J A N E T M A T E OM E D I C A R E P A R T A O U T R E A C H A N A LY S T

MPAA MEETINGWPS MEDICARE UPDATES

01/02/2015

AGENDA

• Probe and Educate Process• Probe 1 and 2 Results

• What’s New • Review of Timely Filing Requirements

Exception Process• Incarcerated Beneficiary Update• WPS Medicare Updates

01/02/2015

PROBE AND EDUCATE PROCESS

PROBE 1 RESULTS

01/02/2015

PROBE 1

J5 J8Part A Hospital Provider Count 800* 300*

# of Providers Sampled 412 151

# of Claims Reviewed 3,625 *1,328

* Approximate Number

01/02/2015

OVERALL DENIAL RATE

J5 27%

J826%

01/02/2015

DENIALS BY TYPE

5PC01

Documentation does not support services medically reasonable/necessary

5PC02

Insufficient documentation

5PC12

Order missing

5PC13

Order unsigned

5PC15

Certification not present

5PC17

No documentation of 2-midnight expectation

J8

01/02/2015

PROBE 2 ESTIMATED TIMELINE

01/02/2015

PROBE 2 REVIEWS

• Prepay• Reason code 5CR85• For WPS Medicare providers

• Begins with admission dates 60 days from date of final letter offering education • Includes providers with• Moderate or high levels of concern• Incomplete or no claims in Probe 1

01/02/2015

PROBE 2

J5 J8Part A Hospital Provider Count 736 253

% of Claims Completed 32% 35%

Top Denial Code 5PC01 5PC01

New in Probe 2• 5PC11 - Procedure not reasonable and

necessary

01/02/2015

TIPS

• Verify your procedures for inclusion on the inpatient-only list• Include the signed admission order• Compare physician notes to orders• Document changes in expected patient

care

01/02/2015

REVIEW RESULTS

WHAT MACS ARE CURRENTLY SEEING

01/02/2015

MISSING OR FLAWED ORDER

• Error• Physician order states “observation” but facility

billed as an inpatient

• Prevention• Use specific language for inpatient orders• Remember all care is outpatient care in the

absence of an inpatient order

01/02/2015

SHORT STAY PROCEDURES

• Error• Patient presented for short stay procedure and

discharged the next day• Prevention• Procedures with typical expected length of stay

of less than two midnights are outpatient for payment purposes

• Multiple short-stay procedures performed together ≠ an inpatient procedure• In the absence of a two-midnight expectation

01/02/2015

UNCERTAIN COURSE

• Error• Patient with complaints of dizziness • Physician notes state intention to monitor

overnight but patient admitted and inpatient claim billed

• Prevention• If clinical course uncertain, utilize outpatient

observation• Keep as outpatient until clear the patient requires

two midnights of care

01/02/2015

ATTESTATION WITHOUT SUPPORT

• Error• Checkbox stating “The beneficiary is expected to

require two or more midnights of hospital care”• Physician notes state “plan to discharge in the morning

if stable” and patient discharged next day

• Prevention• Certification statements not required or adequate to

support payment• Expectation must be supported by entire medical

record

01/02/2015

INCOMPLETE DOCUMENTATION

• Error• Incomplete medical record submitted• Most common items missing include:• Medication Administration Records (MARs)• Nurses notes

• Prevention• Verify the entire record is being submitted• Review record to ensure it is legible

01/02/2015

WHAT’S NEW

2015 UPDATES

01/02/2015

IPPS UPDATES

CR 8900• Provides FY 2015 updates to the Acute

Hospital IPPS and LTCH PPS

01/02/2015

OPPS UPDATES

CR 9014• Describes changes to billing instructions

for various policies implemented in the January 2015, OPPS update• Revision to certification requirements

01/02/2015

JANUARY 1, 2015, CHANGES

CMS currently requires a physician certification, including an admission order

and certain additional elements, for all inpatient admissions.  CMS finalized its

proposal to require the physician certification only for outlier cases and long-

stay cases of 20 days or more. The admission order will continue to be required for all inpatient admissions when a patient has been formally admitted as an inpatient

of the hospital. 01/02/2015

REVISION TO CERTIFICATION REQUIREMENTS

• Inpatient certification requirements eliminated• For short stays < 20 days

• No changes for inpatient psychiatric hospital or inpatient rehabilitation facility

01/02/2015

FURTHER CLARIFICATION

• Stays 20 days or greater and outlier cases • Formal physician certification• Reason for hospitalization• Estimated time to remain in hospital• Plan for post-hospital care

01/02/2015

REVISION TO CERTIFICATION REQUIREMENTS - CAHS

• Effective for admissions on or after October 1, 2014, certification required• One day prior to the day the Part A bill is

submitted

01/02/2015

PAYMENT POLICIES RELATED TO PATIENT STATUS – CMS-1599-F

• CR 8959• Inpatient routine services in a hospital

include• Room and board charges• Regular room, dietary and nursing services• Minor medical and surgical supplies• Medical social services, psychiatric social services• Use of certain equipment and facilities

01/02/2015

THERAPY CAPS

• Financial limitation for 2015• $1,940 for OT• $1,940 for PT/SLP combined

• Associated policies in effect until 3/31/15• Exceptions process (KX modifier)• Manual medical review ($3,700 threshold)

01/02/2015

UPDATE TO THERAPY CODE LIST

CR 8985• Updates the 2015 therapy code list• Added two “Sometimes Therapy” codes• Deleted two “Sometimes Therapy” codes

01/02/2015

2015 UPDATES TO RHC AND FQHC SERVICES

CR 8981• Includes new and clarifying information on FQHC

PPS and RHC updates

01/02/2015

SPECIFIC MODIFIERS FOR DISTINCT PROCEDURAL SERVICES

CR 8863• Four new HCPCS modifiers established to

define subsets of the -59 modifier• Modifier 59 is associated with considerable

high levels of abuse leading to:• Reviews• Appeals• Civil fraud and abuse cases

01/02/2015

FOUR NEW HCPCS MODIFIERS

• Collectively referred to as –X {EPSU}• Selectively identify subset of Distinct

Procedural Services• 59 Modifier still accepted• Should not be used when a more descriptive

modifier is available• CMS may require more specific modifier for

billing certain codes at high risk for incorrect billing

01/02/2015

-X {EPSU}

• XE – Separate Encounter• Service occurred during a separate encounter

• XS – Separate Structure• Service performed on a separate organ or

structure

• XP – Separate Practitioner• Service performed by a different practitioner

• XU – Unusual Non-Overlapping Service• Does not overlap usual components of the main

service

01/02/2015

2015 AMOUNTS

CR 8982• Part A Deductible - $1,260• Part B Deductible - $147• Hospital Coinsurance - $304• Lifetime Reserve Days - $630• Skilled Coinsurance - $157.50

01/02/2015

REVIEW OF TIMELY FILING REQUIREMENTS

01/02/2015

TIMELY FILING REGULATIONS

• Claims must be filed within one calendar year after the Date of Service (DOS)

• Through date used to determine timely filing deadline• For institutional claims

• Claims in Return to Provider (RTP) status (T B9997) are not considered properly submitted claims

01/02/2015

FILING A CLAIM BEYOND THE TIMELY FILING LIMIT

• Provider is responsible• Claims should be processed • Spell-of-illness implications and/or • To record the days, visits, cash and blood

deductibles

01/02/2015

FILING A CLAIM BEYOND THE TIMELY FILING LIMIT

• Beneficiary is charged utilization days, Beneficiary may not be charged for the services• Except for applicable deductible and/or

coinsurance amounts

• Providers may not appeal a timely filing rejection

01/02/2015

FILING A CLAIM BEYOND THE TIMELY FILING LIMIT

• Provider believes the beneficiary is responsible for late filing• File claim• Put “TIMELY-BENE” on the first line of remarks

section

• Include a statement in the remarks field• Usual appeal rights are available to the

beneficiary

01/02/2015

EXCEPTIONS TO TIMELY FILING REQUIREMENT

Administrator Error• Misrepresentation, delay, mistake or other

action by Medicare or its contractors• Time limit will be extended through the last day

of the 6th calendar month • Request for extension only accepted up to 4

years from the DOS

01/02/2015

EXCEPTIONS TO TIMELY FILING REQUIREMENT

Retroactive Entitlement• Beneficiary was not entitled to Medicare at

the time the service was furnished• Beneficiary subsequently received

notification of retroactive Medicare entitlement to or before the DOS

01/02/2015

EXCEPTIONS TO TIMELY FILING REQUIREMENT

Medicaid Agencies• At the time the service was furnished the

beneficiary was not entitled to Medicare• The beneficiary subsequently received

notification of Medicare entitlement effective retroactively to or before the date of the furnished service

01/02/2015

EXCEPTIONS TO TIMELY FILING REQUIREMENT

Retroactive Disenrollment from Medicare Advantage (MA) Plan• At the time the service was furnished the

beneficiary was believed to be enrolled in a MA plan• The beneficiary was subsequently

disenrolled from the MA plan• Effective retroactively to or before the date of the

furnished service

01/02/2015

EXCEPTIONS TO TIMELY FILING REQUIREMENT

Retroactive Disenrollment from Medicare Advantage (MA) Plan• The MA plan recovered its payment for the

furnished service from a provider or supplier 6 months or more after the service was furnished

01/02/2015

TIMELY FILING EXTENSION TIPS

• First line of the remarks page should include a 2 digit justification for timeliness reason code• Additional remarks can be added to line 2• Explanation of circumstances which led to late

filing/why party is responsible

• Request an extension to timely filing in writing

01/02/2015

TIMELY FILING EXTENSION TIPS

• Request for timely filing should be submitted with:• A copy of the claim describing the services

furnished • Official SSA letter, if available• Based on justification for timeliness reason code used

• Mail to General mailing address on the WPS Medicare website• http://

www.wpsmedicare.com/j8macparta/contact_us/mailing-address-info.shtml

01/02/2015

REQUEST FOR REOPENING CLAIMS BEYOND TIMELY FILING LIMITS

• CR 8581• Standardizing the Process• CMS recognized MACs lacked a standard process

for reopenings

• CMS petitioned NUBC for: • Bill type frequency code to indicate a reopening

request • Condition codes to identify type of reopening• Effective for claims received on or after April 1,

2015

01/02/2015

WPS MEDICARE UPDATES

01/02/2015

CERT PROGRAM IDENTIFIED ERRORS

01/02/2015

CERT TASK FORCE

• MACs collaborate to educate • Goal: reduce National payment error rate• Departments>CERT>CERT A/B MAC

Outreach & Education Task Force

01/02/2015

C-SNAP ENHANCEMENTS

• Appeals status

• Discharge Status

• Submitting documentation through C-SNAP• Coming Soon

01/02/2015

FUNCTIONALITY & BENEFITS

• Functionality• Upload your Medical Documentation• For all claims associated with a Probe• For an Additional Development Request (ADR)• For a returned to provider (RTP) claim

requesting Medical Documentation

• Verify Documentation Submitted• View submitted documentation for up to 75

days• Verify the status of the review

01/02/2015

FUNCTIONALITY & BENEFITS

• Benefits• Free• No printing costs• No postage costs• No esMD costs

• Time Saving• Reduced records preparation time• No paper forms to fill out

01/02/2015

FUNCTIONALITY & BENEFITS

• Benefits• Instant Confirmation• Receive a confirmation number• Links directly to claim• No lost records• No fax issues

• No Shipping Delay• Reduce days to payment

• Available 24/7• For documentation submission

01/02/2015

COUNTDOWN TO ICD-10

• Compliance date is 10/01/2015• Resources• SE1410 - ICD-10• CMS website• www.cms.gov > Medicare > ICD-10

• WPS Medicare • www.wpsmedicare.com > J8 MAC Part A > Claims >

ICD-10

01/02/2015

ICD-10 TESTING RESULTS

• Acknowledgement Testing in March• Approximately 2,600 testers participated• 50% were clearinghouses

• Over 127,000 claims submitted• 89% of claims accepted by CMS• Some intentionally submitted with errors

01/02/2015

END-TO-END TESTING

SE 1409• Volunteer for upcoming ICD-10 End-to-End

Testing• April 27 – May 1, 2015

• Additional opportunity for testing available• July 20 – 24, 2015

01/02/2015

ACKNOWLEDGEMENT TESTING

• Upcoming testing weeks • March 2-6, 2015• June 1-5, 2015

• WPS Medicare will be appropriately staffed to handle increased call volume via the EDI Help Desk

01/02/2015

ACKNOWLEDGEMENT TESTING

• Acknowledgment test claims can be submitted anytime up to the October 1, 2015, implementation date• Registration is not required for these virtual

events

01/02/2015

TOP 5 REASONS FOR REJECTS

• Invalid ICD-10 diagnosis code• Some because they used dates of service that

were prior to the effective date of code on the CEM reference file

• Invalid procedure code • Caused by CEM issue

01/02/2015

TOP 5 REASONS FOR REJECTS

• Future dates of service used• Must use current dates

• Missing Data• Not necessarily related to ICD-10

• Other• Invalid data not related to ICD-10

01/02/2015

CLAIM SUBMISSION ALTERNATIVES

• PC- ACE-PRO 32 Free Software • Available to providers that do not complete the

necessary system changes to submit claims with ICD-10 codes by October 1, 2015• Software has been updated to support ICD-10

codes• Does not provide coding assistance• Allows providers to submit claims in ICD-10 claim

submission format

01/02/2015

MONITORING YOUR BUSINESS WITH MEDICARE EDI

• All submitters of electronic claim files should use the tools available to monitor your business• Read 999 responses• Read 277CA responses• Review the Medicare remittances • Monitor cash flow • Identify and correct any issues identified in a timely

manner

01/02/2015

ELECTRONIC REMITTANCE ADVICE (ERA) GO GREEN !

• Providers are encouraged to switch from receiving standard paper remittance advices to electronic remittance advice• Using ERA saves time and• Increases productivity• Provides electronic payment adjustment

information that is portable, reusable, retrievable, and storable

01/02/2015

MEDICARE SECONDARY PAYER (MSP) UPDATE

• MSP hotlines consolidated to one toll free number• (866) 734-1521• Effective November 17, 2014

• Will provide prompts for call routing to the appropriate staff• J5/J8, Part A/B

01/02/2015

MSP UPDATE

CR 8456• Effective October 6, 2014, up to 25 iterations of

diagnosis codes associated with MSP no-fault, liability, and workers’ compensation records will be included on the HETS 271 response transaction • Diagnosis codes will assist providers in better

determining when Medicare is the secondary payer

01/02/2015

MSP GROUP HEALTH PLAN (GHP) WORKING AGED POLICY UPDATE

CR 8875• Under the MSP Working Aged provisions,

“spouse” applies to both opposite and same sex marriages• Effective January 2015

01/02/2015

BILLING MSP CLAIMS - 5010

• MSP claims must be sent electronically• Not an Administrative Simplification Compliance

Act (ASCA) exception

• Avoid front end rejections, delays and unprocessable rejections• http://www.wpsic.com/edi/files/msp5010A1.pdf

01/02/2015

AVOID DELAYS AND UNPROCESSABLE CLAIMS

• Important to determine the correct insurance type code• Always give the MSP insurance type code• Give the complete primary payer’s name

and address

01/02/2015

AVOID DELAYS AND UNPROCESSABLE CLAIMS

• Do not confuse the payers• Medigap or Medicaid information should not be

reported in the primary insurance record

• Primary paid amount should not exceed the billed amount• Primary paid amounts at the claim level

should agree with line level

01/02/2015

REVALIDATION OF PROVIDER ENROLLMENT INFORMATION

• All providers enrolled in Medicare prior to March 25, 2011, must revalidate provider enrollment information by March 2015• Only after receiving notification from WPS

Medicare

01/02/2015

ENHANCED INTERNET-BASED PECOS

• Facilities are encouraged to utilize PECOS to:• Revalidate the CMS-855 Medicare enrollment

application• Enroll in the Medicare Program

• Enhanced internet-based PECOS is easy, fast and secure

01/02/2015

PROVIDER ENROLLMENT APPLICATIONS

• To ensure your application is not delayed, take a second look• Review your application for the following:• Appropriate documentation• Completion of all fields in all sections• Signed and dated Authorization or Certification statement

01/02/2015

01/02/2015

PROVIDER ENROLLMENT NAVIGATOR

• Interactive tool to expedite processing• Helps identify required information• Asks a series of questions

• Guides you to correct forms• Links provided

• Ensures submission to correct address• Saves time and re-work

• Contact information• Assistance with completion or submission

01/02/2015

ENROLLMENT STATUS

Status Dates:• Assigned • Initial Review • Development • In PECOS • Closed • Electronic Funds

Transfer (EFT) Initial Letter Sent

• EFT Second Letter Sent • EFT Approved

Processing Statuses• Processing • Provider Enrollment

Chain and Ownership System (PECOS) is Approved

• Returned • Denial • Rejection • Recommended • Completed

01/02/2015

ENROLLMENT APPLICATION STATUS INQUIRY

• Web based system • Confirms receipt of new applications via email• Provides Application ID • Link to EASI website

• Provides status during process

Current e-mail address in Section 13 willensure application ID and all other notifications are received.

01/02/2015

APPEALS FORM SELECTOR

• Interactive tool to expedite processing• Helps decide if appeal or not• Asks a series of questions

• Guides you to correct form• Links provided

• Ensures submission to correct address• Saves time and re-work

01/02/2015

01/02/2015

INCARCERATED BENEFICIARY UPDATE

01/02/2015

INCARCERATED BENEFICIARY CLAIMS

• Some overpayments for incarcerated beneficiaries were valid and were not refunded• If a claim was erroneously designated as a

overpayment, you may request a reopening• Funds recovered and not subsequently refunded

01/02/2015

INCARCERATED BENEFICIARY CLAIM

• If the facility received a Remittance Advice indicating a temporary allowance without supporting documentation • Contact WPS Medicare to request an

explanation

01/02/2015

WEBSITE SATISFACTION

• Comments help enhance website• Please be specific

01/02/2015

SELF SERVICE TOOLS

• No limits• Available when you are • No wait, or hold time • Easy answers • Multiple users at one time • Most current information available

01/02/2015

Q&AYou have

questions…I have answers…

01/02/2015

DISCLAIMER

This program is presented for informational purposes only.

Current Medicare regulations

will always prevail.

01/02/2015