HFMA Northern California Chapter. Part A/B Provider Outreach and Education March 2018

Transcription

1 HFMA Northern California Chapter Part A/B Provider Outreach and Education March 2018

2 Disclaimer 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 and the CMS website at 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 2018 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. March

3 Agenda Hot topics 2018 CMS Updates Provider Updates Part A/B Medicare Review Contractors Noridian Resources Educational Information March

4 Acronyms Acronyms CMS CPT CR CY DME EOB FQHC HCPCS HICN Description Center for Medicare & Medicaid Service Current Procedural Terminology Change Request Calendar Year Durable Medical Equipment Explanation of Benefits Federally Qualified Health Center Healthcare Common Procedural Coding System Health Insurance Claim Number March

5 Acronyms MAC MBI MDDP MLN MSP NCD PECOS QMB RARC SPR Acronyms2 Description Medicare Administrative Contractor Medicare Beneficiary Identifier Medicare Diabetes Development Plan Medicare Learning Network Medicare Secondary Payer National Coverage Determination Provider Enrollment, Chain & Ownership Systems Qualified Medicare Beneficiary Remittance Advice Remark Code Standard Paper Remit March

6 Objective Our targeted objective is to provide the newest updates with an overview of billing and coverage changes that apply to provider practices for the start of 2018 March

7 CMS Updates 2018

8 New Medicare Card Project Transition period April 1, 2018 to December 31, 2019 Card information: Social Security Numbers removed by April 2019 Health Insurance Claim Number (HICN) replaced by Medicare Beneficiary Identifier (MBI) Use either HICN or MBI starting 4/01/18-12/31/2019 Distribution of cards in geographic waves Beneficiaries may use cards once received MBI availability from Noridian Portal June 2018 March

9 New Medicare Card Project2 Recommended provider action Sign up Noridian list serv bi-weekly s Visit CMS Website/ Attend Their Events Medicare/New-Medicare- Card/index.html Inform Beneficiaries/ Obtain new MBIs Prepare and Test Systems March

10 New Railroad Retirement Board Medicare Card Claims processed through Medicare Administrative Contractor (MAC) Palmetto GBA not Noridian What is the difference? Symbol Red Banner Railroad Retirement Board All other information is the same as the Standard Medicare Card March

11 Prepare Your Patients Resources available on CMS Print and/or order e/new-medicare-card/nmchome.html March

12 2018 Medicare Part A Premiums and Deductibles Annual Inpatient Hospital Deductible Day 1-60 $1,340 per benefit period Day Coinsurance $335 per day Day Lifetime Reserve (LTR) Coinsurance $670 per day Psychiatric Hospital Same as hospital deductible Skilled Nursing Home (SNF) Day 1-20 Paid in full Day Coinsurance $ per day March

13 2018 Medicare Part B Premiums and Deductibles Standard Premium $109 or $134 per month up to $428/month Hold harmless Premium increase offset in Social Security benefits Deductible $183.00/year Co-insurance 20% of eligible charges March

14 Part B Medicare Diabetes Prevention Program (MDPP) Structured behavior change intervention aimed to prevent onset of type II diabetes among Medicare beneficiaries with an indication of prediabetes MDPP services consists of: CDC-approved Diabetic Preventative Program (DPP) curriculum 12-month core benefit Minimum of 16 core sessions First 6 months Monthly maintenance sessions Second 6 months Maintenance sessions AFTER 1st YEAR: monthly maintenance sessions if patient achieves & maintains minimum weight loss Codes include G9873-G9889 Allow between $25-$160 March

15 MDPP Enrollment Prospective MDPP suppliers began enrolling on January 1, 2018 Policies related to furnishing and billing MDPP services effective April 1, 2018 I.E. beneficiary eligibility, MDPP set of services, payment, beneficiary engagement incentives March

16 MDDP Enrollment Form Form CMS Complete using PECOS CMS website Medicare/Provider- Enrollment-and- Certification/Medicare ProviderSupEnroll/Enr ollmentapplications.ht ml March

17 CMS Appeals ALJ Settlement Low volume appeals (LVA) settlement option: Pending at Office of Medicare Hearings and Appeals (OMHA) and Medicare Departmental Appeals Council 62% settlement of net allowed Eligibility for either Part A or Part B claims: Total billed <$ <500 claims pending Education/Outreach/NPC/Downloads/ Appeals-Settlement-Presentation.pdf March

18 Part A/B Provider Updates

19 New Specialty Codes CR9957 Effective October 1, 2017 C7 = Advanced Heart Failure & Transplant Cardiology C8 = Medical Toxicology C9 = Hematopoietic Cell Transplantation & Cellular Therapy Update PECOS online enrollment CMS forms 855I or 855O March

20 Telehealth Services: Elimination of GT Modifier CR10152 effective January 1, 2018 Eliminates requirement to use GT modifier on professional claims for telehealth services Via interactive audio and video telecommunications systems GQ modifier is still required when applicable Critical Access Hospital (CAH) method II on institutional claims, still require GT modifier Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements March

21 Telehealth 2018 & New Codes Originating Site Q3014 = $25.76 (national) G0296 Visit to determine low dose computed tomography (LDCT) eligibility and Health Risk Assessment G0506 Care Planning for Chronic Care Management and Psychotherapy for Crisis Interactive Complexity March

22 New Mammography CPT Codes Effective January 1, 2018 Old HCPCS New CPT Description G Diagnostic mammography, including CAD when performed; unilateral G Diagnostic mammography, including CAD when performed; bilateral G Screening mammography, bilateral (2-view study of each breast), including CAD when performed March

23 Mammography CPT Code Denial CPT 77065, and can be used for both film and digital mammography Codes set as requiring film certification Research determined it was more applicable to have them set up to allow both certification types Noridian updated codes to allow both certification types on January 18, 2018 A mass adjustment will be completed for claims denied incorrectly March

24 New Prolonged Preventive and Anesthesia Service Codes Prolonged preventive services Add-on payment; deductible and coinsurance waived CPT G0513 first 30 minutes CPT G0514 any additional minutes Anesthesia services conjunction support of colorectal cancer service screenings CPT anesthesia for lower intestinal endoscopic procedures CPT anesthesia for lower intestinal endoscopic procedures, screening colonoscopy PT modifiers waves the deductible and coinsurance waived March

25 2018 Therapy Code List CR10303 effective January 1, 2018 Therapy code listing: /index.html CPT has been added as always therapy CPT code has been deleted CPT G0515 has been added as sometimes therapy CPT code has been deleted March

26 Updated Editing of Part B Always Therapy Services CR10176 effective January 1, 2018 Part B only Outpatient therapy (OPT) services Always Therapy HCPCS codes require a GN, GO, or GP modifier, as appropriate Service to be accurately applied to the therapy cap Only applies to professional claims Only one modifier is allowed March

27 Therapy Cap Values Update: Congress repealed February 8, 2018 There will be no therapy cap for 2018, but there will be a threshold Threshold is dollar amount deemed as the reasonable and necessary amount of therapy prior to a review of additional services March

28 Therapy Cap Repeal Claims are no longer subject to separate therapy caps KX modifier indicates medical necessity justification above incurred expenses Must be documented in the patient s medical record Threshold amount $3000 are subject to targeted medical review March

29 Payment Reduction Computed Radiography- Modifier FY Effective January 1, 2018 Modifier FY X-ray taken using computed radiography Reduction only technical component and technical component of global fee Services furnished during CY 2018 to 2022 at 7% reduction 10% reduction starting CY 2023 and all future years Beneficiary is not liable for the reduction Part A All imaging services are listed in the OPPS Addendum B Deletion of Modifier CP March

30 Qualified Medicare Beneficiary (QMB) Program CR9911 effective October 2, 2017 Messages display on remittance advice reflecting QMB status: RARCs: N781, N782 Medicare providers must accept assignment for services furnished to dual eligible beneficiaries Providers cannot charge QMB individuals March

31 Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program SE1128 published December 4, 2017 QMB is a Medicaid-run program For questions contact your state-run Medicaid agency May need to pay a small Medicaid copay in certain circumstances CMS will suspend modifications to the remittance advice (RA) and Medicare summary notice (MSN) for QMB claims made on or after October 2, 2017 Noridian uses HIPAA Eligibility Transaction System (HETS) through our NMP and IVR March

32 QMB Eligibility Effective November 4, 2017 Check QMB eligibility Noridian Medicare Portal (NMP) Interactive Voice Response (IVR) Provider Contact Center March

33 Part A Provider Updates

34 Correcting Payment of IPPS Transfer Claims CR10145 effective January 1, claims date of service and after Medicare Severity - Diagnosis Related Group (MS-DRG) 385 Inflammatory bowel disease with Major Complication or Comorbidity (MCC) should be subject to transfer policy Part A deductible will be allowed on Medicare Secondary Payer (MSP) same day transfer claims Identified by a value code March

35 RHC/FQHC Care Coordination Services and Payment CR10175 effective January 1, two new HCPCS added with payment amount set at Average of 3 national non-facility PFS payment rates for chronic care management (CCM) and general behavioral health integration (BHI) codes General Care Management (G0511) Psychiatric Collaborative Care Model (CoCM) (G0512) Billing CPT on or after January 1 will be denied March

36 340B Drug Program Extends front-end discounts on covered outpatient drugs to eligible facilities/covered entities Maximum statutory price that may be charged by the manufacturer Modifier JG indicates the drug or biological was acquired with the 340B drug pricing program discount Modifier TB indicates the drug or biological was acquired with the 340B drug pricing program discount and is reported for informational purposes Questions Contact government contractor Apexus at or March

37 Part B Provider Updates

38 Elimination of Paper Remits CR10151 effective January 1, 2018 Elimination of paper remits All providers receiving electronic remittance advice (ERAs) for 45 days or more Effective January 1, 2018 All providers EDI-enrolled receiving ERAs and standard paper requests (SPRs) Effective February 14, 2018 Some exceptions for natural disaster or CMS discretion All Part B portal users with Remittance functionality access March

39 NCD Leadless Pacemakers CR10117 effective January 18, 2017 Contractors allow payment with Coverage with Evidence Development (CED) when billed using: CPT codes: 0387T, 0389T, 0390T, and 0391T Claims for leadless pacemakers are only payable in Place of Service (POS) 06, 21, 22 or 26 If claim doesn t contain modifier Q0 edit 113L will set Contain diagnosis code Z00.6 or the 114L will set March

40 Medicare Part A/B Review Contractors Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), Targeted Probe & Educate (TPE), Officer of Inspector General (OIG), Zone Program Integrity Contractor (ZPIC)

41 Responding to The Letter Request for documentation: CERT, Medical Review, RAC,SMRC,TPE, and ZPIC Documentation request letters have due date for response Verify your address is correct in PECOS Respond timely with organized documentation Make sure signatures are present and legible Submit an attestation if missing or illegible signature Ensure all required information is sent to correct review contractor March

42 Noridian Review Contractor Resources Jurisdiction E Medicare Part A/B Medical Review Targeted Probe & Educate Other Review Entities Comprehensive Error Rate Testing (CERT) Office of Inspector General (OIG) Recovery Auditor (RAC) Supplemental Medical Review Contractor (SMRC) ZPIC March

43 Comprehensive Error Rate Testing (CERT) Randomly selects provider submitted claims Issued a Claim Identifier (CID) number CERT medical record request is faxed or mailed by AdvanceMed Medical records are reviewed for compliance by AdvanceMed March

44 AdvanceMed CERT Review Contractor Attn: CID# 1510 E. Parham Road Henrico, Virginia Phone: Fax: Include requested medical documentation along with bar coded sheet Website medcorp.com/ Comprehensive Error Rate Testing (CERT)2 March

45 Recovery Audit Contractor (RAC) HMS Federal Solutions (HMS) New name for Region 4 post pay auditor Region 4 is all Noridian states (JE/JF A/B) Medicare Part A/B Identifies Medicare overpayments and/or underpayments through audits March

46 SMRC Medical Reviews CMS regulations, Internet Only Manual (IOM), Publication , Program Integrity Manual (PIM), Chapter 7 Noridian conducts medical reviews Started March 2018 Disclaimer: no copy of the record request at this time March

47 Who is the Supplemental Medical Review (SMRC) Contractor? Strategic Health Solutions, LLC ended February 2018 Review claims to lower the improper payment rates and claim errors Conduct nationwide medical review Part A Part B Durable Medical Equipment (DME) Notify CMS of improper payments and noncompliance of documentation requests May result in claim adjustments completed by the MACs March

48 Office of Inspector General (OIG) Compliance with Nation's fraud and abuse laws Educate public Monthly reporting orts-andpublications/workplan/i ndex.asp#current March

49 OIG Current Work Plan March

50 Targeted Probe & Educate (TPE) Noridian Pilot review process - June 2017 Medical Review (MR) conducting reviews One-on-one education edicare.com/web/jea/ cert-reviews/targetedprobe-educate March

51 How TPE Works March

52 TPE Targeted Probe and Educate (TPE) with extrapolation claims per provider Per item or service Per round Three rounds of prepayment probe review Denial rate unchanged Refer provider to CMS for possible further action March

53 Zone Program Integrity Contractor (ZPIC) California: Zone 1 Safeguard Services (SGS) Primary goal investigate instances of suspected fraud, waste, and abuse Identify improper payments recouped by MACs Support victims of Medicare identity theft March

54 Noridian Updates 2018

55 Self-Service Requirements Effective February 5, 2018 Noridian Medicare Portal (NMP) and/or Interactive Voice Response (IVR) Part A/B patient eligibility and deductible Claim status-remittance Advice (RA) includes details Total charges, payment amount, date and check number Claim Control Number (CCN), Internal Control Number (ICN) and Document Control Number (DCN) Reason code for denial Electronic Funds Transfer (EFT)/check #/amount/date Self Service Reopenings (NMP only) Enrollment Application Status Search Enrollment application status March

56 New Look to Noridian Website Part A Part B March

57 Noridian Foresee Survey Foresee Link ults.com/survey/display? cid=wtsu0tp0khbzxlugc pcmxa==&sid=linknoridian-je March

58 2018 Medicare Physician Fee Schedules Noridian Website Jurisdiction F Medicare Part A/B Fees & News Fee Schedules or New Quick Link March

59 Updated Medicare Secondary Payer (MSP) Calculator Tool determines line by line claim payment calculations when Medicare is secondary Noridian Website re.com/ Jurisdiction F Medicare Part A/B Browse by Topic Medicare Secondary Payer (MSP) March

60 New Enrollment Application Search Tool Noridian Website dicare.com/ Jurisdiction E Medicare Part A/B Enrollment Enrollment Application Status Search March

61 New Enrollment Application Search Tool2 December 14, 2017 Checking your status Information needed to complete search: Application/tracking # or web-tracking ID Progression: Received In Progress Corrections Requested Completed Unable to Complete March

62 Noridian Medicare Portal (NMP) New quick link Keep up to date Notifications & Updates Have New Users? Get them registered Functionality: Verify eligibility Check claim status Reopening Submit an appeal March

63 Noridian Part B Reopenings No longer accept requests containing spreadsheets for Part B only December 4, 2017 Providers are encouraged to use the Self Service Reopenings option through NMP Learn more: JE: p/end-user-manual/self-service-reopenings March

64 NMP Self Service Part B Reopenings No more calling or mailing Just log on to NMP! Adjustment types available for Part B: Billed amount Billed in error (initiate overpayment) Date of service Diagnosis Modifier MSP type Place of service Procedure code and billed amount Procedure code, modifier and billed amount Rendering provider Referring provider Reprocessing Units and billed amount Units, modifier and billed amount March

65 NMP Functionality

66 Medical Review Comments Part A Only March

67 Appeal Submission March

68 Eligibility Results March

69 Eligibility March

70 HMO March

71 MSP March

72 Home Health March

73 Hospice March

74 Hospital March

75 SNF March

76 ESRD March

77 Financial Inquiry March

78 Financial Results Part A March

79 Preventive March

80 DDE Preventive Services Eligibility March

81 Learn More about NMP Webinar Registration Noridian Medicare Portal Registration and Functionality March 27, :00 pm 2:00 pm Central Daylight Time March

82 March

83 Online Provider Education Education on Demand: View selfpaced tutorials at your convenience Certificate ed upon completion March

84 Resources and Educational Tools

85 Noridian Website Free site Resources Jurisdiction E Medicare Part A/B Browse By Topic Browse By Specialty Fees &News Policies Medical Review Education & Outreach Enrollment Forms March

86 CMS Educational Materials MLN products downloadable or request copy free of charge Brochures, Fact sheets Web-based training MLN dedicated web pages General Information ninfo Matters Articles tersarticles Products ducts March

87 Part A/B Upcoming Webinars Earn your CEUs Webinars JE/A on/training-events JE/B education/training-events After Hours Part B webinars will continue monthly in 2018 March

88 National Enrollment Conference Join us for the National Provider Enrollment Conference April 24 & 25, 2018 in San Diego CA Hosted by CMS and Noridian with breakout sessions for new providers/staff, seasoned clinic/group staff, IDTF, DMEPOS, certified provider/suppliers, ect Register by March 30, 2018 at onal-provider-enrollment-conference Questions? Do NOT call the provider enrollment call center 3/23/

89 Sign Up - Medicare News! Receive most recent Noridian/CMS news MLNs are posted under What s New Articles Tuesday/Friday Simple/quick signup Located at the bottom of every page March

90 Collaboration with External Entities Form Form for Associations Send to: Subject line: Collaboration Request March

91 Questions? Thank you!