Medicare Keeping Up With the Pace of Change Presented by Medicare Part B Provider Outreach and Education 2017
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 https://med.noridianmedicare.com and the CMS website at http://www.cms.gov. 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 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. September 2017 2
ACRONYM ABN APM CERT CMS CR ERA IOM LCD MAC DESCRIPTION Advance Beneficiary Notice of Non Coverage Advanced Alternative Payment Model Comprehensive Error Rate Testing Centers for Medicare and Medicaid Services Change Request Electronic Remittance Advices Internet Only Manual Local Coverage Determination Medicare Administrative Contractor September 2017 3
ACRONYM MCD MPFS MIPS MLN NCD RAC SMRC SPR ZIPC DESCRIPTION Medicare Coverage Database Medicare Physician Fee Schedule Merit-based Incentive Payment System Medicare Learning Network National Coverage Determination Recovery Auditor Contractor Supplemental Medical Review Contractor Standard Paper Remittance Zone Integrity Program Contractor September 2017 4
Agenda CMS Initiatives Upcoming Changes Reviewing Contractor Updates CERT, Medical Review, RAC, SMRC Medical Documentation Requirements Signatures Noridian Items of Interest Web Page Additions Portal Enhancements Educational Opportunities Resources Question and Answer Session September 2017 5
CMS Initiatives September 2017 6
MIPS and APM Webpage October 1, 2017 Deadline Choose how to take part based on practice size, specialty or patient population with these two (2) tracks: Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Model (APM) Exempt from MIPS/APM Programs Providers (MD, DO, DMD, DC, DPM, PA, NP, CNS, CRNA) billing less or equal to $30,000 Part B allowed charges or 100 or less Medicare patients annually Newly graduated from a program or not enrolled as Medicare provider If 2017 is your first year participating in Medicare, then you re not in the MIPS track of the Quality Payment Program. September 2017 7
Merit-Based Incentive Payment System (MIPS) Quality replaces prior Physician Quality Reporting System (PQRS) Resource use replaces prior Value-Based Modifier (VBM) Advancing Care Information replaces Meaningful Use Clinical practice improvement activities (new) September 2017 8
MIPS Performance Assessment Penalty or bonus At the threshold: no adjustment Above the threshold: bonus Below the threshold: penalty Range of adjustments: 2019: ± 4%; 2020: ± 5%; 2021: ± 7%; 2022 and after: ± 9% May adjust to equate bonus & penalty totals September 2017 9
Pick Your Pace in MIPS September 2017 10
Hardship Process September 2017 11
Determine MIPS Participation Status September 2017 12
Avoid 2019 Penalties!! One Patient, One Measure, No Penalty 1 st year of Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) Pick your pace reporting for 2017 AVOID -4% negative adjustment One Patient, One Measure = No Penalty September 2017 13
MIPS starting 1/1/2019 (based on 2017 reporting) Consolidates negative adjustments ( penalties ) Adds Clinical Practice Improvement Activity (CPIA) as a component Increases potential incentives Ranks peers nationally Publicly reports September 2017 14
Clinical Practice Improvement Activities (CPIAs) - Examples Expanded practice access (e.g. portal) Population management (e.g. data registry) Care coordination (e.g. remote or telehealth) Patient engagement (e.g. care plans, shared decision-making) Patient safety and practice assessments Participation in APMs September 2017 15
New Medicare Card Project Social Security Numbers removed from all Medicare cards by April 2019 Replaced with new Medicare Beneficiary Identifier (MBI) Example 1EG4-TE5-MK73 Transition period Providers use either HICN or MBI Begins no earlier than April 1, 2018 and runs through December 31, 2019 Beneficiaries may use the new card upon receipt September 2017 16
Five Steps to Get Ready for New Medicare Card Project Sign up for CMS MLN Connects newsletter Attend quarterly calls Verify all patient addresses Assists with Beneficiary receiving new card Display helpful information for patients Available this fall from CMS This will help patients be aware of the changes, and avoid any delays. Make sure that you test all system changes. What that means is, you can use the transition period as a live test and make adjustments as necessary, yet still have claims submitted and processed with HICNs until the transition period ends September 2017 17
Fee-for-Service Claim Exceptions: Appeals - HICN or the MBI for claims appeals and related forms will be accepted. Claim status query HICN or MBI to check the status of a claim (276 transactions) if the earliest date of service on the claim is before January 1, 2020. For claims status with DOS on or after January 1, 2020, you have to use the MBI. September 2017 18
Span-Date Claims You can submit claims received between April 1, 2018 and December 31, 2019 using the HICN or the MBI. If a patient starts getting services in an inpatient hospital, home health, or religious nonmedical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019 September 2017 19
Elimination of Paper Remits Change Request (CR) 10151 Effective 1/01/2018 For all providers/suppliers who receive ERAs for 45 days or more Effective 2/14/2018 For all providers/suppliers EDI enrolled who are receiving ERAs and SPRs Some exceptions, i.e.: Natural disaster or CMS discretion September 2017 20
Advanced Beneficiary Notice of Noncoverage (ABN) Form Effective June 21, 2017 Exp. 3/2020 Alternative format available in Spanish and larger font size Form available on CMS website: https://www.cms.gov/medic are/medicare-generalinformation/bni/abn.html September 2017 21
Provider Self-Audit with Validation and Extrapolation Pilot (PSAVE) CMS authorized pilot program JF states - Part B only Noridian education provided while allowing providers to self-audit documentation with many benefits Immunity granted from MAC and Recovery Auditor reviews on pilot claims involved upon successful completion Visit website for information and PSAVE recording: https://med.noridianmedicare.com/web/jfb/certreviews/psave Questions? Contact us: (800) 284-4351 or email PSAVE@noridian.com September 2017 22
Targeted Probe & Educate (TPE) CMS authorized Noridian to conduct TPE Pilot review process Targeted by Medical Review (JF only) Driven by data analysis Educational opportunity for error reduction CR 10073 Targeted Probe & Educate Pilot CMS is expanding to three contractors, Jurisdictions B, D, and E September 2017 23
TPE Webpage September 2017 24
Contractor Updates CERT, RAC, SMRC & OIG
Responding to The Letter Request for documentation: CERT, Medical Review, RAC,SMRC, ZPIC Demand letters have a response date Verify your physical address is correct in PECOS Gather the information quickly and neatly Make sure the signatures are present and legible. Ensure the information is sent to the correct person September 2017 26
PECOS Help Provider Enrollment, Chain and Ownership System (PECOS) PECOS used for enrolling or making changes to enrollment Tutorials available Noridian website / Enrollment / Potential Providers / Enrollment on Demand Tutorials September 2017 27
CERT Webpage September 2017 28
Updating Address for CERT Letters CERT sends correspondence to Pay-To address in PECOS Update address in PECOS https://pecos.cms.hhs.gov/pecos/login.do#headinglv 1 September 2017 29
CERT November 2016 Report - JF September 2017 30
Rheumatology and CERT CERT has identified specific errors for this specialty They include Lab, E/M and injection codes From these orders missing dates and signature Unbundling of services incorrectly, Insufficiencies in documentation September 2017 31
CERT Findings A common CERT finding relates to providers billing the saline used with the drug injection separately. In these cases, the saline would not be separately billable as reimbursement is bundled into the payment for the drug code. September 2017 32
Outpatient Drug Admin. Orders Orders may come from MD, DO, DDS, DM, OD, DC, DPM and NPPs (PA, NP) Orders not required to be signed; must clearly document his/her intent of service/test Doctor of Pharmacy (PharmD) not authorized CMS provider Any orders written or transcribed by Pharm D need cosigned by authorized provider Refer to Documentation Guidelines for Medicare Services page for signature/documentation requirements September 2017 33
Supplemental Medical Review Specialty Contractor (SMRC) September 2017 34
SMRC Sample Letter September 2017 35
SMRC Discussion/Education Period After medical review project is completed Provider will receive review results letter including: Specific Claims Reviewed Review Findings Will indicate if discussion/education period is available If provider is afforded a discussion period Submit discussion period request in writing within 30 days from date of review results letter September 2017 36
Supplemental Medical Review Contractor (SMRC) Current Projects Cardiac Rehabilitation TDL 2017-0446 Each Current Project s page lists: Coverage requirements for service Example of Additional Documentation Letter Resource: https://strategichs.com/smrc/current-smrc-projects/ September 2017 37
Recovery Auditor Contractor (RAC) HMS Federal Solutions (HMS) https://racinfo.hms.com/home.aspx Discussion Period Date of the informational letter 30 Days review Part B Providers Telephone: (877) 350-7993 Fax: (702) 240-5510 September 2017 38
RAC Webpage September 2017 39
RAC Summary of Findings Findings of claims reviewed from March 10, 2017 - June 8, 2017 are as follows: 740 Claims Reviewed 129 Claims Paid 611 Claims Corrected or Denied 82.59% Error Rate The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If providers disagree with a claim determination, the normal Appeal process may be followed as directed in your claim Remittance Advice (RA). September 2017 40
New Additions to the RAC Reviews September 2017 41
OIG Work Plan Update OIG 2017 monthly updates Additions of newly initiated items Completed items Newly published reports Created a What's New Page Website https://oig.hhs.gov/reports-andpublications/workplan/index.asp September 2017 42
Medical Documentation Requirements September 2017 43
Valid Signature Valid signature criteria which must be met: Services provided/ordered must be authenticated by ordering practitioner Signatures are: Handwritten Electronic Stamped If requirements to utilize stamped signature are met Signatures are legible September 2017 44
Signature Requirements For Medical Review Purposes For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable. Note: Refer to exceptions for stamped signatures September 2017 45
Acceptable Valid if anywhere on document it states Signed or Final September 2017 46
Request for Signature Provider has 20 days from date of receipt of phone call from Noridian to submit attestation Failure to submit records with valid signatures upon request, or valid and timely attestations, will result in your claims being denied Result of signature requirements not met Causes overpayment and recoupment of payment September 2017 47
CPT 99354 99357 Prolonged Services Prolonged services involving direct (face-to-face) patient contact Inpatient or outpatient setting beyond usual service In addition to E/M once per day Without face-to-face, bundled into other services CPT Description 99214 With direct face-to-face services (including visit) = 95 minutes 99214 x 1 Evaluation and Management (E/M) 99354 x 1 Prolonged 1 hour 99355 x 1 Prolonged Additional 30 minutes September 2017 48
Prolonged Services Prolonged services are intended to be used for unusual circumstances requiring additional time beyond typical/average time of visit code billed Prolonged services is an example of time-based service that requires time be documented in medical record September 2017 49
Top denial reasons: Prolonged Services 2 Summary of Findings Prolonged E/M service not supported by submitted documentation Provider failed to submit requested documentation Non responder to ADRs Automatic claim denial September 2017 50
Common Documentation Errors Missing physician signature on order Incomplete progress notes Unauthenticated medical records No documentation of intent to order services and procedures No signed and dated attestation statement for operative report (if physician signature was missing or illegible) September 2017 51
Documentation Tips Use attestation/signature log for illegible signatures Ensure authenticated physician order included or there is sufficient documentation in the patients medical record proving intent to order Requisition alone may not support intent to order Includes physician rationale, patient symptoms and all other observations used to determine appropriate care and patient course of action Contact ordering/referring physician if insufficient documentation received September 2017 52
Noridian Items of Interest
New Additional Static Pages Care Plan Oversight (CPO) Chronic Care Management (CCM) Locate under Browse By Specialty/ E/M Chemotherapy Administration Locate under Browse By Topic/ Drugs & Biologicals Outpatient Therapy Locate under Browse By Specialty September 2017 54
Medicare Secondary Payer (MSP) Calculator Used to determine line by line payment calculations Will not accurately calculate: Non-participating providers/suppliers Sequestration 100% allowed payments (i.e. lab codes) Psychiatric reduction Tertiary payments September 2017 55
Don t Forget the Portal September 2017 56
Correct Claims through NMP Noridian Medicare Portal (NMP) Free, online submission of Reopenings Changes available: Billed amount Modifiers (some exceptions apply) Date of service Procedure code, modifier and billed amount More! See Noridian website / Browse by Topic / Noridian Medicare Portal September 2017 57
Redeterminations and Reopenings via NMP Letters Medicare Redetermination Notices (MRNs) will no longer be mailed Providers /suppliers who submit Redetermination or Reopening requests through NMP will receive MRNs via NMP Ability to view/print determination letters September 2017 58
Noridian Upcoming Part B Webinars Date Time (CT / PT) Title 9/19 1 p.m. / 11 a.m. Modifier 59 Clarification and Changes 9/20 3 p.m. / 1 p.m. Basic E/M Avoiding Common Errors 9/26 1 p.m. / 11 a.m. Chronic Care Management (CCM) 9/26 2 p.m. / 12 p.m. CPT 20610 Coding Guidance 9/26 3 p.m. / 1 p.m. New Provider-Biller Part I 9/27 3 p.m. / 1 p.m. New Provider-Biller Part II 9/28 3:30 p.m. / 1:30 p.m. Initial Preventive Physical Examination and Annual Wellness Visit REGISTER NOW! Education & Outreach / Schedule of Events September 2017 59
Medicare After Hours Webinars Date Topic 9/28 Chronic Care Management (CCM) 10/26 Roster Billing for Influenza and Pneumonia Immunizations 11/16 Transitional Care Management Services 12/7 Understanding National and Local Coverage Determinations 6 p.m. PT / 8 p.m. CT Webinars also during day - earlier same week All webinars earn 1.0 CEU Register at Noridian: Education and Outreach- Schedule of Events September 2017 60
In Summary Use Noridian/CMS website tools Attend workshops like this presentation Read Medicare emails and articles Refer to links to Noridian and CMS website for signature requirements September 2017 61
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