Audio or Video Recording is Prohibited WPS MEDICARE UPDATES 11/04/2014

Transcription

1 WPS MEDICARE UPDATES Mary E. Muchow, Sr. Analyst Provider Outreach & Education Presented for MI MGMA Third Party Payer Day November 21, 2014 Audio or Video Recording is Prohibited 2 1

2 Disclaimer This presentation is a tool to assist providers. Every reasonable effort was made to ensure the accuracy of the information. However, providers have the ultimate responsibility for correct submission of claims. WPS Medicare bears no liability for results or consequences of any misuse of the information. 3 Today s Agenda ICD-10 and Policy Comprehensive Error Rate Testing (CERT) Program Medicare Signature Requirements 4 2

3 Today s Agenda Electronic Health Record Considerations Nuggets Questions 5 ICD-10 and Policy 6 3

4 Local Coverage Determination (LCD) Transition to ICD-10 LCD policies containing ICD-9 have been end dated LCDs with ICD-10 are available 7 ICD-10 Updates to National Coverage Determinations (NCDs) First maintenance update of ICD-10 conversions and coding updates Medicare Learning Network (MLN) Matters Number MM8691 Edits to ICD-10 coding specific to NCDs will be included in subsequent, quarterly recurring updates No policy-related changes included 8 4

5 Comprehensive Error Rate Testing (CERT) Program 9 CERT Process Random Claim Selection Medical Record Requests Review of Claims Assignment of Improper Payment Categories Calculation of the Improper Payment Rate 10 5

6 Why should I care? Many entities use CERT identified improper payments to target medical review activities and strategies Common denominator to identify program vulnerabilities Includes reviews by Office of Inspector General (OIG) Recovery Auditor Medicare Administrative Contractors Supplemental Medicare Review Contractor Zone Program Integrity Contractors Program Safeguard Contractors CMS 11 CERT Errors Handout WPS Medicare Part B Quarterly (3rd Quarter 2014) CERT Error Findings Report - Michigan Handout Forecasting of errors provided by CERT contractor 12 6

7 CMS/WPS Medicare CERT Web Pages CMS CERT web page Systems/Monitoring-Programs/Medicare-FFS- Compliance-Programs/CERT/index.html WPS Medicare J8 MAC B CERT web page rtments/cert/ 13 Obtaining CERT Review Results WPS Medicare Part B CERT Point of Contact medicareadmin@wpsic.com Include CERTReview Results in Subject Line ProviderTransaction Access Number (PTAN) Requester s full name, address, and telephone number Claim Identification Number (CID) Detailson requested information Note: Consider requesting information on claims deemed to be correct Please do not include protected health information 14 7

8 Medicare Signature Requirements 15 Authentication by Author Required Do not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) Instead, consider use of signature authentication process Many CMS educational products on this topic are available MLN Matters Number MM6698 Signature Guidelines for Medical Review Purposes Learning-Network- MLN/MLNMattersArticles/downloads/MM6698.pdf 16 8

9 Attestation Statement Authenticates entry in the medical record Can be used in cases of illegible or missing provider signatures (excluding physician orders) Must be signed and dated by the author of the medical record entry Must contain sufficient information to identify the beneficiary 17 Signature Log Used to identify author associated with initials or an illegible signature Might be included on actual page where initials or illegible signature are used or in a separate document Used by reviewers regardless of the date created 18 9

10 Electronic Health Record (EHR) Considerations 19 Shortcuts That Pose Risks Cloning Copy and paste Carrying forward Scribing or authenticating notes made by another person, if not acknowledged Documenting by exception 20 10

11 Each Medical Record Stands Alone Practitioner must Document what was reviewed in previous record and must indicate any changes Verify that all elements entered into the record were performed and the results documented for that specific date 21 Protocols If using a protocol or referring to a protocol in medical record documentation, a copy should be included when sending documentation to the Medicare contractor 22 11

12 What s missing? Note Time indicates 05/11/2014-9:10 AM Original Note by MD filed at 05/11/2014 at 9:10 AM Progress note signed by MD at 05/12/ :36 PM 23 Amendments, Corrections and Delayed Entries in Medical Documentation Publication , Chapter 3, Section Also referenced in MLN Matters Number SE1237 Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents must: 1. Clearly and permanently identify any amendment, corrections or addenda, and 2. Clearly indicate the date and author of any amendment, correction or addenda, and 3. Clearly identify all original content (do not delete) 24 12

13 Misunderstood Modifiers Used to add information or change the description of service in order to improve accuracy or specificity Documentation must support use Information issued by CMS may differ from the American Medical Association s (AMA) coding advice regarding the use of modifiers 25 Modifier 25 Used when evaluation and management (E/M) is separate and distinct from the work normally associated with a service or minor surgical procedure 26 13

14 Modifier 25 Considerations Did the provider perform and document key components of an E/M service for the separate complaint or problem? Could the complaint or problem stand alone as a billable service? Is there a different diagnosis for this portion of this visit? If the diagnosis is the same, did the provider perform extra work that went above and beyond the typical pre-or postoperative work associated with the procedure code? 27 Modifier 59 Used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances Used only when no other already established modifier is appropriate or when no more descriptive modifier is available to best explain the circumstances 14

15 Modifier 59 Documentation Must support a different session, different procedure or surgery, different site or organ system (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual National Correct Coding Initiative Procedure-to-Procedure (PTP) Edits PTP edits define code combinations when codes should not be reported together either in all situations or in most situations A Correct Coding Modifier Indicator (CCMI) will indicate when the code pair may be reported together only in defined circumstances 15

16 Correct Coding Modifier Indicators 0 Not Allowed There are no modifiers associated with NCCI that are allowed to be used with this code pair There are no circumstances in which both procedures of the code pair should be paid for the same beneficiary on the same day by the same provider 1 Allowed The modifiers associated with NCCI are allowed with this code pair when appropriate 9 Not Applicable An NCCI edit does not apply to this code pair The edit for this code pair was deleted retroactively New Specific Modifiers for Distinct Procedural Services (XE, XS, XP, XU) Effective Date: 01/01/2015; Implementation Date: 01/05/15 XE Separate Encounter A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service 32 16

17 MLN Matters Number MM8863 Specific Modifiers for Distinct Procedural Services Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8863. pdf 33 CMS-Secure Net Access Portal (C-SNAP) WPS Medicare s comprehensive, secure, information source for patient and claim data Registration and password required do 34 17

18 C-SNAP A Continuing Evolution New functionality Part B Appeals Status Part B Overpayment Claim Adjustment Part B Clerical Error Reopening Upcoming functionality Part A Discharge Status WPS Nerve Conduction Velocity Presentation - October 4, 2013 Page 35 QUESTIONS? NOTE: Until 10/30/14, presentation related questions may be ed to MSHO After 10/30/14, contact WPS Medicare Customer Service by phone or via Contact Us (on WPS Medicare website) 36 18

19 THANK YOU 37 19