10/28/2014 Medical Oncology Association Southern CA Medicare Updates

10/28/2014
Medical Oncology Association
Southern CA
Medicare Updates
Presented by Cheryl Bradley
Provider Outreach and Education (POE)
November 4, 2014
DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC. 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 Noridian and CMS. The most current edition of the information contained
in this release can be found on the Noridian 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 2014 American Medical
Association. All rights reserved. Applicable FARS/DFARS apply.
November 2014
2
Agenda
•
•
•
•
•
New Costs
Medicare Hot Topics
Avoiding Common Errors
Appeals
Resources
November 2014
3
1
10/28/2014
New Costs
4
November 2014
2015 Part B Deductible and
Coinsurance Rates Unchanged
• Deductible-$147.00
• Coinsurance
– 20% of eligible charges
November 2014
5
2015 Part B Premiums
Income Parameters for Part B Premiums
Premium/
Mthly
Individual
Income
Combined Income
(Married)
Married
Filing Separate
<$85,000
$104.90
< $85,000
< $170,000
$146.90
$85,000.01 to
$107,000
$170,000.01 to
$214,000
$209.80
$107,000.01 to
$160,000
$214,000.01 to
$320,000
$272.70
$160,000.01 to
$214,000
$320,000.01 to
$428,000
$85,001.00 to $129,000
$335.70
$214,000.01 >
$428,000.01 >
$129,001.00 >
November 2014
6
2
10/28/2014
2015 Part A Deductible
and Co-Pays
• $1,260 deductible
– 1st 60 days of hospitalization
• $315 co-pay
– Days 61-90
• $630 co-pay
– Days 91 – 150 Lifetime Reserve
• $157.50 co-pay
– SNF days 21 - 100
November 2014
7
2015 Part A Premium
• Fewer than 30 quarters
– $407.00 per month
• 30 to 39 Quarters
– $224.00 per month
November 2014
8
Beneficiary Open Enrollment
• Review cost and coverage for 2015
– October 15 – December 7, 2014
• Compare medical plans & make changes
• Questions
– 1-800-MEDICARE
– http://www.medicare.gov/
November 2014
9
3
10/28/2014
Medicare Hot Topics
November 2014
10
2015 MPFS Proposed Rule
• The current conversion factor is $35.8228
– 0% Update January 1, 2015-March 31, 2015
– Protecting Access to Medicare Act
• Without Congressional Action
– 20.9 percent reduction (April 1st)
– Due to Sustainable Growth Rate
– Hematology/Oncology Impact = + 1%
• CMS will finalize Physician Payment
– Publishes in Federal Register December
– Watch Noridian Website for 2015 MPFS!
November 2014
Proposed
Chronic Care Management
11
:
• Non-face-to-face care coordination
– 2 (or 4) or more chronic conditions expected to last at least
12 months, or until death,
– Pose significant risk of death, decline in function, or acute
exacerbation or decompensation
• 20 min. of services / 30-day billing cycle
– By clinical staff (directly or contract)
– Provide general supervision at all times, not just after hours.
• Also: 24-hour coverage, med review, ongoing post institution
coordination, and patient-centered care plans will continue
• Fee: $43.67 PMPM in an office; $32.58 in a facility,
November 2014
12
4
10/28/2014
Revalidation: Phase III
• September 2013 through March 2015
• Continuing with the revalidation process for all
remaining providers/suppliers required by ACA
prior to March 25, 2015
• www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidation
s.html
• CMS continued focus
 Working with large chains/organizations
November 2014
13
Revalidation: Phase III 2
• When you receive notice to revalidate
– Update your enrollment through internetbased PECOS or complete CMS 855
– Sign the certification statement on the
application
– If applicable, pay the fee $542
• https://pecos.cms.hhs.gov/pecos/feePayment
Welcome.do
– Mail supporting documents to Noridian
14
November 2014
Meaningful Use – New Hardship
Deadline
• CMS extending hardship exception deadline to
November 30, 2014 by 11:59 Eastern Time
• Avoid 2015 payment adjustments, by
demonstrating meaningful use of Certified
Electronic Health Record Technology (CEHRT)
• Hardship application found at
http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/
PaymentAdj_Hardship.html
November 2014
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5
10/28/2014
PQRS Incentive Payment
and Payment Reductions
• Eligible professionals that do not satisfactorily
report data on quality measures for the January
1, 2014-December 31, 2014 reporting period,
will be subject to the 2.0% adjustment in their
fee schedule amount in 2016.
•http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/PaymentAdjustment-Information.html
November 2014
16
PQRS Incentive Payment
and Payment Adjustments
Program Year
Incentive
Payment
Adjustment
2011
1.0%
None
2012
0.5%
None
2013
0.5%
None
2014
0.5
None
2015
None
1.5%
Based on 2013
participation
2016 >
None
2.0 %
Based on 2014
participation
17
November 2014
PQRS Assistance
• If providers have any Physician Quality
Reporting System (PQRS) questions,
please contact
• QualityNet Help Desk at 1-866-288-8912
or via email at [email protected]
November 2014
18
6
10/28/2014
ICD-10
Will change everything October 1, 2015!
November 2014
19
• CMS invites Family Practice/Internal Medicine
providers to view new webcast @
cms.gov/ICD10 “Road to 10”
• Click “Webcast” tab located in left-hand navigation
– Physician perspective/clinical impact of ICD-10
– Documentation changes and new concepts
– Use of "unspecified" codes in ICD-10
• Other specialty webcasts previously available
(orthopedics, cardiology, etc.)
November 2014
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Plan Your Journey to ICD-10
•
•
•
•
•
Assess staff training needs
Educate and Train Staff
Review Clinical Documentation Practices
Contact practice management system vendor
Contact clearinghouses, billing services and
payers
• Budget time and costs
• Conduct testing
– Trading Partners and clearinghouses
– Allow time for approval
November 2014
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7
10/28/2014
• CMS National Provider Call
– Transition to ICD-10
• When: Wednesday, November 5, 2014
• Time: 1:30 PM - 3:00 PM Eastern Time
• Registration
– http://www.eventsvc.com/blhtechnologies
November 2014
22
CPT Modifier 59
• Distinct Procedural Service
– Indicate a procedure or service was distinct or
independent from other services performed
on the same day
• Most widely used modifier
– Considerable abuse and high level of manual
audit
– Lead to even civil fraud and abuse cases
• Siphons off funds that should be available to
legitimate providers
November 2014
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Modifier 59 Misuse
• 2013 CERT Report
– Part B claims
• $2.4 Billion in payment made
– $320 million projected in errors
– Part A claims
• $11 Billion billed
– $450 million projected in errors
November 2014
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8
10/28/2014
Distinct Procedural Service
New Modifiers for 2015
November 2014
CR 8863- Specific Modifiers for Distinct
Procedural Services (Modifier 59) Update
• Effective January 1, 2015
• Four new HCPCS modifiers
– Subset of Modifier 59
• Defines a subset of the work of the first code
• Used to identify
– A separate encounter
– A separate anatomic site
– A distinct service
November
November2014
2014
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Subset Modifiers
• XE Separate encounter
• XS Separate Structure
• Performed on a separate organ/structure
• XP Separate Practitioner
• Performed by a different practitioner
• XU Unusual non-overlapping service
• Does not overlap usual components of the main
service
November 2014
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9
10/28/2014
Modifier 59 and Subset Modifiers
• Modifier 59 still recognized
– Should not be used when a more descriptive
modifier is available
• Subset modifiers
– To be used with certain codes at high risk for
incorrect billing
– More selective versions of modifier 59
– Not to be used with modifier 59 on the same
line
November 2014
28
Modifier 59 Update
• Check NCCI edit tables on CMS website
– Indicator 1 allows for unbundling
– Indicator 0 cannot unbundle codes
• To avoid repeat procedure denials, bill
– Modifier 76 - Repeat procedure by same
physician or
– Modifier 91 - Repeat clinical diagnostic
laboratory test to obtain multiple results
November 2014
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Avoiding Common Errors
10
10/28/2014
Avoid and Prevent Duplicate Claim
Submissions CR 8121
• Fraud and Abuse monitoring
– Post to patient’s account appropriately
– Verify payment prior to submission
– Identify duplicate claim submissions internally
– Eliminate processes which may be causing
duplicate submissions
November 2014
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Top Claim Errors
• Procedure with modifier inconsistent/missing
– Check Fee Schedule, Indicator List, Local
Coverage Determination (LCD) policies and
CPT/HCPCS books
• Missing/invalid referring or ordering provider
• Patient or Insured HIC #/name do not match
• Patient cannot be identified as our insured
November 2014
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Correct Patient/HIC# Errors
• Check patient’s Red, White, Blue Medicare card
• Two last names
– With space = bill with space
– Without space = bill without space
• Hyphenated name
– With hyphen = bill with hyphen
– Patient may need to contact local SSA to remove hyphen
• Check for alpha-prefix vs. alpha-suffix
– Ex. A123-45-6789
– Railroad Medicare – Palmetto GBA
• Need Details? Scroll down to Claim Submission workshop
– JE
• https://med.noridianmedicare.com/web/jeb/education/eventmaterials
November 2014
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11
10/28/2014
Item 17 – Name of Referring or
Ordering Physician
Paper:
Electronic:
Loop
•Enter the name of the
referring or ordering
physician if the service or
item was ordered or
referred by a physician.
Segment
Description
NM103
DN= Referring
Provider Last
Name
NM104
Referring
Provider First
Name
NM103
DK= Ordering
Provider Last
Name
NM104
Ordering
Provider First
Name
2310A
2420E
November 2014
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Item 17a & 17b – NPI of Referring or
Ordering Physician
Paper:
Electronic:
Item 17a
•Leave Blank
Loop
Segment
Description
2310A
NM109
DN= Referring
Provider
Primary ID
2420E
NM109
DK= Ordering
Provider
Primary ID
Item 17b
•Enter NPI of
referring/ordering physician
November 2014
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Item 11 (possible MSP)
DENIAL
SOLUTION
CO16
Claim/service lacks
information which is
needed for adjudication
Add NONE (if no primary •Verify Primary
insurance to Medicare)
Insurance information
•Verify patient’s eligibility
before billing
COMMENTS
MA83
Did not indicate whether
Medicare is primary or
secondary payer
•If Medicare Secondary
Payer (MSP), MUST fill
out items 11 – 11C
•Check dates of service
correctly entered
•MSP incorrect?
Contact Coordination of
Benefits Contractor
(COBC)
•800-999-1118
•Need details? Scroll down to MSP workshop
JE
https://med.noridianmedicare.com/web/jeb/education/event-materials
November 2014
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12
10/28/2014
Top Adjudication issues
• Unlisted codes or NOC
• J3490, J9999, and J3590
– Name of the drug, NDC number and dosage
must
– Block 19
– Electronic equivalent
• Claims not providing information deny
unprocessable.
November 2014
37
Patients Supplying Their Own Drugs
• Providers can bill Medicare only when such drugs
are purchased by physician, from the pharmacy and
administered in physician’s office
– Providers NOT allowed to instruct patients to purchase
drugs themselves and then bring to provider’s office for
administration
• Drug charge, if any, must be included in physician’s
bill and cost represents expense to physician
– Pharmacies can not bill Medicare Part B for drugs
furnished to a physician for administration to a Medicare
beneficiary
– Pharmacies, suppliers and providers can not bill Medicare
Part B for drugs dispensed directly to a beneficiary for
administration “incident to” a physician service, such as
refilling an implanted drug pump
November 2014
38
Patients Supplying Their Own Drugs2
• Donated or Free of Charge Patient Supplied Drug
– To avoid chemotherapy/other drug administration
denial, drug code must be on same/prior claim
Item
Description
19 (Narrative) “Drug Donated” with description, strength and dosage
when billing Not Otherwise Classified (NOC) HCPCS
24D
Drug (J code) HCPCS
28
Billed amount of $0.00 or $0.01
• If the drug is not donated/free of charge, then provider
must provide the drug under incident to guidelines
• IOM Publication 100-02, Chapter 15, Sections 50/50.3
November 2014
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13
10/28/2014
Medical Review (MR)
Modifier 25
• If a significant separately identifiable E/M
service is performed, the appropriate E/M
code should be reported utilizing modifier 25
in addition to the chemotherapy
administration or non- chemotherapy injection
and infusion service (96360–96549). For an
E/M service provided on the same day, a
different diagnosis is not required.
• http://www.cms.gov/manuals/downloads/clm1
04c12.pdf
November 2014
41
CPT 99211
• CPT code 99211 is not allowed with or without
the modifier 25 on the same day as nonchemotherapy or chemotherapy administration
codes.
• CPT 99211 not allowed:
• Phone calls to patients
• Drawing of blood for laboratory analysis or when
performing other diagnostic tests
• Administration of medications when an injection or
infusion code is submitted separately
November 2014
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14
10/28/2014
99213-25
• Insufficient Documentation Submitted
– Does not support beneficiary was seen for a
“significant, separately identifiable evaluation
and management service by the same
physician on the same day of the procedure
or other service”
– Submitted progress note states: “Patient is
here for chemo. No new problems. Same as
last visit”
November 2014
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Signature Requirements
Signatures:
– Services provided/ordered must be
authenticated by the author
– Must be legible and should include the
practitioner’s first and last name
– Handwritten or Electronic
– No Stamps
November 2014
44
Electronic Signature Guidelines
• Systems and software products must include protections
against modification and should apply administrative
safeguards that correspond to standards and laws;
• The individual whose name is on alternate signature method
and provider bears responsibility for authenticity of information
being attested to;
• Physicians are encouraged to check with their attorneys and
malpractice insurers in regard to use of alternative signature
methods;
• Part B providers must use qualified electronic prescribing (eprescribing) system; and
• Prescriptions for drugs incident to Durable Medical Equipment
(DME) must be made via qualified e-prescribing system
November 2014
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15
10/28/2014
For an attestation
statement to be valid, it
must be signed by the
performing provider
JE –
https://med.noridianmedicare.co
m/documents/10525/78978/Sig
nature+Attestation+Statement/
November 2014
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Unique Signature Situations
Situation:
Performed by:
Signature
Requirement:
Ancillary Staff
Must be signed by billing
provider
NPP (Non-Physician
Practitioner)
May be signed by the NPP
or the supervising physician
NPP and Physician
Must be signed by billing
provider
NPP and Physician
Must be signed by billing
provider
Ancillary staff
The scribes name must be
listed in the medical record
and identified as scribe.
Provider must sign
Incident to
Split/Shared
Office/Clinic
Split/Shared hospital
inpatient/outpatient/
Emergency dept. setting
Scribe
47
November 2014
Medical Record Cloning
• Cloned documentation may be handwritten, but
generally occurs when using a preprinted template or
an Electronic Health Record (EHR). While these
methods of documenting are acceptable, it would not
be expected the same patient had the same exact
problem, symptoms, and required the exact same
treatment or the same patient had the same
problem/situation on every encounter.
Cloned documentation does not meet medical
necessity requirements for coverage of services.
Identification of this type of documentation will lead to
denial of services for lack of medical necessity and
recoupment of all overpayments made.
November 2014
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16
10/28/2014
Amended Medical Records
2
• Provider may add “late” entry within a few
days
• Medical reviewers give less weight when
making review determinations to
documentation created >30 days following
date of service.
• If pattern of “late” entries identified, may
be referred to Zone Program Integrity
Contractor (ZPIC)
November 2014
49
Comprehensive Error Rate
Testing (CERT)
Post Pay Audit Review Program
Who is Reviewing my Claims?
• Multiple post pay contractors are able to
review facility claims
– Comprehensive Error Rate Testing (CERT)
– Noridian Medical Review (MR)
– Recovery Auditor (RA)
– Office of the Inspector General (OIG)
– Zone Program Integrity Contractor (ZPIC)
November 2014
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17
10/28/2014
Receive Part B CERT Request?
• CERT post pay audit review random
documentation sampling on previous claims
• Need Part B CERT assistance? Please email:
– [email protected] or
[email protected]
• Follow email steps:
– “Subject” line enter CERT Claim Identification (CID#)
(seven-digit number starting with “1”)
– “Body of email”, provider office contact information
(name, phone/fax number, CID#, city/state)
November 2014
52
Noridian CERT Checklists
•
•
•
•
•
•
•
•
•
Ambulance Documentation Checklist
Chiropractic Documentation Checklist
Dialysis Documentation Checklist
Evaluation and Management (E/M)
Documentation Checklist
Laboratory Documentation Checklist
Physical, Occupational and Speech Therapies
Documentation Checklist
Psychiatric-Mental Health Documentation
Checklist
Radiation Oncology Documentation Checklist
Radiology Documentation Checklist
November 2014
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Checklist: E/M Documentation
Requests
November 2014
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18
10/28/2014
Documentation Tips
• Documentation is important
– “If it is not documented, it did not happen”
• Good documentation practice protects you
– Fraudulent billing results in stiff penalties
• Medical record should be complete and legible
• Coding and billing
– CPT and ICD-9 codes supported
• Appropriate health risk factors identified
• Proper signatures
November 2014
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Recent Recovery Auditor Issues
Relevant to Physicians
Region D
• Aldesleukin wastage
• Observation codes for inpatients
• Bevacizumab 1 unit per 10 mg
• Observation codes for less than 8 hours
• Multi-use vials for HERCEPTIN
• MUE edits
• Rituximab 1 unit per 100 mg
• Reclast once per year @ 1 mg
• Initial hospital E/M once per day includes all E/M
• Neulasta the same day as chemo
• Only one hospital visit per day per specialty
•
Region D
–
https://racinfo.healthdatainsights.com
November 2014
56
Recovery Auditor Update
• August 27, 2014 – A contract
modification, allowing the current
Recovery Auditors to restart some reviews
has been completed for Regions A, B, and
D. Most reviews will be done on an
automated basis, but a limited number will
be complex reviews of topics selected by
CMS.
November 2014
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19
10/28/2014
2014 OIG Part B Focus**
• Evaluation and Management (E&M)
– During global surgery periods
•
•
•
•
“Incident To” services
Laboratory services
Diagnostic Radiology
Anesthesia Services
– Personally Performed Services
**Not all inclusive
http://oig.hhs.gov/reports-andpublications/archives/workplan/2014/WorkPlan-2014.pdf
November 2014
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Compliance Program
• A proactive program incorporating
fundamental elements
– Written policies and procedures
– Compliance professionals
– Effective training
– Effective communication
– Internal monitoring
– Enforcement of standards
– Prompt response
November 2014
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You Have Appeal Rights!
November 2014
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20
10/28/2014
Appeal Level
Time limit for
Filing Request
Monetary
Threshold
(AIC) - 2013
Redetermination
120 days from
date of receipt of
notice initial
determination
None
Noridian
60 days from
date of receipt
180 days from
Reconsideration date of receipt of
Redetermination
None
QIC
60 days from
date of receipt
Administrative
Law Judge
(ALJ) Hearing
60 days from
date of receipt of
Reconsideration
$150
Effective
1/1/15
Departmental
Appeals Board
(DAB) Review
60 days from
date of receipt of
the ALJ hearing
decision
None
Federal Court
Review
60 days from
date of receipt of
DAB decision or
declination of
review by DAB
$1,460
Effective
1/1/15
Where to File
Appeal
Contractor
Time Limit to
Complete
MAC or HHS
OMHA field
90 days from
office, if heard date of receipt
by a QIC
DAB or ALJ
None
Hearing Office
November 2014
None
61
Redetermination Reminders
• Complete appropriate request form
• Submit all pertinent medical records to
support services provided
– Include documentation of physician’s intent
and/or order
– Records include physician’s legible signature
• Check for correct DOS on records
• Check records are for correct beneficiary
• Ensure signature on request form
November 2014
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Resources
21
10/28/2014
Medicare Quarterly Provider
Compliance Newsletter July 2014
• Includes RA Findings
–
–
–
–
–
CERT
Bariatric Surgery
Obesity Counseling
E/M services
Recovery Auditor
Findings
– Archive of Previously
Issued Newsletters
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909012.PDF
November 2014
64
CMS Educational Materials
•
•
•
•
•
MLN products downloadable
– Free of charge/free shipping
Brochures
Fact sheets
Quick reference charts
Web-based training
MLN dedicated web pages
•
•
•
•
MLN General Information
http://www.cms.gov/MLNGenInfo
MLN Matters Articles
http://www.cms.gov/MLNMattersArticles
MLN Products
http://www.cms.gov/MLNProducts
MLN Web Guides
http://www.cms.gov/MLNEdWebGuide
November 2014
65
Endeavor Online Provider Portal
• Free to providers with Internet
–
–
–
–
–
–
Beneficiary Eligibility
Claim Status including Reviewer Comments
Payment Floor / Prior Checks Issued
Single Claim / Entire Remittance Advice
Reopening & Redetermination Submission
Appeal Status
• Additional resources include
–
–
–
–
Self-Paced tutorial for Part B
System availability alerts on the Medicare website
User Manual; valuable, many screen images and guides
Workshops and presentations
• Eligibility “Main Menu” page next slide
November 2014
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22
10/28/2014
Part B Web-Based Workshops
Date
Time (CT)
11/12/14
1:00 PM
Quarterly Release
Workshop Title
11/18/14
1:00 PM
Recovery Auditor (RA) Program with HDI
11/19/14
1:00 PM
Compliance Program
11/20/14
1:00 PM
Protecting Your Practice from Fraud and Abuse
Register Now!
JE https://med.noridianmedicare.com/web/jeb/education/training-events
November 2014
67
Resources
• CMS Change Request (CR) 6698
– www.cms.gov/MLNMattersArticles/downloads/MM6698.
pdf
• MLN Fact Sheet Signature Requirements
– www.cms.gov/MLNProducts/downloads/Signature_Req
uirements_Fact_Sheet_ICN905364.pdf
• CMS Internet Only Manual (IOM) Publication1008;Chapter 3, Section 3.4.1.1
– www.cms.gov/manuals/downloads/pim83c03.pdf
• CERT Report
– www.cms.gov/CERT/Downloads/CERT_Report.pdf
November 2014
68
Resources
• https://med.noridianmedicare.com/web/jeb/po
licies/coverage-articles/chemotherapyadministration
• CMS IOM Pub. 100-04, Chapter 17. Section
20.5.7
– www.cms.gov/manuals/downloads/clm104c17.pdf
• 96360–96549 are not intended to be reported by
the physician in the facility setting
– www.cms.gov/Regulations-and-Guidance
/Guidance/Manuals/Downloads/ clm104c04.pdf
November 2014
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