Kelly Miller Payer Summit: Medicare Part B Provider ... Kelly... · • CO-243 on remittance advice...

Kelly Miller Payer Summit: Medicare Part B Provider Outreach & Education Event

April, 2019

Presented by:

Swandra Miller

Senior Provider Relations Representative

Disclaimer

The information provided in this presentation was current as of March 29, 2019. Any changes or new information superseding the information in this presentation is provided in articles with publication dates after March 29, 2019 posted on our website at: www.PalmettoGBA.com/JJB

CPT® only copyright 2019 American Medical Association.

All rights reserved.

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2019 American Dental Association (ADA). All

rights reserved.

Survey

• Website Navigation

• Medicare Updates and Changes

• Hot Topics and Reminders

• Ways to Connect to Palmetto GBA

• Comprehensive Error Rate (CERT) Testing and Results

• Targeted Probe and Educate

• Provider Resources

• Q&A

AGENDA

Website Navigation

WWW.PALMETTOGBA.COM/JJB

The Jurisdiction J Part B MAC website is for providers that bill Palmetto GBA for Part B services rendered in AL, GA, and TN.

Homepage

News

MLN Connect Articles Special Editions Provider Enrollment Information Training and Holiday Closure Schedule

Topics

Medicare Basics E/M Help Center Documentation E-mail Updates Denial Resolution

Education

Conferences Webcasts Teleconferences Workshops

Self-Service Tools

Appeals Calculator CMS 1500 Claim Form eServices Portal Interactive ABN Forms

eServices

• Eligibility

• Claim Status

• eClaim Submissions

• Clerical Error Claim

• Reopening Requests

• Online Remittances

The Multi-Factor Authentication

(MFA) Code is good for 8 hours

• Financial Forms

• Financial Information

• MBI Lookup

• Secure Forms

• eDelivery

• eReview

• eServices User Guide

eServices: Eligibility

Information entered must match with CMS’ HIPPA Eligibility Transaction System (HETS) Date Range: 4 years prior and up to 4 months in the future

eServices: Eligibility

Eligibility Deductible/Caps Preventive MSP Hospice/Home Health Inpatient

eServices: Forms

Secure Fast Access Receipt Verification

eServices: Security Updates

Medical Policies

LCDs NCDs Coverage Articles LCD Reconsideration Process

Medical Policies

Claims Payment Issues Log (CPIL)

Listserv – E-mail Notifications

A confirmation e-mail is sent once the registration is completed The confirmation e-mail contains the PalmettoGBA.com username and password

Medicare Updates and Changes

• 2019 Updates

• Medicare Beneficiary Identifier (MBI) Updates

• JJ Part B Top Inquiries

• Medicare Part B Focus Services

2019 Updates

Streamlining Evaluation and Management (E/M) Payment and Reduced Clinician Burden • 1995 or 1997 E/M documentation guidelines should be used to document E/M

office/outpatient visits billed to Medicare

CY 2019 • Established Patients: No need to re-record the defined list of required elements if

there is evidence that the practitioner reviewed the previous information and updated as needed – practitioner should still review prior data, update as necessary, and indicate in the medical record that they have done so

• New and Established Patients: No need to re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary – practitioner may simply indicate in the medical record that the information has been reviewed and verified

2019 Updates

Medicare Telehealth Services • January 1, 2019

• New HCPCS codes: G0513 and G0514 • Newly recognized originating sites:

• Renal dialysis facilities • Homes of end stage renal disease (ESRD) beneficiaries • Mobile stroke units

Telehealth Service Expansion for the Treatment of Opioid Use Disorder and Other Substance Use Disorders • July 1, 2019

• Originating site geographic requirements removed • A beneficiary’s home is now a permissible originating site

2019 Payment Adjustment Reminders

Mandatory Payment Reduction - Sequestration • April 1, 2013 • 2 % reduction in Medicare payment • CO-243 on remittance advice (RA)

Merit-based Incentive Payment System (MIPS) Payment Adjustments • Year 1 (2017) participants will receive payment adjustments in 2019 • Payment is determined by data submitted on quality measures and activities for

2017 • MIPS positive payment adjustments: CO-144 on RA along with Reason and Remarks

Code N807 • MIPS negative payment adjustments: CO-237 • https://qpp.cms.gov/ • 866-288-8292

MIPS Positive Adjustment with Sequestration Reduction

Example: Fee Schedule Amount: $1927.07 Applied to Deductible: -$40.50 Sub-Total: $1886.57 (1927.07-40.50) 20% Co-Insurance: -$377.31 (1886.57 x 20%) Sub-Total: $1509.26 (1886.57 – 377.31) MIPS (indiv. prov. %): -$28.37 (1509.26 x 1.88%) (amount appears on RA with CO-

144 and CARC N807 and a negative sign)

Sub-Total: $1537.63 (1509.26 + 28.37) 2% Legislative: $30.75 (1537.63 x 2%) (amount appears on RA with CO-253)

Amount Paid: $1506.88 (1537.63-30.75)

Medicare Beneficiary Identifier (MBI) Get It, Use It

MBI Timeline

• April 2018: Medicare began mailing out new cards and beneficiaries were able to look up their new MBI

• June 2018: Providers enrolled in eServices were able to look up their patient’s MBI

• October 2018: The MBI was returned on Medicare Remittance Advices

• April 2019: Removal of Social Security Numbers (SSNs) from all Medicare cards

• January 1, 2020: Only the MBI will be accepted on claims

MBI Look-up Tool

https://palmettogba.com/eservices

Beneficiary’s Last Name First Name Date of Birth Social Security Number

JJ Part B Top Inquiries

0 2000 4000 6000 8000 10000 12000

HIPPA: 699

Billing Issues: 1,342

Financial Information: 1,423

Appeals: 1,687

General: 1,924

Eligibility: 2,245

Provider Enrollment: 3,076

Claim Status: 3,160

Unprocessable: 3,734

Claim Denials: 11,110

Part B Focus Services: What is Palmetto GBA’s focus for Part B?

• Evaluation & Management:

• 99233 – Subsequent Hospital Care Visits (currently on Medical Review) • 99284,99285 – Emergency Department Visits • 99291,99292 – Critical Care Visits (currently on Medical Review) • 99309,99310 – Subsequent Nursing Facility Visits

• Surgical Services:

• 66984 – Extracapsular Cataract Extraction Removal with Insertion of Intraocular Lens Prosthesis (Ophthalmology CBR)

• CPT codes 11042-11047: Surgical Debridement (previous Medical Review and CBR)

Part B Focus Services: What is Palmetto GBA’s focus for Part B?

• Diagnostic Services:

• 93306 – Imaging, Echocardiography with Contrast (CBR) • 77301,77338 – Intensity Modulated Radiotherapy (IMRT)

• Rehabilitation Services:

• 97110,97140,97112 – Therapeutic Exercises (97110 currently on Part A Medical Review)

• ESRD Monthly Capitation Payments (MCP):

• 90960-90963 (TPE TBD) Listserv sent 1/25/19 to nephrologists

• Hyperbaric Oxygen: • G0277

Part B Focus Services: What is Palmetto GBA’s focus for Part B?

• Diagnostic Services: Drugs of Abuse Laboratory Tests:

• 82542 – Column Chromatography/Mass Spectrometry • G6053 - Assay of Methadone • G6056 - Assay of Opiates • G6042 - Assay of Amphetamines • G6031 - Assay of Benzodiazepines • G6044 - Assay of Cocaine (CBR)

• Ambulance Services: Non-Emergent (currently on Medical Review) • A0426 – Advanced Life Support • A0428 – Basic Life Support • A0425 - Ground Mileage

Part B Focus Services: What is Palmetto GBA’s focus for Part B?

• Drugs & Biological Services:

• J0897 – Denosumab (Prolia®) • J0178 - Aflibercept (Eylea®) – (currently on Part A Medical Review) • J9271 - Pembrolizumab • J9299 – Nivolumab • J9355 - Trastuzumab • J9145 – Daratumumab • J2357 – Omalizumab • J3398 - Voretigene

Hot Topics and Reminders

• Medicare Secondary Payer (MSP) • Submitting Additional Documentation • Reopening: Simple Claim Correction • Top 10 Part B Medical Review Denials • Documentation Requirements/Denial Tips • The Medicare Learning Network • Education Opportunities • Part B Medicare Advisory

MSP Lookup Tool

MSP Claim Rejections

• The MSP type entered on an electronic claim must correspond to the information Medicare has on file or the claim will be rejected

• Rejected claims: • Do not have appeal rights • Must be submitted as a new claim

The above rules apply to all unprocessable/rejected claims

Submitting Additional Documentation

Certain CPT/HCPCS codes and modifiers require additional documentation for adjudication. Providers can submit the additional documentation via: • eServices – online portal

where documents can be uploaded

• Fax – Claims Processing PWK Fax Cover Sheet

Codes/Modifiers That Require Additional Documentation

Reopening: Simple Claim Correction

• Requests can be submitted via telephone, fax, or eServices

• Rejected claims cannot be reopened

• Timely filing requirements still apply

• Complex issues cannot be reopened

• Requests to correct minor clerical errors • Incorrect units of Medically Unlikely Edits (MUE) submitted on a claim • Transposed diagnosis or procedure codes • Change date of service (month and day only) • Submission of a claim for services that were not rendered • Incorrect rendering provider on claim

Top 5 Part B Medical Review Denials

Action Code

MR Comment

Description Amount Denied

# of Lines Denied

F26 BILER CLAIM BILLED IN ERROR PER PROVIDER $69,138

715

529 NOTMN PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPORT MEDICAL NECESSITY OF SERVICES BILLED

$32,163

168

F10 NODOC DOCUMENTATION REQUESTED FOR THIS DATE OF SERVICE WAS NOT RECEIVED OR WAS INCOMPLETE

$13,196

136

F41 DNSRP INFORMATION SUBMITTED CONTAINS AN INVALID/ILLEGIBLE PROVIDER SIGNATURE

$6,462

59

F12 WRONG DOCUMENTATION RECEIVED CONTAINS INCORRECT/INCOMPLETE/INVALID PATIENT IDENTIFICATION OR DATE OF SERVICE

$2,633

30

Documentation Principals & Requirements

MLN Matters: SE1237 Importance of Preparing/Maintaining Legible Medical Records

• General Principles of Medical Record Documentation

• Medical records should be complete and legible • Medical records should include provider legible identifier and date of service

• Amendments, Corrections and Delayed Entries in Documentation

• Documents containing amendments, corrections, or delayed entries must employ acceptable recordkeeping principles

• Medicare Signature Requirements • Handwritten or electronic signature

SE1237: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1237.pdf

Additional Documentation Requests (ADR) Response Tips

• It’s the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

• Ensure the documentation has legible signatures and dates

• Ensure physician orders and documents contain the interventions performed

• Include test results and lab results (if applicable)

• Make sure the copy sent to the review contractor is legible

• Number the pages before making a copy, so it will be easy to see if one of the pages are missing

Denial Tips

• Review and use the CPT and HCPCS Code Sets effective for the billed date of service

• Review the current CPT Coding Manual and CMS coverage guidelines to determine the qualifying service/procedure

• Review the CMS Medicare Learning Network Items and Services Not Covered Under Medicare Booklet

• Contact the patient or their responsible party for information regarding other insurance that may be liable for the changes related to the care provided

• Review the CMS Medicare Learning Network® Medicare Preventive Services Publication for a list of Medicare covered screening and preventive services along with any specific coverage and billing guidelines

Drugs & Biologicals: Avoiding Denials

• Follow the guidelines in Coverage

Article A53387

• Include the history that supports the need of the drug

• Include the documentation the supports the diagnosis of why the patient is receiving the drug

• Make sure it’s for right patient and the correct dates for billed services

• Must have a signed and dated

physician’s order

• Must follow the protocol when administering the drug

• Documentation must support the services billed

• Document the drug was administered and how and where it was administered

The Medicare Learning Network®

Publications and Multimedia News and Updates Events and Training Continuing Education MLN Matters Articles

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS)

Education

• Provider Outreach and Education Advisory Groups (POE-AGs)

• Webcasts/Teleconferences

• June 3, 2019 – Medical Review Targeted Probe and Educate - 2 P.M. ET • September 3, 2019 – Medical Review Targeted Probe and Educate – 2 P.M. ET • December 2, 2019 – Medical Review Targeted Probe and Educate – 2 P.M. ET

• Videos

• Self-Paced Learning

• Ask the Contractor Teleconferences (ACTs)

• May 8, 2019 – 11 A.M. ET • August 7, 2019 – 11 A.M. ET • November 12, 2019 – 11 A.M. ET

Part B Medicare Advisory

Ways to Connect to Palmetto GBA

• Provider Contact Center (PCC)

• Interactive Voice Response (IVR)

• Online Resources

JJ Part B Provider Contact Center (PCC)

• Our PCC responds to issues related to: • Claims • Billing • Eligibility • Provider Education • Other Provider Issues

• Telephone Corrections (reopening) • Electronic Data Interchange (EDI) • Provider Enrollment

• 877-567-7271

• PCC hours: 8 A.M. to 6 P.M. ET

Interactive Voice Response (IVR)

• Providers may use the IVR to request routine claims, beneficiary eligibility

and payment information

• 877-567-7271

• IVR hours: 24 hours a day, 7 days a week (general information)

• IVR Flowchart

• Call Flowchart

• IVR Conversion Tool

Online/Social Media Resources

Live Chat Facebook Twitter LinkedIn YouTube

Comprehensive Error Rate Testing Program

• Overview

• CERT Errors and Statistics

CERT Overview

• CMS implemented the CERT Program to measure improper payments in the Medicare FFS Program. Under the CERT Program, a random sample of all Medicare FFS claims are reviewed to determine if they were paid properly under Medicare coverage, coding, and billing rules

• Once identified, a request via a faxed or mailed letter for the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim is sent

• If there is no response to the request for medical records, the CERT contractor may also make a telephone call to solicit the documentation. Once the documentation is received, it is then examined by medical review professionals to see if the claim was paid or denied appropriately

CERT Errors

• The reason for the improper payment determines the error category for

the claim

• There are five major error categories: • No documentation • Insufficient documentation • Medical necessity • Incorrect coding • Other

CERT: Missing Documentation

• Notification of missing documents in the form of a letter or phone call

• Outlines the document(s) needed to complete CERT review

• Only submit the requested documentation, do not resubmit the entire

medical record

• May received a missing documentation reminder call from Palmetto GBA

CERT: Resources

CERT: Jurisdiction J Statistics

• Part B Error Rate – 13.0% (national rate 10.7%)

• Number of claims reviewed – 1,560

• Top five improper payment rate by type of service:

• Laboratory/Other: $148,864,018

• Ambulance: $80,189,683

• Office Visits – Established: $76,155,093

• Hospital Visit – Initial: $58,616,510

• Hospital Visit – Subsequent: $55,407,618

Targeted Probe and Educate

• Process/Current Review Topics

Targeted Probe and Educate (TPE)

• MACs conduct data analysis to identify areas with the greatest risk of inappropriate program payment

• CMS may also identify areas of risk and direct the MACs to review

• Providers are selected for review based on data analysis • Provider specific only • Eliminates service-specific reviews

TPE Process

• Up to three rounds of probe review

• Each round consists of a 20-40 claims for review

• One on one education intervention with clinical staff

• Allow 45-56 days between education intervention and next round

• Review may be discontinued when the provider becomes compliant

• Monitor for one year via data analysis with follow-up review if needed

TPE Process

• Conduct data analysis of billing data indicating aberrancies that may suggest questionable billing practices

• Jurisdiction J Reviews • 99232-99233 • 99291-99292 • A0426/A0428/A0425

• May include providers previously reviewed on a targeted or service-specific

review with high error rate

TPE Process

• ADR letters are generated for each claim selected

• Providers must respond to the ADR within 45 days of the date of the letter • For pre-pay reviews, MAC will review documentation within 30 days

of the receipt date • For post-pay reviews, MAC will review documentation within 60 days

of the receipt date

TPE Process

• For easily curable errors that are identified (e.g., missing nursing visit note), the reviewer will contact provider to afford them the opportunity to submit the missing documentation

• Prior to conclusion of each round, medical reviewer will call provider with moderate to high error rate to discuss the summary of errors found

• At conclusion of each round, letter with review results will be mailed to the provider

• When high denial rate continues after three rounds, provider will be referred to CMS

TPE Process

• It is imperative when responding to the TPE ADR that you include the name and number of your designated contact person

• The medical reviewer will contact your designated person to discuss a pattern discovered during the review and/or prior to the conclusion of each TPE round to discuss the review summary

Provider Resources

Contacts and Resources

Jurisdiction J (JJ) Jurisdiction M (JM)

Palmetto GBA JJ and JM Part B

www.PalmettoGBA.com/JJB www.PalmettoGBA.com/JMB

Palmetto GBA E-Mail Updates

Select ‘Listservs’ from the top-right of your jurisdiction’s home page

Palmetto GBA eServices

Select ‘eServices’ from the top navigation bar or select ‘eServices’ from the ‘Forms/Tools’ box in the center of your

jurisdiction’s homepage

CMS Website www.CMS.gov

JJ Provider Contact

Center 877-567-7271

JM Provider Contact

Center 855-696-0705

Q&A

QUESTIONS

For claim specific questions, please contact the Jurisdiction J Provider Contact Center (PCC) at

1-877-567-7271

Thank You

Thank You for Attending!