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Wpsghalearningcenter.com
IA HFMA-AAHAM Conference
Mary Sue Gardner, RN/BSN – Outreach and Education
Specialist
Karen Kroupa – Outreach and Education Specialist
WPS GHA
Time: 1:45 PM – 2:45 PM
Agenda
• Targeted Probe and Educate (TPE)
• Current reviews and their findings
• New in review: Part A and B
• CERT claims look up tool
• 21st Century Cures Act
• IPPS
• OPPS
• WPS GHA Updates
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Acronym/
AbbreviationMeaning
CAH Critical Access Hospital
CERT Comprehensive Error Rate Testing
E/M Evaluation and Management
GAO Government Accountability Office
HAC Hospital Acquired Condition
HBO-T Hyperbaric Oxygen Therapy
HRRP Hospital Readmission Reduction Program
IPPS Inpatient Prospective Payment System
IPO Inpatient Only
IPS/IPF Inpatient Psychiatric Service/Facility
IRF/IRU Inpatient Rehabilitation Facility/Unit
LCD Local Coverage Determination
LTCH Long Term Care Hospital
MS DRG Medicare Severity-Diagnosis Related Group
OPPS Outpatient Prospective Payment System
PDPM Patient Driven Payment Model
SNF Skilled Nursing Facility
THA Total Hip Arthroplasty
TPE Targeted Probe and Educate
VBP Value Based Purchasing
Wpsghalearningcenter.com
Review Findings Part A
Hyperbaric Oxygen Therapy (HBO/HBO-T)
• Lack of documentation on failed standard course of
wound therapy for 30 days (diabetic wounds)
Skilled Nursing Facility
• Documentation not supporting need for continued
therapy services
• High level RUGs
• No updated plan of care for higher skill levels and
surpassing prior level of function
• WPS GHA is currently in the process of switching current
TPE related to the PDPM
Inpatient Rehabilitation Facility/Unit
• Documentation does not support the need for intensity of
services at the time of admission
Inpatient Psychiatric Services
• Missing certification/recertification requirements
• Initial – at the time of admission
• 12th day of hospitalization
• No less frequent then every 30 days
Wound Care
• Physician orders describing debridement prior to delivery
by therapist
• Non-qualified personnel performing
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Review Findings Part B
HBO-T
• Ensure the documentation contains all elements
to support the HBO-T services in accordance
with CMS IOM 100-03 Chapter 1 Part 1 Section
20.29
• Providers have seen over a 45%
improvement in their denial rate from
Round 1 to Round 2
E/M 99223 for Initial Hospital Visits
• Documentation doesn’t support level billed
• Missing history
Therapy 97110
• Documentation doesn’t support units billed (time)
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New in Review Part A
97530 – SNF Outpatient
• Focus on type of bill 22X (SNF Part B)
• Looking at medical necessity of code utilization
• Focus on entire plan of care
Routine Food Care
• Focus on regulations in 100-02, Ch. 15, Section 290
• Treatment of non-covered subluxation
• Treatment of flat feet
• Routine foot care
• Cutting or removal of corns/calluses
• Nail care: trim, cut, debride
• Hygienic and preventive maintenance
care
• Supportive devices of feet
• Looking for exceptions to routine foot care that may be
covered
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New in Review Part B
Ambulance A0427 – ALS 1 Emergency
• Current high CERT error rate in J5
• Billed disproportionately in J5 compared to
nation
• Review based on regulations for this service
Botox J0585 1 unit
• Based on GAO findings of high-cost drug
• Data shows high utilization for J5
• Review based off LCD L34635
Total knee 27447
• Identified as outlier in J5 compared to other
contractors
• Review based on SSA for documentation of failed
conservative treatment
• Physician’s note detailing conservative
treatments
Critical Care 99291
• Error rate for 2018 was 20% for incorrect coding
• Review based on E/M guidelines
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Targeted Probe and Educate Checklists
• Located on the WPS GHA portal
• Claim Review>Guides and
Resources>Targeted Probe and Educate
• Downloadable file
• Contains recommended documentation to submit for
successful first round review
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CERT Claim Lookup Tool
Topic Center>Claim Reviews>Guides and
Resources>CERT Claim Lookup Tool
• Verify current status of CERT claim review
• Use CERT Identification Number (CID)
• Found below bar code on request
from AdvanceMed
• Additional questions on CERT claims status
• Part A: CERTPartA@wpsic.com
• Part B: CERTPartB@wpsic.com
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21st Century Cures Act
• Signed December 13, 2016 by President Obama
• CMS Change Request 10901 notified MACs about Program Integrity changes to the LCD process
• Promotes process transparency including stakeholder notification of proposed reviews to, and
drafting of, new LCDs
• Improves old ineffective process for soliciting from, and providing feedback to, stakeholders
during Contractor Advisory Committee (CAC) meetings
• Meetings now have open public meeting portion
• MACs now may consider requests for new LCDs from
• Beneficiaries
• Health care professionals doing business within the MAC’s jurisdiction
• Any interested party doing business in the MAC’s jurisdiction
• Specific guidance on LCD requests and reconsiderations to follow
• Changes in content of LCD
• It is no longer appropriate to include CPT codes or ICD-10-CM codes in LCDs
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761 MS-DRGs FY 2020
CMS is creating two new MS-DRGs and deleting two MS-DRGs for FY 2020
• New MS-DRGs
• MS-DRG 319 Other Endovascular Cardiac Valve Procedures with MCC
• MS-DRG 320 Other Endovascular Cardiac Valve Procedures without MCC
• Deleted MS-DRGs
• MS-DRG 691 Urinary Stones with ESW Lithotripsy with CC/MCC
• MS-DRG 692 Urinary Stones with ESW Lithotripsy without CC/MCC
Replaced Devices Offered without Cost or with a Credit
• For FY 2020, new MS-DRG 319 and MS-DRG 320 (Other Endovascular Cardiac Valve Procedures
with and without MCC, respectively)
• MS-DRG 266 title revised from “Endovascular Cardiac Valve Replacement with MCC” to
“Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC”
• MS-DRG 267 title revised from “Endovascular Cardiac Valve Replacement without MCC” to
“Endovascular Cardiac Valve Replacement and Supplement Procedures without MCC”
Post-acute Transfer and Special Payment Policy
• No new MS-DRGs added to the list of MS-DRGs subject to the post-acute care transfer
policy
• MS-DRGs 273 and 274 removed from the list of MS-DRGs that are subject to the post-
acute care transfer policy and the special payment policy
• See Table 5 of the FY 2020 IPPS/LTCH PPS Final Rule for a listing of all post-acute and
special post-acute MS-DRGs available on the FY 2020 Final Rule Tables webpage
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New Technology Add-On
• Increased to 65% (75% for certain antimicrobials that are designated by the Food and Drug
Administration (FDA) as a Qualified Infectious Disease Product (QIDP))
• MM11361 (Related CR 11361) Page 5 of 16
• Names of Approved New Technology
Hospital Quality Initiative
https://www.qualitynet.org/
• Information regarding Hospital Quality Initiative programs
Hospital Acquired Conditions (HAC) Reduction Program
• Adjusted payments to hospitals that rank in the worst performing 25%
• Hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores (the worst
performing quartile)
• Subject to a 1% payment reduction that applies to all Medicare fee-for-service discharges
for that FY
• Updated hospital-level data for the HAC Reduction Program will be made public on
the Hospital Compare website in January 2020
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Hospital Readmission Reduction Program (HRRP)
• HRRP payment adjustment factors for FY 2020 posted in Table 15 of the FY 2020 IPPS/LTCH PPS
final rule
• Available on the FY 2020 IPPS Final Rule Tables webpage
• Hospitals not subject to a reduction under the HRRP in FY 2020 (such as Maryland hospitals), have
an HRRP payment adjustment factor of 1.0000
• For FY 2020, hospitals should only have an HRRP payment adjustment factor between 1.0000 and
0.9700
Hospital Value-Based Purchasing (VBP)
For FY 2020, CMS implements the base operating MS-DRG payment amount reduction and the value-
based incentive payment adjustments, as a single value-based incentive payment adjustment factor
applied to claims for discharges occurring in FY 2020
• Table 16B of the FY 2020 IPPS/LTCH PPS final rule
• Available on the FY 2020 IPPS/LTCH PPS Final Rule Tables webpage
Multicampus Hospitals
• Where the regulations require data that cannot be combined, hospital needs to demonstrate
• The main campus and its remote location(s) each independently satisfy requirements in
order for the entire hospital, including its remote location(s), to be reclassified as rural or
obtain a special status
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CAH Payment for Ambulance Services
Medicare Claims Processing Manual, IOM 100-04, Chapter 4, Section 250.5, Medicare Payment for
Ambulance Services Furnished by Certain CAHs
• Interpreting the statutory requirement that the CAH or the CAH-owned and operated entity be the
only provider or supplier of ambulance services within a 35-mile drive of the CAH to exclude
consideration of ambulance providers or suppliers that are not legally authorized to furnish
ambulance services to transport individuals to or from the CAH
• Effective for cost reporting periods beginning on or after October 1, 2019
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Public List of Standard Charges
• 300 services
• 70 CMS selected services
• 230 hospital selected services
• Information displayed on a public website
• Updated annually
Transparency
• Proposal for making all standard hospital charges public
• Gross and negotiated charges
• Online
• Machine readable format
Increasing Choices; Encouraging Site Neutrality
• 2nd year phase-in to control unnecessary increases in the volume of covered hospital outpatient
department (HOPD) services
Inpatient Only List
• CMS proposes to remove THA from the IPO list
• Assign CPT code 27130 to C-APC 5115 with status indicator “J1”
• A single bundled payment will be made for both the surgical procedure and all
ancillary services furnished in conjunction with it during the outpatient encounter
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Ambulatory Surgery Center (ASC) Covered Procedure List
• Total Knee Arthroplasty (TKA)
• Knee Mosaicplasty
• Six additional coronary intervention procedures
• Twelve procedures with new CPT
High-Cost/Low-Cost Threshold for Packaged Skin Substitutes
• Continue policy established in CY 2018, assigning skin substitutes to low-cost or high cost group
Device Pass-through Applications
• 5 device pass-through applications for the CY 2020
• No proposals to approve or deny
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Rural Health
• Wage Index Disparities Addressed in CY 2020 IPPS Final Rule Carried Over to OPPS Final Rule
• Removed urban to rural reclassifications from the calculation of the rural floor
• Increased the wage index value for hospitals with a wage index value below the 25th
percentile
• Applied a 5% cap for FY 2020 on any decreased in a hospital’s final wage index from the
hospital’s final wage index in FY 2019
Supervision Level of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals
• Leveling of supervision for hospital outpatient therapeutic services from direct supervision to
general supervision
• Procedure is furnished under a physician’s overall direction and control, but the
physician’s presence is not required during the performance of the procedure
2 Midnight Rule and the Inpatient Only List
• Procedures would not be eligible for referral to Recovery Audit Contractors (RACs) for
noncompliance with the Beneficiary and Family-Centered Care Quality Improvement
Organizations (BFCC-QIOs) would have the opportunity to review such claims in order to provide
education for practitioners and providers about compliance with the 2-midnight rule
• Claims identified as noncompliant would not be denied under Medicare Part A
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Organ Procurement Organization Conditions for Coverage (CfC): Revision to “Expected
Donation Rate”
• Correcting the oversight by revising the CfC definition to:
1. Be based on the national experience for OPOs serving similar eligible donor populations
and DSAs; and
2. Be adjusted for the distributions of age, sex, race, and cause of death among eligible deaths
• If finalized, the changes would become effective with the final rule, thereby occurring during the
ongoing 2022 OPO certification cycle
Revisions to Laboratory Date of Service Policy
• Changes to the laboratory DOS for molecular pathology tests and advance diagnostic laboratory
tests (ADLTs)
1. Changing the Test Results Requirement
2. Limiting the Laboratory DOS Exception to ADLTs
3. Excluding Blood Banks and Blood Centers from the Laboratory DOS Exception for ADLTs and
Molecular Tests
Prior Authorization Process
• Applied for Certain Covered Hospital Outpatient Department Services
• List of Hospital Outpatient Services requiring Prior Authorization
• Table 38
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Customer Service Changes
The customer service phone lines and the Integrated Voice Response (system) contact
number have merged
We kept the CS number – J5 (866) 518-3285
• New options for eligibility, claim status, or payment information takes you to the IVR when
you answer “Yes” to “Are you calling about patient eligibility, claim status or payment
information?”
Before reaching the main menu, callers need to provide:
• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• Last 5 digits of their Tax Identification Number
• IVR new items:
• Overlapping claims information
• Need ICN/DCN
• Claim denials
• Additional steps and information for common denials
• Overpayment features
• Additional information on open accounts receivable
• Transfer to Customer Service
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Call Center Closures
Training
• November 15
• December 20
Holiday
• November 28 – 29
• December 24 – 25
• January 1, 2020
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Medicare Beneficiary Identifier (MBI)
Transition period ends December 31, 2019
• Can submit either HICN or MBI
January 01, 2020
Only use MBI
https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers-and-office-
managers.html
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New Letter Feature
Additional Documentation Request (ADR) and Demand Letters (DL) issued after 09/06/19 are
available in secure portal
• Providers receive one email, per user, per day for each NPI
• 1 for ADR
• 1 for DL
• Able to view the same information as the paper ADR
• Available earlier than the paper ADR
NPI Administrator Account Reactivation
• When “Your account has been disabled” message is received upon log in, account can be
reactivated
• Select the link, enter the information exactly as it appears in the system
• User Login ID
• Date of Birth
• Select one of your Secret Questions from the drop down
• Secret Answer
• NPI for the financial data
• Financial data for one of the tabs; Patient Lookup, Medicare Check # or Medicare
Claim # that matches the NPI you entered
• Select enter and email will be sent
• Only NPI administrator accounts locked after 8/9/19 are eligible
New Portal Help
Email medicareadmin@wpsic.com
• Include
• Details (no PHI/PII) regarding needed assistance or the difficulties you are having
• Best way to contact you – phone or email
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Signatures not completed when an application is submitted will cause development
• Part A – can be as soon as 24-48 hours after submission
• Part B – as soon as 7 days after submission
• Avoid receiving development for these signatures
• Submit the application after an uploaded signature is attached to the application
• Fill out the Internet-based Provider Enrollment, Chain and Ownership System
(PECOS) application and print the Certification Statement from the upload
documentation page
• Obtain the signatures, scan and upload when completing the application
submission
• Electronic signatures – no way to complete before submission
• Reminders sent to request signature
• Who can sign (e-signature on Internet-Based PECOS)?
• 855I – the individual enrolling in Medicare
• 855B – the authorized or delegated official
• 855A – the authorized or delegated official
• 855R – both providers affected
• The authorized or delegated official of the organization receiving payment
• The individual allowing the organization to receive payment for their services
• EFT agreement
• Authorized or delegated official of the organization receiving payment
• Individual receiving payment
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