ReviewReminder from Medical Review

• Medical record documentation for MRI, CT scans and X-rays should include:– Physicians’ orders to support diagnostic

radiology services performed– Complete interpretation and reports

• Report released by Office of Inspector General– https://oig.hhs.gov/oei/reports/oei-07-09-

00450.pdf


2013 HCPCS LCD Revisions2013 HCPCS LCD Revisions


• L24280 - Botulinum Toxin Types A and B • L32528 - Circulating Tumor Cell Marker Assays• L24308 - Genetic Testing • L24473 - Non-Covered Services• L24273 - Application of Bioengineered Skin Substitutes:

Ulcers (of Lower Extremities) • L24359 - Sensory Evoked Potentials & Intraop

Neurophysiology Monitoring


MSP Reminder MSP Reminder

• Against Medicare Secondary Payer (MSP) laws to accept payment from a beneficiary– Upon admission or when services rendered – When another insurer is primary to Medicare

• If you are performing this practice, stop immediately

• Per Special Edition (SE) 1227


Prompt Payment Act Interest Rate Prompt Payment Act Interest Rate

• Effective date: January 1, 2013 – CPT interest rate changed to 1.375% – Previously, was 1.750% – Current and previous rates available at:

• http://www.treasurydirect.gov/govt/rates/tcir/tcir_opdprmt2.htm


Electronic Remittance Advice (ERA)Electronic Remittance Advice (ERA)

• Tired of paper piling up on your desk?• Sign up for benefits of ERAs

– Earlier notification of payment status– ERA is same as Standard Paper Remit (SPR)– Free software to read, view and print

• ERA Hot Line – 800-279-2833, 11 a.m. – 3 p.m. CT

– Automatic posting*• *There are some software that have this capability

• http://www.edissweb.com/cgp/


Electronic Funds Transfer (EFT)Electronic Funds Transfer (EFT)

• All providers not currently receiving EFT payments must submit CMS-588 EFT form– With Provider Enrollment Revalidation

application, or – When any change is being made to enrollment

record

• Enrollment Revalidation information– Special Edition Article SE1126 at

http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf


Upcoming Part B POE WorkshopsUpcoming Part B POE Workshops


January 2013 55

What Questions Do You Have?

NAS, LLC Proprietary

silverdale aapc chapter meeting january 10, 2013 medicare updates for 2013 medicare part b provider...

Documents

llc nas

llc proprietarynas

llc proprietary2013

llc proprietarysection

nas website

llc proprietary2013

llc proprietarypresident

therapy providers