Medicare Part B Presents: Medicare Updates

Transcription

1 Medicare Part B Presents: Medicare Updates Medical Office Managers' Society of South Jersey January 3, 2019 Disclaimer All Current Procedural Terminology (CPT) only are copyright 2017 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. Novitas Solutions does not permit videotaping or audio recording of training events. 1

2 Novitas enews Subscribe Now! Receive current updates directly from Novitas Solutions: JH and JL Part A and Part B News Issued every Tuesday and Friday CMS MLN Connects issued Thursdays Choose the line of business and topics YOU NEED: Novitasphere Part A News Part B News Electronic Billing (EDI) Veterans Affairs ABILITY PC-ACE Medicare Remit Easy Print (MREP) Indian Health Services (IHS) Subscribing to enews Subscribing is quick and easy! JH: JL: A verification will be sent to you minutes after subscribing Didn t receive the verification? Your network firewall or spam filter is blocking us Please alert your network IT personnel Follow these simple steps to allow enews: o 2

3 Remaining Enrolled No action required if receiving Novitas enews as scheduled! If you ever stop receiving Novitas enews on Tuesdays and Fridays, alert your IT personnel! Your company s firewall or spam filter is blocking your subscription Please alert your network IT personnel Follow these simple steps to allow enews: o Today s Presentation Agenda: Medicare Updates/Reminders Novitas Solutions News Top Claim Denials Objectives: Provide the latest news and updates Stay updated on Medicare changes Take advantage of the various self-service options available to the provider community 3

4 Acronym List Acronym ADR CERT CMS CR EDI HETS HIPAA ICD-10 LCD MBI Definition Additional Documentation Request Comprehensive Error Rate Testing Centers for Medicare & Medicaid Services Change Request Electronic Data Interchange HIPAA Eligibility Transaction System Health Insurance Portability and Accountability Act International Classification of Diseases, Tenth Revision Local Coverage Determination Medicare Beneficiary Identifier More Acronyms Acronym MLN NCD NPI PHI Definition Medicare Learning Network National Coverage Determination National Provider Identifier Personal Health Information 4

5 Medicare Updates/Reminders New Instructions for Local Coverage Determinations (LCDs) MM 10901: Implementation: January 8, 2019 Key Points: New LCDs: Informal meetings are optional for customers to request information on how to submit valid new LCD request: Will be conducted via teleconference New LCD requests have specific requirements to be valid Comment period and notice period will not change for new LCDs Contractor Advisory Committee (CAC): Will now be open to interested parties to observe: Locations and times will be posted to our website CAC members will also include non-physician healthcare professionals such as Dentist, Certified Registered Nurse Anesthetist (CRNA), Physical Therapist (PT) and Licensed Clinical Social Worker (LCSW) 5

6 New LCD Process LCD reconsideration request: Coding updates only, such as adding diagnosis code, will be handled through revision to companion local coverage article: No longer appropriate to include CPT or ICD-10 codes in LCDs instead they will be placed in billing and coding articles linked to LCD (process could take up to 1 year to complete) Change in coverage will require a comment and notice period: This change may delay LCD revisions for a reconsideration request Revised LCDs and Articles The list of revised LCDs and Articles are on our website under December 28: The revised LCDs and Articles will be published to the Medicare Coverage Database and on our Website in February 6

7 What is Novitasphere? Definition: Free, secured web-based Portal which allows enrolled users access to time-saving features Purpose: Allows enrolled users access to Eligibility, MBI Lookup, Claim Information, Remittance Advice, Appeal Requests, Medical Review Records and more Available to JH and JL Part A/B providers, billing services and clearinghouses Live Chat For demonstrations and more information on Novitasphere visit: JL Providers Part B Navigation Bar 7

8 Keep your Novitasphere Access Active All users must log in at least once every 30 days, or their Novitasphere access will be removed If your office is already enrolled, please share this reminder with users in your organization New Medicare Card New Medicare card: o o Health and Human Services (HHS) logo Gender and signature line removed 8

9 Important Dates For The New Medicare Card Date Action April 2018 May 2018 Begin mailing cards to Newly Eligible People with Medicare Begin mailing new Medicare cards to people with Medicare June 2018 October 2018 April 16, 2019 January 2020 Launch provider MBI look-up tool Return MBI on Remittance Advice Statutory deadline for issuing new Medicare cards Transition Period Ends: Must use the MBI on data exchanges (some exceptions) MBI Lookup Select the MBI Lookup from the left navigation bar Complete the I m not a robot verification once every 5 searches Select your NPI from the drop down box 9

10 MBI Inquiry Tab New Medicare card with MBI not yet mailed MBI Lookup Results If the card containing the new beneficiary s MBI has been mailed, you will be able to click on the MBI Lookup Info tab to obtain the patient s new MBI number 10

11 Update to Medicare Deductible, Coinsurance and Premium Rates for 2019 MM11025: Effective Date: January 1, 2019 Implementation Date: January 7, 2019 Key Points: 2019 Part A Hospital Insurance: Deductible: $1, Coinsurance: $ a day for 61st-90th day $ a day for 91st-150th day (lifetime reserve days) $ a day for 21st-100th day (Skilled Nursing Facility coinsurance) 2019 Part B Medical Insurance: Deductible: $ a year Coinsurance: 20 percent Additional Reference: 2019 Medicare Parts A & B Premiums and Deductibles Fact Sheet Therapy Cap Values for Calendar Year (CY) 2019 MM11055: Effective: January 1, 2019 Implementation: January 7, 2019 Key Points: Outpatient therapy limits (KX modifier threshold) for: Physical Therapy (PT) and Speech-Language Pathology (SLP) combined is $2,040 Occupational Therapy (OT) is $2,040 Medical Review (MR) threshold amount : PT and SLP services combined is $3,000 OT services is $3,000 Provider Specialty: Therapy (JL) 11

12 Novitasphere Eligibility Details When there is data available under a specific category, the tab will be displayed in blue When there is no data available under a specific category, the tab will be displayed in grey Deductible Tab Deducitble Year Remaining Deductible Part A 01/01/ /31/2018 $1, Part B 01/01/ /31/2018 $

13 2019 Amounts in Controversy Appeal Level Time Limit for Filing Appeal Amount in Controversy Redetermination 120 days $0.00 Reconsideration 180 days $0.00 Administrative Law Judge (ALJ) Hearing Medicare Appeals Council of the Departmental Appeals Board (DAB) Judicial Review in Federal District Court 60 days $ for 2018 $ for days $ days $ for 2018 $1, for 2019 Appeals JL Revision of Definition of the Physician Supervision of Diagnostic Procedures MM11043: Effective January 1, 2019 Implementation- January 2, 2019 Key Points: CMS is revising its policy to specify that beginning with dates of services on or after January 1, 2019, diagnostic procedures that are furnished by a Radiologist Assistant (RRAs), who are certified by The American Registry of Radiologic Technologists, and RPAs, who are certified by the Certification Board for Radiology Practitioner Assistants, require only a direct level of physician supervision, when permitted by state law and state scope of practice regulations 13

14 Revised Definition of the Physician Supervision of Diagnostic Procedures Beginning with dates of services on or after January 1, 2019, the description for Physician Supervision of Diagnostic Procedures indicator "03" on the Medicare Physician Fee Schedule is revised to say the following: "03 = Procedure must be performed under the personal supervision of a physician. (Diagnostic imaging procedures performed by a Registered Radiologist Assistant (RRA) who is certified and registered by The American Registry of Radiologic Technologists (ARRT) or a Radiology Practitioner Assistant (RPA) who is certified by the Certification Board for Radiology Practitioner Assistants (CBRPA) and is authorized to furnish the procedure under state law, may be performed under direct supervision Fee Schedule Look-up Tool Fee Schedule Search Tool 14

15 Medicare Physician's Fee Schedule (MPFSDB) Indicator Descriptions MPFSDB Indicator Descriptions Clarification of Diabetes Self- Management Training (DSMT) Telehealth Services MM11043: Effective January 1, 2019 Implementation- January 2, 2019 Key Points: CMS is clarifying DSMT policy to specify that all 10 hours of the initial DSMT training and the two (2) hours of annual follow-up DSMT training may be furnished via telehealth in cases when injection training is not applicable 15

16 New Modifier for Expanding the Use of Telehealth for Individuals with Stroke MM10883: Effective: January 1, 2019 Implementation: January 7, 2019 Key Points: New HCPCS informational Modifier G0 (G zero) For telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke: Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X); or Telehealth originating site facility fee, billed with HCPCS code Q3014 Telehealth Service Modifiers (JL) MSP Diagnosis Codes Available in HETS Effective December 8, 2018, HETS will return MSP diagnosis codes when applicable: MSP diagnosis codes primarily relate to treatment from an injury or illness resulting from and auto or other accident which: Liability or no-fault insurance may pay Another party is responsible for payment Workers compensation benefits for a given condition Helps you determine primary and secondary billing for patient services Reference: MLN Connects December 6,

17 HETS Includes Medicare Diabetes Prevention Program Information Effective December 8, HETS will return Medicare Diabetes Prevention Program (MDPP): Use this information to determine the next available (MDPP) services for you patients HETS will not return MDPP if the Medicare Beneficiary is ineligible for MDPP Reference: MLN Connects December 13 Preventive Services Part B (JH) (JL) Medicare Diabetes Prevention Program (MDPP) Definition: The MDPP is defined as an expanded model which includes an evidence-based set of services aimed to help prevent the onset of Type 2 diabetes among Medicare beneficiaries with an indication of prediabetes Purpose: Coverage of structured sessions with a coach, using a CDC-approved curriculum to provide training in dietary changes, increased physical activities, and weight loss strategies Organizations who enroll as an MDPP supplier are paid performancebased payments through the CMS claims systems: Medicare payments to suppliers will vary Payments can be up to $670 per beneficiary over a two year-period, depending on the beneficiary s attendance and weight loss 17

18 Eligible Beneficiaries Eligible beneficiaries are those who: Are enrolled in Medicare Part B Have a body mass index (BMI) of at least 25, or at least 23 if selfidentified as Asian Meet one of the following three blood test requirements within the 12 months of the first core session: A hemoglobin A1c test with a value between 5.7 and 6.4 percent A fasting plasma glucose of mg/dl A 2-hour plasma glucose of mg/dl (oral glucose tolerance test) Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes) Do not have end-stage renal disease (ESRD) Overview of the Benefit The first year includes six months of weekly core sessions followed by six months of monthly maintenance sessions The second year is contingent upon beneficiary performance and monthly maintenance sessions The maximum payment is $670 over a two year period Ongoing maintenance session attendance and maintenance of 5 percent weight loss MDPP suppliers must use a CDC-approved curriculum to guide sessions Copayment is waived No referral is required 18

19 Core Sessions Months 0 to 6: MDPP suppliers must offer a minimum of 16 sessions, offered at least one week apart Sessions are available to eligible beneficiaries regardless of weight loss and attendance performance while on the program Months 7-12: MDPP suppliers must offer a minimum of six monthly sessions during the second six months Sessions are available to eligible beneficiaries regardless of weight loss and attendance performance while on the program Months 13-24: MDPP suppliers must offer monthly maintenance sessions Eligible beneficiaries who achieve and maintain weight loss and attendance goals have coverage for three-month intervals of monthly maintenance sessions for up to one year Detailed information regarding payment and billing is available in the Quick Reference Guide Payment and Billing MLN Matters Article MM Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates Medicare Diabetes Prevention Program (MDPP) Enrollment To enroll as an MDPP supplier, organizations must: Have MDPP preliminary recognition or full CDC DPRP recognition Have an active and valid tax-identification number (TIN) or national provider identifier (NPI) Pass enrollment screening at the high categorical risk level Submit a list of MDPP coaches on the MDPP enrollment application who will lead sessions, including full name, date of birth, social security number (SSN), and active and valid NPI and coach eligibility end date (if applicable) Meet MDPP supplier standards and requirements, and other requirements of existing Medicare providers or suppliers Once enrolled, revalidate enrollment every five years MDPP Enrollment and Recognition Information: Preparing to Enroll as an MDPP Supplier Enrollment Checklist Complete the CMS20134 Application 19

20 Interactive Preventive Services Tool Preventive Services Tool Preventive Services Tab Current Procedural Terminology (CPT) only copyright 2017 American Medical Association. All rights reserved. 20

21 Targeted Probe and Educate (TPE) Background CR10249 Effective: October 1, 2017 Implementation: October 1, 2017 Key Points: CMS has authorized MACs to conduct the TPE review process and MACs will select the topics for review MACs will focus on specific providers/suppliers: That bill a particular item or service rather than all providers/suppliers billing a particular item or service Who have the highest claim denial rates or who have billing practices that vary significantly from their peers: Based on Data Analysis & CERT error rates TPE review process includes three rounds (if warranted) of probe review with education: Sample limited for each probe round to a minimum of twenty (20) and a maximum of forty (40) claims Targeted Probe and Educate (TPE) Purpose: TPE process will lower provider payment error rates TPE provides opportunity to educate providers before, during and after the probe Program Overview: TPE program will allow for time after education to correct errors before the next round occurs Automated reviews and prior authorizations are not part of the TPE program 21

22 Topics For Review All topics for review are published on the Novitas Solutions website with a link to education that will assist in ensuring a successful review These lists will be continually updated as new topics are added Not all providers will be subject to review: Part A TPE Topics for Review Part B TPE Topics for Review Provider Notification Providers/suppliers selected for review will be notified with an initial letter ADR letters will be generated on each claim selected for review: ADRs will be generated per the usual process Part A providers will receive ADRs mailed to the correspondence address in FISS: ADRs may also be printed or viewed in FISS Part B providers will receive ADRs mailed to the correspondence address 22

23 Initial Letter and Education Initial letter will include: Topic being reviewed Reason for the selection which will be supported by data analysis Number of claims requested for review Documentation checklist Review process Contact information for the reviewer assigned to the probe Initial education: Clinical Reviewer will call to: Establish a contact person Educate on the documentation requirements Discuss educational tools available on our website Additional Development Request (ADR) When a claim is selected for prepayment medical review, an ADR request is generated and contains necessary information for the review Claims associated with the ADR are placed in a suspended location to allow time for the provider to respond to the request Once an ADR is received a provider should do the following: Collect all requested documentation associated with the claim Verify all documentation requested is included in the submission Verify all documentation submitted is appropriately signed or also includes signature attestation Attach the first page of the original ADR request as the cover sheet to the records 23

24 Provider Response to ADRs Provider has 45 days to respond to the contractor with medical records Options for sending in medical records: Novitasphere (free) Faxing (free) esmd (cost) CD/DVD submission (cost) US Mail, FedEx or UPS (cost) Novitasphere : Submit Documentation Feature ONLY used to respond to your ADR letters. Enter Claim Number Click Browse to locate the files on your computer for submission Add More Documentation can be used to add multiple files You may use the Comment field at your discretion. The review is based on the medical documentation that you submit Password protected documents cannot be processed and will not be accepted 24

25 Medical Review Record Submission Confirmation Record submission acknowledgement will be issued once documentation records are submitted Submit Documentation Feature - Submission History This option will allow you to view any submissions sent under the Submit Documentation feature Select the submission type from the drop down, and select either Date Range or Confirmation ID. Click Search Submission History does not provide a status of the document review, it is only a status of the document transmission to Novitas. If there are any errors with the file, it will show Upload Fail and you will need to resubmit 25

26 Retrieve Documents Feature - Appeal Development Letter Date of letter field is auto-populated with a 15 day date range from the current date. You may enter a single date, or range dates, but not a date beyond the 15 day date range Click VIEW to view a PDF copy of the letter of your choice Medical Review Claims Feature - Review Tab Review Status: Awaiting ADR response Review has begun Review completed Review Outcome: Approved Denied Reduced lower level Underpaid - upcoded 26

27 Medicare Review Claims Feature - Education Tab Type and date of the education offered during the medical review. Only the most recent education that was provided will be displayed Novitas News 27

28 Coming Soon! New Novitas Learning Center (NLC) coming January 2019! Improved look and feel and streamlined navigation More sophisticated design: Intuitive dashboard provides quick view of learning customized for the learner Learn anywhere, anytime on any device Improved content library Take the lead in your own professional development when seeking and accessing Medicare training opportunities New Novitas Learning Center Novitas strives to continually improve the services and resources provided to our customers. Our most recent innovation is the redesign of the Novitas Learning Center. Effective January 1, 2019, Novitas Learning Center users will observe a few changes: The username previously established to access a Novitas Learning Center account will be replaced by the user s address. Existing users will log into their account using the address associated with the user account in the Novitas Learning Center. All users will be prompted to reset their passwords after the January 1, 2019, transition. Users will only need to reset their password one time. Historical learning information associated with the Novitas Learning Center account will be migrated to the new system for all completed courses. If a course is still in progress at the time of the transition, it will not be moved to the new system. 28

29 Trending Inquiries Received in the Customer Contact Center Trouble using IVR to obtain beneficiary eligibility or claim status using an MBI? When speaking an MBI in the IVR be sure to speak naturally, including normal pauses every few characters Convert a MBI to a number that can be keyed into the IVR using the IVR Alphanumeric Conversion Tool (JL): Example: MBI number EG-4TE-5MK-72 converted 1*32*414*81*325*61*5272 Consider using the Novitasphere (JL) for most self service inquiries Top Claim Denials 29

30 Where To Find The Top Claims Submission Errors Issues, Denials, Rejections & Top Errors JL Top Claim Errors Top Claim Errors 30

31 Examples of Claim Errors Resource outlines how to interpret the information published on the remittance advice and advises next steps for how to resolve the claim error Duplicate Services Remittance Advice Message 18: Services already processed or pending Duplicate claim currently processing: Allow claim to process: Electronic claims processing time: 14 days from date of receipt Paper claims processing time: 29 days from date of receipt Resolution: To find the duplicate claim : Interactive Voice Response say next claim after listening to your denial: IVR Part B (JL) Check claim status in Novitasphere If claim is not a true duplicate: Submit an appeal (redetermination) Include relevant medical documentation 31

32 Novitasphere Checking claim status through Novitasphere for duplicates Complete all fields with the red asterisk. Date of service will always default to the current date Claim Status Results Results of claim status through Novitasphere Refine your search by selecting the claim status drop down Search by: Rejected status Approved and Paid Current Active Claim Denied Original claim has been adjusted 32

33 Medical Necessity Denials Remittance Advice Message 50: These are non-covered services because this is not deemed a medical necessity by the payer Resolution: Review Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs): Medical Policy Search Tool (JL) Any updates to the claim may be processed by using the IVR or Novitasphere: Example, if a diagnosis was missed on the claim Medical Policy Searching for LCDs and NCDs using the search tool 33

34 Medical Policy Search Tool Search tool Local Coverage Determinations Active, draft and retired LCDs Current Procedural Terminology (CPT) only copyright 2017 American Medical Association. All rights reserved. 34

35 Claim Not Covered by this Payer/Contractor Remittance Advice Message 109: Claim not covered by this payer/contractor This denial indicates that the service is one that is processed or paid by another contractor Examples of these types of service are: Durable Medical Equipment Medicare Advantage Other MAC Jurisdictions Resolution: Claim must be sent to the correct payer/contractor Interactive Jurisdiction Map Benefit Included in Payment For Another Service Remittance Advice Message 97: The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated Resolutions: B Status code on the Medicare Fee Schedule Database Part of global surgery package: The cost of the care before and after surgery or procedure is included in the approved amount for that service An evaluation and management billed during the global period Miner surgeries have a 10 day global period and major surgeries have a 90 day global period 35

36 B Status Code Bundled services Current Procedural Terminology (CPT) only copyright 2017 American Medical Association. All rights reserved. Global Status Indicators Indicator for global surgery days Current Procedural Terminology (CPT) only copyright 2017 American Medical Association. All rights reserved. 36

37 Global Surgery Self-Service Options Global surgery calculator Global Period Calculator Global Surgery Calculator 37

38 Summary Provided the latest news and updates Stay up to date with the latest Medicare changes by visiting the Novitas Solutions website Take advantage of the various self-service options available to the provider community Customer Contact Information Providers are required to use the IVR unit to obtain: Claim Status Patient Eligibility Check/Earning Remittance inquiries Jurisdiction L: Customer Contact Center Provider Teletypewriter Patient / Medicare Beneficiary: MEDICARE ( ) 38

39 Contact Information Stephanie Portzline Manager, Provider Engagement Phone: (717) Janice Mumma Supervisor Provider Outreach and Education (717)