2019 11 12 IA HFMA-AAHAM -Handout · 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

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

1


2

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


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

3

Notes:

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________


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)

4

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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

5

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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

6

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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

7

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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: [email protected]

• Part B: [email protected]

8

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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

9

Notes:

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________


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

10

Notes:

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________


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

11

Notes:

______________________

______________________

______________________

______________________

______________________

______________________


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

12

Notes:

______________________

______________________

______________________

______________________

______________________

______________________


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

13

Notes:

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________


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

14

Notes:

______________________

______________________

______________________

______________________

______________________

______________________

______________________


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

15

Notes:

______________________

______________________

______________________

______________________

______________________

______________________

______________________


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

16

Notes:

______________________

______________________

______________________

______________________

______________________

______________________

______________________


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

17

Notes:

______________________

______________________

______________________

______________________

______________________

______________________


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

18

Notes:

______________________

______________________

______________________

______________________

______________________

______________________

______________________


Call Center Closures

Training

• November 15

• December 20

Holiday

• November 28 – 29

• December 24 – 25

• January 1, 2020

Notes:

______________________

______________________

______________________

______________________

______________________

______________________

______________________


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

20

Notes:

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________


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 [email protected]

• Include

• Details (no PHI/PII) regarding needed assistance or the difficulties you are having

• Best way to contact you – phone or email

21

Notes:

______________________

______________________

______________________

______________________

______________________

______________________


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

22

Notes:

______________________

______________________

______________________

______________________

______________________

______________________


23

Notes:

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Documents

2019 11 12 IA HFMA-AAHAM -Handout · 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