Reopening and Redetermination Submissions

Transcription

1 A CMS Medicare Administrative Contractor Reopening and Redetermination Submissions Understanding your next steps are very important for quick reimbursement and providers are required to know the difference between a Reopening and a Redetermination. A reopening is a reprocessing of a claim to fix minor mistakes A redetermination is an examination of a claim that includes analysis of documentation Providers are encourage to register for NGSConnex. Providers who are registered to use NGSConnex, should use this option to submit reopening requests electronically. This guide distinguishes the differences between a reopening and redetermination. Please review and share this information with anyone in your organization who can benefit from this guide. Reopening (Clerical Error) To correct a claim(s) determination resulting from minor errors, you should use the reopening process Mathematical or computational mistake Transposed procedure or diagnostic codes Inaccurate data entry Computer errors Incorrect data items Redetermination (Appeal- 1 st level) For partially paid or denied claim(s) resulting from more complex issues that require analysis of documentation Coverage of furnished items and service Medical necessity claim denials Determination on limitation of liability provision Overpayment determinations

2 Note: Documentation cannot be submitted with the Reopening request when using NGSConnex Note: Documentation shall be submitted with the Redetermination request when using NGSConnex REOPENING: NGSConnex or Part B Reopening If the situation meets the criteria for a clerical error reopening (CER), submit a reopening rather than an appeal (redetermination). Reopening is the quickest route to correct a claim that contained errors. When there are no changes to the claim; however, the claim needs to be reprocessed with statistical data or information, these claims cannot be reopened in the NGSConnex portal; therefore, initiate via the Part B Reopening. Please refer to the chart below for additional guidance. Providers who are registered to use NGSConnex, should use this option to submit reopening requests electronically. Refer to the list of changes and tips below: (NGSConnex) or Part B Reopening Modifiers 24 and 25 Appropriate for E&M and eye exam codes (99 series and codes 92002, 92004, 92012, 92014) Reopening and Redetermination Submissions June

3 (NGSConnex) or Part B Reopening Modifier 26 Appropriate for radiology codes ( ), lab ( ) Modifier 33 Modifier 50 Appropriate to identify preventive services when the primary purpose of the service is the delivery of an evidence-based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory) To identify procedures done bilaterally Could be a correction for a claim that was billed with 2 units of service (UOS) instead of being billed with 1 UOS and a 50 modifier Modifier 57 Appropriate for E&M and eye exam codes (99 series and codes 92002, 92004, 92012, 92014) Appropriate for surgery codes ( ), but NOT for surgery codes that have a 0 day global period Modifier 58 Modifiers 59 (XE, XP, XS, or XU) View the NGS Fee Schedule Lookup tool. The Details screen will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Appropriate for distinct procedural services. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day to the same patient Modifier 78 Reopening and Redetermination Submissions June Not appropriate with E&M codes Appropriate for surgery codes ( ), but not for some surgery codes that have a 0 day global period View the NGS Fee Schedule Lookup tool. The Details will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Modifier 79 Appropriate for surgery codes ( ) Modifier 90 Only independent billing clinical laboratories (specialty 69) can bill with the 90 modifier. Line item 20 or electronic equivalent shall be checked "yes, list purchase price, and complete item 32 with NPI, name and address where test was performed

4 (NGSConnex) or Part B Reopening Modifiers: FX and FY Modifiers GV and GW FX is appropriate to use when x-ray is taken by film FY is appropriate when ray taken using computed radiography technology/cassette-based imaging GV appropriate when attending physician is not employed or paid under agreement by the patient's hospice provider GW appropriate when service not related to the hospice patient's terminal condition KX appropriate when patient qualifies above the threshold under the exception regulations Modifier KX Modifier PT Modifier QW These should not be routine reopenings. Providers are required to pre-calculate up to the therapy caps and submit initial claims with the KX modifier Appropriate to report a diagnostic procedure that began as a screening colonoscopy or screening sigmoidoscopy Appropriate for lab codes ( ) that are CLIA (clinical lab improvement amendment) waived test Modifier TC Appropriate only codes Radiology ( ) and Lab ( ) Changing procedure code(s) Date of service changes To correct a code that either underpaid or overpaid Ensure that the billed amount reflects appropriate amounts for the changed procedure code(s) Month and day changes only Diagnosis codes Place of Service Cannot add another date of service to a claim; this constitutes a new claim To correct a claim that denied for diagnosis code inconsistent with the patient s age or sex code. Noncovered services because services not deemed a medical necessity. Procedure not covered with submitted diagnosis or diagnoses To correct a claim that treatment was deemed by the payer to have been rendered in an inappropriate facility If payment is affected, the ZIP Code will also need to be changed Reopening and Redetermination Submissions June

5 (NGSConnex) or Part B Reopening Rendering Provider Units of service To correct a claim, because claim was submitted with an incorrect rendering National Provider Identifier (NPI) To correct a claim because the information submitted did not support this many services Anesthesia claims shall be reported in minutes Telephone Reopening Unit (TRU) Refer to the chart below for the only scenarios that cannot be initiated in NGSConnex, but can be done via the Telephone Reopening Unit or Part B Reopening. Telephone Reopening Unit Assignment of claims Contractor error only CLIA Certifications denials Duplicate claim denial HICN MBI corrections Contractor error only Incorrect Fee Schedule Allowance Medicare Advantage beneficiaries in a clinical trial or hospice related only MSP Medicare, now primary Assignment: certain claims and certain providers are required by law to accept the Medicareapproved amount as full payment for covered services CLIA certification numbers are ten-digit, issued by State Agencies, and used on claim submissions Does not include QW modifier additions TRU will only reopen duplicate denials when a modifier is not required for two exact services that were submitted for the same services Health Insurance Claim Number or Medicare Beneficiary Identifier are issued by Social Security Administration To view fee schedule amounts, use the NGS Fee Schedule Lookup Tool Beneficiaries may select Medicare Advantage Plan instead of traditional Medicare. These plans are also referred to as Medicare Part C Always check the beneficiary s eligibility via NGSConnex or the IVR Reopening and Redetermination Submissions June

6 Medicare Secondary Payer claims can only be processed within one year from the date of denial or payment Patient paid amount Contractor error only If Medicaid or another government entity paid in error, please submit a written request To view specific claim submission instructions, please refer to the NGS CMS Claim Form Instructions, line item 29 or the electronic equivalent REDETERMINATIONS: (NGSConnex) or Part B Redetermination If you disagree with a coverage or payment decision on an initial claim determination and your scenario is not listed in the Reopening section above, a redetermination may be requested. Your redetermination request shall include documentation for NGS to review. The quickest route is to appeal via NGSConnex and upload documentation to substantiate the services. Providers are encouraged to register for NGSConnex and then should use NGSConnex to submit redetermination requests electronically. Refer to the following table for applicable tips to help with your redetermination submission. (NGSConnex) Initiate Redetermination or Part B Redetermination Modifier AS Modifiers 80, 81, and 82 A Redetermination must be submitted within 120 days form the claim determination Include office records, test results, operative notes, and hospital records to substantiate any extenuating circumstance AS appropriate to indicate that a non-physician practitioner (PA, NP or CNS) served as the assistant at surgery 80, 81, or 82 appropriate to indicate assistant-at-surgery services are provided by a physician Modifier AQ Modifier CT Check to see if assistant at surgery is allowed at: NGS Fee Schedule Lookup tool. The Details will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Appropriate when services provided in ZIP code area that does not fall entirely within a designated full county HPSA bonus area Commonly used with CPT codes Reopening and Redetermination Submissions June

7 (NGSConnex) Initiate Redetermination or Part B Redetermination Modifiers GA, GY, GZ Modifier 22 Modifier 23 Modifier 51 A Redetermination must be submitted within 120 days form the claim determination Include office records, test results, operative notes, and hospital records to substantiate any extenuating circumstance Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR standard, will result in reduction in payment and CT modifier shall be used Requests to add the GA, GY or GZ modifier requires a copy of the Advance Beneficiary Notice of Noncoverage (ABN); therefore, please upload ABN Surgeries for which services performed are significantly greater than usual Providers are required to provide a concise statement to support the modifier 22 on the service. Appropriate when no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. Providers do not report modifier 51. When multiple surgical procedures performed the same session, to the same beneficiary, by the same provider, multiple surgery guidelines apply and NGS will apply appropriately to surgery codes. Not appropriate for E&M codes Check to see if assistant at surgery is allowed at: NGS Fee Schedule Lookup tool. The Details will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Modifier 52 Appropriate to indicate that a service was partially reduced or eliminated at a physician's discretion Reopening and Redetermination Submissions June

8 (NGSConnex) Initiate Redetermination or Part B Redetermination Modifier 53 A Redetermination must be submitted within 120 days form the claim determination Include office records, test results, operative notes, and hospital records to substantiate any extenuating circumstance Appropriate with medical diagnostic and surgical codes when the procedure is discontinued because of extenuating circumstances. This modifier is used to report the procedure is discontinued after anesthesia is administered to the patient Modifiers 54 and 55 Commonly billed with codes 44388, 45378, G0105 and G for surgery only and appropriate when surgical procedure and another physician provides preoperative and/or postoperative management 55 for Postoperative management only and appropriate to indicate postoperative management Appropriate when two surgeons work together as primary surgeons performing distinct part(s) of a procedure. Each surgeon should report their distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes(s) Modifier 62 Modifier 66 Modifier 76 Check to see if assistant at surgery is allowed at: NGS Fee Schedule Lookup tool. The Details will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Appropriate when highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the surgical team concept. Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure code Check to see if assistant at surgery is allowed at: NGS Fee Schedule Lookup tool. The Details will show the Medicare Physician Fee Schedule (MPFS) data base policy indicators. The descriptor of the indicators can be found on the NGS Fee Schedule Assistance page Appropriate to identify repeat procedure or service by the same provider Reopening and Redetermination Submissions June

9 (NGSConnex) Initiate Redetermination or Part B Redetermination Modifier 77 Modifier 91 Ambulance Modifiers A Redetermination must be submitted within 120 days form the claim determination Include office records, test results, operative notes, and hospital records to substantiate any extenuating circumstance If the quantity billed is over the MUE, documentation must be provided. Refer to the CMS Medically Unlikely Edits web page for additional information Appropriate to identify repeat procedure by a different provider If the quantity billed is over the MUE, documentation must be provided. Refer to the CMS Medically Unlikely Edits web page for additional information Appropriate with laboratory codes to report repeat of the same laboratory test on the same day to obtain subsequent (multiple) test results If the quantity billed is over the MUE, documentation must be provided. Please refer to the CMS Medically Unlikely Edits web page for additional information Ambulance claims may be complex and suppliers may need to provide separate run times and trip records; therefore, initiate a redetermination and upload documentation to support medical necessity Anesthesia Modifiers Anesthesia claims may be complex and providers may also need to provide separate surgery times; therefore, initiate a redetermination Documentation may include pre-anesthesia record, anesthesia record, operative report, radiology report and reason for which anesthesia was rendered for a radiology service. Changing procedure code to a new patient care code Cosmetic surgery Disputing an overpayment for NGS Medical Review, CERT, Reopening and Redetermination Submissions June A new patient means a patient who has not received any professional services from the physician or physician group practice (same physician specialty) within the previous three years Before initiating an appeal, please refer to the Definition of New Patient for Billing Evaluation and Management Services article on our website. Be sure to upload documentation to support services Documentation of medical necessity, operative report, admission summary, history and physical Contractor-initiated overpayments require review of additional documentation; therefore, always initiate a redetermination

10 (NGSConnex) Initiate Redetermination or Part B Redetermination RAC, OIG, down coding or denials Processed based on multiple or concurrent procedure rules Unlisted or not otherwise classified (NOC) codes A Redetermination must be submitted within 120 days form the claim determination Include office records, test results, operative notes, and hospital records to substantiate any extenuating circumstance You have 120 days from the date of the demand letter to get your appeal to NGS Be sure to upload documentation to support services Records for entire hospital course including admission summary, progress notes and order sheets Since NOC procedure codes are used to describe many different procedures, Medicare allowable amounts are not established and allowance is based on the supporting documentation Be sure to upload documentation to support services Reopening and Redetermination Submissions June