Medicare Part A Quarterly Updates. Palmetto GBA JM A/B MAC Provider Outreach & Education September 13, 2017

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1 Medicare Part A Quarterly Updates Palmetto GBA JM A/B MAC Provider Outreach & Education September 13,

2 Disclaimer This information is current as of August 25, Any changes or new information superseding this webcast is provided in articles with publication dates after August 25, 2017, posted on our website at: CPT only copyright 2017 American Medical Association. All rights reserved.

3 Objective To provide pertinent updates, changes and reminders to assist our provider community in staying compliant with Medicare rules and regulations.

4 Agenda Change Requests (CR) Updates & CMS Initiatives Claims Submission Errors & CERT Data Palmetto GBA Updates

5 Change Request Updates & CMS Initiatives 5

6 Quarterly Updates Comprehensive CMS resources! Purpose of publications: Provide non-regulatory changes Define policy & manual instructions Information about new developments Clarification & understanding of CMS policies & programs

7 Change Requests (CR)

8 Change Requests (CR)

9 CR Effective 1/1/18 ESRD Facilities: Injectable, intravenous, & oral calcimimetics qualify for Transitional Drug Add-On Payment Adjustment (TDAPA) To receive payment using the TDAPA Report the HCPCS for the drugs/biologicals with AX modifier (item furnished in conjunction with dialysis services)

10 CR Effective 1/1/18 Hospitals: Correcting payment of IPPS transfer claims assigned to MS DRG Inflammatory Bowel Disease with MCC Received full prospective payment instead of graduated per diem for each day in error

11 CR Effective 1/1/18 MACs cannot bypass edit C IPPS claim with Through date equal to IPPS From date Transfer logic not bypassed when assigning review codes on IPPS claims classified into MS-DRG 385 with discharge status codes: 02, 07, 66, 82, or 94 and Through date of service is equal to or greater than 1/1/18

12 CR Effective 1/1/18 Allowing Part A deductible on Medicare Secondary Payer (MSP) same day transfer inpatient claims FISS was not allowing Medicare covered/payable expenses paid by the primary insurer and billed with the value code for Part A deductible on same day transfer MSP claims

13 CR Effective 1/1/18 Allow Part A deductible on MSP same day transfer claims for Medicare covered services paid by the primary payer As it currently does for regular MSP claims Deductible is identified by a value code

14 CR Effective 1/1/18 Suppression of SPR in 45 days if also receiving ERA Effective 45 days from 1/2/18, as of 2/14/18 SPR generation will be discontinued to any EDI enrolled provider receiving any format of ERA

15 CR Effective 10/1/17 October quarterly update to 2017 annual update of HCPCS codes used for SNF CB edbilling/index.html?redirect=/snfconsolidatedbilling / Certain radiation therapy codes are not subject to SNF CB 77014, 77750, 77761, 77762, 77763, 77776, 77777, 77778, 77785, 77786, 77787, 77789, 77790, 77799, 79005, & 79445

16 CR Effective 10/1/17 CR corrects error for claims reporting these codes with DOS on or after 1/1/15 that denied/rejected in error prior 10/1/17 Palmetto GBA will adjust claims when brought to our attention

17 CR Effective 1/1/18 Quarterly Influenza Virus Vaccine Code Update - January 2018 From 8/1/17 12/31/17 use code Q2039 for new influenza virus vaccine product For dates of service on or after1/1/18 use the influenza virus vaccine code is 90756

18 CR Effective 10/1/17 Identifies changes required as part of the Annual IPF PPS update from the FY 2018 IPF PPS Notice Applicable to IPF discharges occurring during FY 10/1/17 9/30/18 Refer to Claims Processing Manual, chapter 3, section

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22 New Medicare Card Project Social Security Number (SSN) Removal Initiative 22

23 Social Security Number (SSN) Removal By April 2019; MACRA requires removal of SSN from all Medicare cards & assignment of a Beneficiary Identification Number (BNI) When SSNs are replaced on all Medicare cards, CMS can better protect: Private health care & financial information Federal health care benefit & service payments

24 May 2017 Complete MBI development September 2017 Medicare & You books w/ MBI card details CMS begins robust education outreach April 2018 All systems & processes able to accept MBI Begin MBI card distribution to 60M beneficiaries October 2018 MBI returned on Remit Advice Expect launch of Look-Up tool

25 Apr 16, 2019 Statutory deadline to issue MBI cards January 2020 HICN no longer exchanged with limited exceptions Action to be ready Subscribe to weekly MLN Connects newsletter for updates & new information Palmetto GBA Website at

26 Claim Submission Errors Quarterly Data Analysis Report 26

27 Claims Submission Errors Claim submission error data includes: Claims in Returned To Provider (RTP) Claims that have Rejected Claim Submission Error Help Self-Service Tool Quarterly Top 10 Denials

28 Part A Quarterly Total Denials April - July 2017 Data

29 Reason Code Editing

30 Reason Code Editing

31 Reason Code Editing

32 Comprehensive Error Rate Testing (CERT) A Partnership 32

33 CERT Purpose and Process

34 CERT Contractor Responsibilities

35 MAC Contractor Responsibilities 35

36 Medicare A/B MAC CERT Task Force 36

37 Medicare A/B MAC CERT Task Force 37

38 Our Objective Our objective is to help you reduce your error rates relative to documentation errors and signature requirements For both Palmetto GBA & CERT contractor, these two errors continue to be the top reasons why claims are denied Yet, they are simple to fix!

39 Medical Record Once medical records are submitted many providers may think: Signed, sealed, delivered, it s now yours! True - Palmetto GBA receives the medical records for review - but what happens next? What are the important elements that Palmetto GBA looks for in medical record?

40 Documentation Errors Two major categories of documentation errors: Insufficient documentation Medically unnecessary services What is the purpose of documentation?

41 Purpose of Documentation Historical account Professional responsibility Legal requirement Communication tool for other disciplines and/or providers

42 Purpose of Documentation Measurement of patient outcomes Need for services Justification for plan of treatment Basis for the quality of care Reimbursement for services

43 Insufficient Documentation Failure to respond to medical record requests Documentation missing important facts Includes documentation with invalid or missing signatures Illegible medical records

44 The Golden Rule If it isn t documented, it wasn t done You re paid for what you document, not what you did Document, Document, Document! More is better

45 Inpatient Acute Facility Services Documentation Tips Hospital history & physical Progress notes Nurse s notes Disposition/discharge notes Hospital discharge summary

46 Inpatient Acute Facility Services Consultation reports Medication administration records Procedure notes Treatment records Physician's order/intent

47 Inpatient Acute Facility Services Diagnostic test results/reports Including imaging reports Observation orders & progress notes for each day Emergency room records Perioperative & Intraoperative record Operative reports

48 Inpatient Acute Facility Services Recovery room record Rehabilitation records Anesthesia records Authorized provider order Lab/pathology report Full detailed itemized bill indicating revenue code

49 Medical Need & Necessity 49

50 Medical Necessity Medicare allows coverage & payment for only those services that are considered to be medically reasonable and necessary Documentation must support service billed, that it was needed & service was certified by provider Provider must maintain documentation Medical records must be available to contractor upon request Failure to submit requested documentation may result in complete or partial denial of services

51 Medical Unnecessary Services Documentation is incomplete Documentation does not support services billed Documentation does not substantiate medical need for the services

52 Example Illegible Documentation

53 Signature Requirements 53

54 Signature Requirements CMS guidelines mandate the presence of signatures for medical review purposes Signature requirements are applicable to all Medicare claims and medical records submitted for Medical Review purposes

55 Illegible/Invalid Signature

56 CERT Appeal Receive a CERT denial? Appeal CERT decision! CERT Redetermination Request Form Do not resubmit the claim Denial decision was based on review of medical records; therefore, claims for these services may not be resubmitted, they may be appealed

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58 Provider Outreach & Education Palmetto GBA education opportunities: On-line via our website Webcasts, web-based training, self-service tools YouTube videos & tutorials In-person events Workshops or partnership speaker requests Teleconference Education requests or Quarterly ACTs

59 Upcoming POE Events Live Workshop Conference: Mactoberfest Innovation Today for Success Tomorrow 10/11/17, 8:30 am - 4:30 pm Palmetto GBA Headquarters, Columbia, SC Go to the Education Portal to register for this FREE event!

60 Upcoming POE Events MACtoberfest topics include: Medicare Part A Updates, EDI & Appeals eservices Online Secure Portal Medical Affairs & Medical Review Provider Enrollment Revalidations Schedule a 30 minute appointment with a PCC or eservices subject matter expert

61 Upcoming POE Events Ask the Contractor Teleconference (ACT) 10/19/17 at 2:00 pm ET Speaker - Appeals Subject Matter Experts Submit a question form is located at: Fax questions at least 5 days before the ACT!

62 Please use POE Education Request Form 62

63 Provider Contact Center

64 Please take the Survey! 64