SD MGMA

Third Party Payer Day

Presented by:

Part B Provider Outreach and Education

September 2017

Disclaimer

2

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 https://med.noridianmedicare.com and the CMS website at

https://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 2017 American

Medical Association. All rights reserved. Applicable FARS/DFARS apply.

September 2017

Agenda

• CMS Updates

– Current Changes

• Noridian Updates

– Current Changes & Additions

– Reviewing Contractor Updates

• Items of Interest

September 2017 3

CMS Updates

New Medicare Card Project

• Social Security Numbers removed from all Medicare cards by April 2019

• Replaced with new Medicare Beneficiary Identifier (MBI)– Example 1EG4-TE5-MK73

– MBI Format Specifications• https://www.cms.gov/Medicare/New-Medicare-

Card/Understanding-the-MBI-with-Format.pdf

• Transition period April 1, 2018 through December 31, 2019– Beneficiaries may use the new card upon receipt

September 2017 5

Elimination of Paper Remits

• Change Request (CR) 10151

• Effective 1/01/2018

– For all providers/suppliers who receive ERAs for 45

days or more

• Effective 2/14/2018

– For all providers/suppliers EDI enrolled who are

receiving ERAs and SPRs

• Some exceptions, i.e.:

– Natural disaster or CMS discretion

September 2017 6

Noridian Updates

Targeted Probe & Educate (TPE)

•CMS authorized Noridian to conduct TPE Pilot review process

•Targeted by Medical Review (JF only)• Driven by data analysis

• Educational opportunity for error reduction

• Note:– CR 10073 Targeted Probe & Educate Pilot

• CMS is expanding to three contractors, Jurisdictions B, D, and E

8September 2017

TPE Webpage

September 2017 9

Provider Self-Audit with Validation

and Extrapolation Pilot (PSAVE)

• CMS authorized pilot program

• Noridian education provided while allowing providers to

self-audit documentation with many benefits

• Immunity granted from MAC and RAC reviews on pilot

claims involved upon successful completion

• Visit website for information and PSAVE recording:

– https://med.noridianmedicare.com/web/jfb/cert-

reviews/psave

• Questions? Contact us:

– (800) 284-4351 or email PSAVE@noridian.com

September 2017 10

Prolonged Services Findings

• CPT 99354 – 99357

• Prolonged services are intended to be used for

unusual circumstances requiring additional time

beyond typical/average time of visit code billed

• Prolonged services is an example of time-based

service that requires time be documented in

medical record

September 2017 11

Medicare Secondary

Payer (MSP) Calculator

• Used to determine line by line payment calculations

• Will not accurately calculate:– Non-participating

providers/suppliers

– Sequestration

– 100% allowed payments (i.e. lab codes)

– Psychiatric reduction

– Tertiary payments

September 2017 12

New Additional Static Pages

• Noridian Website

– https://med.noridianmedicare.com/

• Care Plan Oversight (CPO)

• Chronic Care Management (CCM)

– Locate under Browse By Specialty/ E/M

• Chemotherapy Administration

– Locate under Browse By Topic/ Drugs & Biologicals

• Outpatient Therapy

– Locate under Browse By Specialty

September 2017 13

Contractor Updates

CERT, RAC, SMRC & OIG

Responding to “The Letter”

• Request for documentation:

– CERT, Medical Review, RAC ,SMRC

• Demand letters have a response date

• Verify your physical address is correct in PECOS

• Gather the information quickly and neatly

• Make sure the signatures are present and

legible.

• Ensure the information is sent to the correct

person

September 2017 15

Updating Address for CERT Letters

• CERT sends correspondence to Pay-To address

in PECOS

• Update address in PECOS

– https://pecos.cms.hhs.gov/pecos/login.do#headingLv

1

September 2017 16

CERT Webpage

September 2017 17

CERT November 2016 Report - JF

September 2017 18

CERT November 2016 Report - JF

September 2017 19

November 2016: JFB Root Causes Errors Weighted

Error $

South Dakota Totals 9 $3,686,107.62

Chiro-There is no chiropractic treatment plan documented to support a plan of care and documentation

does not adequately describe the service billed

1 $2,174,393.67

Missing valid physician order and/or documentation to support intent

1 $748,434.06

Does not meet medical decision making and physical exam key element for billed E/M service level

1 $525,349.30

Valid ICD-9/ICD-10 code(s) was submitted, however record is insufficient to support services billed

5 $224,595.07

Umbilical Hernia repair with mesh billed, record indicates no mesh used

1 $13,335.52

Recovery Auditor Contractor (RAC)

September 2017 20

• HMS Federal Solutions (HMS)

– https://racinfo.hms.com/home.aspx

– Contact information• Part B Providers

• Telephone: (877) 350-7993

• Fax: (702) 240-5510

RAC Newest Complex Review

• Annual Wellness Visits (AWV) for G0439

(subsequent visits)

• Errors found:

– Failure to submit documentation

– Service did not meet key elements

September 2017 21

RAC Webpage

September 2017 22

Supplemental Medical Review Specialty

Contractor (SMRC)

September 2017 23

SMRC Sample

Letter

September 2017 24

Office of Inspector General (OIG)

• 2017 work plan

• Current Reporting:– https://oig.hhs.gov/reports-and publications/workplan/index.asp

September 2017 25

Medical Documentation

Requirements

September 2017 26

Surgical Pathology Medical

Documentation Letter

September 2017 27

Documentation Letter• https://med.noridianmedicare.

com/documents/10546/12345

760/Surgical+Pathology+Medi

cal+Documentation+Letter

Signature Requirements For Medical

Review Purposes

For medical review purposes, Medicare requires

that services provided/ordered be authenticated by

the author. The method used shall be a hand

written or an electronic signature. Stamp

signatures are not acceptable.

September 2017 28

Note: Refer to exceptions for stamped signatures

Valid Signature

• Valid signature criteria which must be met:

– Services provided/ordered must be authenticated by

ordering practitioner

– Signatures are:

• Handwritten

• Electronic

• Stamped – If requirements to utilize stamped signature are

met

– Signatures are legible

September 2017 29

Acceptable

Valid if anywhere on document it states “Signed” or Final”

September 2017 30

Request for Signature

• Provider has 20 days from date of receipt of

phone call from Noridian to submit attestation

– Failure to submit records with valid signatures upon

request, or valid and timely attestations, will result in

your claims being denied

– Result of signature requirements not met

• Causes overpayment and recoupment of payment

September 2017 31

Signature Errors

• Missing physician signature on order

• Incomplete progress notes

• Unauthenticated medical records

• No documentation of intent to order services and

procedures

• No signed and dated attestation statement for

operative report (if physician signature was

missing or illegible)

September 2017 32

Utilize Documentation Checklists

September 2017 33

Items of Interest

Redeterminations and Reopenings via

NMP Letters

• Medicare Redetermination Notices (MRNs) will

no longer be mailed

• Providers /suppliers who submit

Redetermination or Reopening requests through

NMP will receive MRNs via NMP

• Ability to view/print determination letters

35September 2017

Advanced Beneficiary Notice of

Noncoverage (ABN) Form

• Effective June 21, 2017

– Exp. 3/2020

• Alternative format

available in Spanish and

larger font size

• Form available on CMS

website:

– https://www.cms.gov/medic

are/medicare-general-

information/bni/abn.html

September 2017 36

CMS-1500 Claim Form Updated Version

• Effective August 30, 2017

• CMS-1500 claim version 02/12 only acceptable version

– Photocopies are NOT acceptable

– Purchase forms from U.S. Government Printing Office website• https://bookstore.gpo.gov/catalog/health-

insurance-claim-forms

–Call (202)512-1800– IOM 100-04 Chapter 26, Section 10

September 2017 37

CMS-1500 Claim Form Updated Version 2

September 2017 38

Top

Bottom

Noridian Medicare Portal (NMP)

September 2017 39

Noridian Upcoming Part B WebinarsDate Time (CT / PT) Title

9/13 3 p.m. / 1 p.m. Duplicate Claims

9/14 1 p.m. / 11 a.m. Critical Care

9/19 1 p.m. / 11 a.m. Modifier 59 Clarification and Changes

9/20 3 p.m. / 1 p.m. Basic E/M Avoiding Common Errors

9/26 1 p.m. / 11 a.m. Chronic Care Management (CCM)

9/26 2 p.m. / 12 p.m. CPT 20610 Coding Guidance

9/26 3 p.m. / 1 p.m. New Provider-Biller Part I

9/27 3 p.m. / 1 p.m. New Provider-Biller Part II

9/28 3:30 p.m. / 1:30 p.m.

Initial Preventive Physical Examination and Annual Wellness Visit

REGISTER NOW!

Education & Outreach / Schedule of Events

September 2017 40

Medicare “After Hours” Webinars

• 6 p.m. PT / 8 p.m. CT • Webinars also during day - earlier same week• All webinars earn 1.0 CEU• Register at Noridian: Education and Outreach- Schedule of Events

Date Topic

9/28 Chronic Care Management (CCM)

10/26 Roster Billing for Influenza and Pneumonia Immunizations

11/16 Transitional Care Management Services

12/7 Understanding National and Local Coverage Determinations

September 2017 41

In Summary

• Use Noridian/CMS website tools

– Attend workshops like this presentation

– Read Medicare emails and articles

– Refer to links to Noridian and CMS website for

signature requirements

September 2017 42

Questions?

Thank you!