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Medicare 2018
What's on the Horizon Part A/B Provider Outreach and Education
April 2018
Disclaimer
2
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
https://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 copyright 2018 American
Medical Association. All rights reserved. Applicable FARS/DFARS apply.
April 2018
Agenda
• 2018
– CMS initiatives
• Part A/B
– Medicare Review Contractors
– Noridian Updates
• Resources
• Educational Information
3 April 2018
Acronyms https://www.cms.gov/apps/acronyms/
Acronyms Description
CMS Center for Medicare & Medicaid Service
CPT Current Procedural Terminology
CR Change Request
CY Calendar Year
DME Durable Medical Equipment
EOB Explanation of Benefits
FQHC Federally Qualified Health Center
HCPCS Healthcare Common Procedural Coding System
HICN Health Insurance Claim Number
April 2018 4
Acronyms2
https://www.cms.gov/apps/acronyms/
Acronyms Description
MAC Medicare Administrative Contractor
MBI Medicare Beneficiary Identifier
MDDP Medicare Diabetes Development Plan
MLN Medicare Learning Network
MSP Medicare Secondary Payer
NCD National Coverage Determination
PECOS Provider Enrollment, Chain & Ownership Systems
QMB Qualified Medicare Beneficiary
RARC Remittance Advice Remark Code
SPR Standard Paper Remit
April 2018 5
CMS Initiatives
April 2018 6
Review Medicare Programs
Patients Over Paperwork
This is the second issue of our recurring newsletter about Patients over Paperwork, our effort to reduce administrative burden and improve the customer experience while putting patients first. In this edition, we reflect on 2017 and update you on how we have been working to reduce burdensome regulations, streamline requirements and improve the clarity of our programmatic guidance. This work is in accordance with our agency’s strategic goals:
1. Empower patients and clinicians to make decisions about their health care.
2. Usher in a new era of state flexibility and local leadership.
3. Support innovative approaches to improve quality, accessibility, and affordability.
4. Improve the CMS customer experience.
Stay Connected
Click HERE to learn more about Patients over Paperwork.
To ensure that you receive this newsletter and any other Patients over Paperwork updates, be sure to join our listserv. You may also review past newsletter editions HERE.
Tweet about Patients over Paperwork by using the hashtag #patientsoverpaperwork and #regReform
February 2018 7
Patients Over Paperwork (2)
Quality Measures
You Said: CMS quality programs have too many quality measures that are not meaningful to patients or providers. Reporting on these measures takes valuable time away from patient care.
We Heard You: Across our rules, CMS is adopting policies that balance the meaningfulness of quality measurement data with efforts to limit provider burden and improve the doctor-patient relationship. In 2017, CMS took initial steps to reduce the number of quality measures in our programs, and will continue to make progress on this initiative in 2018.
Hospital Outpatient Quality Reporting Program
CMS finalized the removal of six measures, resulting in an estimated burden reduction of 457,490 hours
and $16.7 million reduction in associated stakeholder costs for the 2020 payment determination.
April 2018 8
Patients Over Paperwork (3)
Ambulatory Surgical Center (ASC) Quality Reporting Program
CMS finalized the removal of three measures. Removing these measures will alleviate maintenance costs and administrative burdens to the ASCs, resulting in reducing burden by an estimated 1,314 hours and $48,066 for the 2019 payment determination.
CMS also delayed implementation of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) under the ASCQR Program beginning with the
2018 data collection.
April 2018 9
New Medicare Card Mailing - Insert
Recommended provider action Sign up Noridian list serv bi-weekly emails Visit CMS Website/ Attend Their Events
https://www.cms.gov/ Medicare/New-Medicare-Card/index.html Inform Beneficiaries/ Obtain new MBIs Prepare and Test Systems
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
February 2018 11
MBI State Mailing Schedule
Zone 2 (April – June 2018)
• Alaska, American Samoa, California, Guam,
Hawaii, Northern Mariana Islands, Oregon
Zone 3 (After June 2018)
• Arkansas, Illinois, Indiana, Iowa, Kansas,
Minnesota, Nebraska, North Dakota, Oklahoma,
South Dakota, Wisconsin
Zone 6 (After June 2018)
• Arizona, Colorado, Idaho, Montana, Nevada, New
Mexico, Texas, Utah, Washington, Wyoming
April 2018 12
Medicare Diabetes
Prevention Program (MDPP)
February 2018 13
• Pilot to prevent onset of Type II Diabetes
• Separate enrollment for MDPP coach/provider
– Special PECOS Enrollment Form CMS-20134
• Codes include G9873 - G9889
– Allow between $25 - $160
• Services available after 4/01/18
• https://www.cdc.gov/diabetes/prevention/pdf/
dprp-standards.pdf
MDPP Overview https://www.cms.gov/Newsroom/MediaReleaseDatabas
e/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html
February 2018 14
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
– https://innovation.cms.gov/Files/fact-sheet/mdpp-
cy2018fr-fs.pdf
– https://innovation.cms.gov/initiatives/medicare-
diabetes-prevention-program/index.html
April 2018 15
MDDP Enrollment Form
• Separate CMS-20134
• Enroll using PECOS
• CMS website
– https://www.cms.gov/
Medicare/Provider-
Enrollment-and-
Certification/MedicareP
roviderSupEnroll/Enroll
mentApplications.html
February 2018 16
Inquiry Reduction initiative
April 2018 17
Noridian Self-Service Required2
• CMS requires providers use self-service options
• CMS Internet Only Manual (IOM), Publication
100-09, Chapter 6, Section 50.1
• Providers shall be required to use IVRs to access claim status
and beneficiary eligibility information. CSRs shall refer
providers back to the IVR if they have questions about claims
status or eligibility that can be handled by the IVR or portal...
• Process change allows our CSRs to assist
callers with more complex inquiries which
cannot be answered through self-service tools
February 2018 18
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)
– Electronic Funds Transfer (EFT)/check #/amount/date
– Self Service Reopenings (NMP only)
• Enrollment Application Status Search
– Enrollment application status
April 2018 19
Noridian Medicare Portal (NMP)
• New quick link
• Keep up to date
• Notifications & Updates – https://www.noridianmedicareportal.com/
– Have New Users?
• Get them registered
• Functionality: – Verify eligibility
– Check claim status
– Reopening
– Submit an appeal
April 2018 20
NMP Advantages Over the IVR
NMP IVR
Users enter information
using computer keyboard
Callers must follow voice prompts and use
telephone touch-tone keypad or voice
recognition to enter information
Users able to view
information as it is entered
Callers must wait for an audio response to
verify information entered
Users able to view immediate
inquiry results
Callers must wait for audio
response to hear inquiry results
Users can download and save
viewed information
Callers able to hear inquiry results only
Offers "How To" tutorials No tutorials available
Continuous updates with
increased access coming soon
No future enhancements planned
April 2018 21
Portal - Reopenings
Corrections effective February 5, 2018
• Billed amount
• Diagnosis
• Modifiers - exceptions apply
• Month/day of service changes
• MSP type
• Place of service
• Procedure code, modifier and billed amount
• Rendering National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) or Referring NPI
• Reprocess claim (without changes)
• Units, modifier and/or billed amount
February 2018 22
Elimination of Paper Remits
Part B only
• 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
April 2018 23
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 <$9000 + <500 claims pending
• https://www.cms.gov/Outreach-and-
Education/Outreach/NPC/Downloads/2018-01-
09-Appeals-Settlement-Presentation.pdf
April 2018 24
Appeals Timeliness Calculators https://med.noridianmedicare.com/web/jfb/
topics/appeals/calculators
April 2018 25
First Quarter
HIGLAS Enhancement for Overpayment
Based Denials
• CR 10166 Effective April 1, 2018
– Under Code of Federal Regulation (CFR) §
424.530(a)(6)(i), enrollment applications may be
denied if enrolling provider, supplier or owner thereof
has existing Medicare overpayment greater than or
equal to $1,500.00
– HIGLAS will report this information to PECOS
April 2018 27
Qualified Medicare Beneficiary
(QMB) Indicator • CR 9911 Effective October 2, 2017 claims
processed on/after this date
– Implemented April 2, 2018
– Medicare Summary Notices (MSNs) to include
message 62.0 when date of service falls within QMB
period
• “This notice contains claims covered by the Qualified
Medicare Beneficiary (QMB) program, which pays your
Medicare costs. When you’re enrolled in the QMB program,
providers and suppliers who accept Medicare aren’t allowed
to bill you for Medicare deductibles, coinsurance, and
copayments.”
April 2018 28
Inpatient Information Only Claims for
Beneficiaries Enrolled in MA Plans
• CR 10238 Effective April 1, 2015
– Implementation April 2, 2018
– CWF will set edit 5233 on inpatient information only
claims billed with condition codes 04 and 30 for
Investigational Device Exemption (IDE) Studies and
Clinical Studies Approved Under Coverage with
Evidence Development (CED)
• Allows FISS to zero out payment
April 2018 29
TDAPA for AKI
• CR 10281 Effective April 1, 2018
– Transitional Drug Add-on Payment Adjustment
(TDAPA) for patients with Acute Kidney Injury (AKI)
– Under ESRD PPS drug designation process, CMS
provides payment using TDAPA for new injectable or
intravenous drugs and biologicals that qualify under
42 CFR 413.234(c)(1)
– Reason codes 36228C and 36229C added to RTP
claims back for billing with modifier AX –or- billing with
HCPCS J0604 or J0606
April 2018 30
Remove Obsolete Edits from FISS
• CR 10274 Effective April 1, 2018
– CMS requests FISS remove and archive 26 obsolete
reason codes
• 31715, 31724, 32222, 32223, 32231, 32245, 32361, 32396,
32924 - 32940, 32972
April 2018 31
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
April 2018 32
2018 Telehealth
• Originating Site Q3014 = $25.76 (national)
• G0296 – Visit to determine low dose computed tomography (LDCT)
eligibility
• 96160 and 96161 – Health Risk Assessment
• G0506 – Care Planning for Chronic Care Management
• 90839 and 90840 – Psychotherapy for Crisis
• 90785 – Interactive Complexity
April 2018 33
Mammography Production Alert
•CPT 77065, 77066 and 77067 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
April 2018 34
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 00811 anesthesia for lower intestinal endoscopic
procedures
– CPT 00812 anesthesia for lower intestinal endoscopic procedures, screening colonoscopy
• PT modifiers waves the deductible and coinsurance waived
April 2018 35
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
• CR10341 effective January 1, 2018
• Physical therapy and speech-language pathology combined
– CY 2018 cap is $2,010
• Occupational therapy,
– CY 2018 cap is $2,010
April 2018 36
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
April 2018 37
Correcting Payment of IPPS
Transfer Claims- Part A
• 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
April 2018 38
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 99490 on or after January 1 will be
denied
April 2018 39
340B Drug Program
Part A
• 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 1-888-340-2787 or [email protected]
April 2018 40
NCD 20.8.4 Leadless Pacemakers
• Part B only
• 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
April 2018 41
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)
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
April 2018 43
Noridian Review Contractor Resources https://med.noridianmedicare.com/
• Jurisdiction F
• Medicare Part A/B
• Medical Review – Targeted Probe &
Educate (TPE)
– Other Review Entities • Comprehensive Error
Rate Testing (CERT)
• Office of Inspector General (OIG)
• Recovery Auditor (RAC)
• Supplemental Medical Review Contractor (SMRC)
• ZPIC
April 2018 44
Comprehensive Error
Rate Testing (CERT)2
• AdvanceMed – CERT Review Contractor – Attn: CID#
1510 E. Parham Road Henrico, Virginia 23228
– Phone: 888-779-7477
– Fax: 804-261-8100 • Include requested
medical documentation along with bar coded sheet
• Website – https://certprovider.a
dmedcorp.com/
April 2018 45
Jurisdiction F
Part B
• National Error Rate: 10.2%
• Breakdown by State:
April 2018 46
State Projected Error
Rate
Projected Improper Payment
Overall JF 7.2% $1,231,662,868
AZ 13.6% $553,572,353
WA 4.0% $161,390,236
MT 16.4% $104,163,334
OR 3.3% $94,084,207
UT 4.6% $70,738,681
ID 8.4% $55,632,865
CA 9.6% $55,067,884
SD 4.7% $46,474,707
ND 2.7% $23,924,747
WY 10.1% $19,224,030
Recovery Audit Contractor (RAC) https://racinfo.hms.com/home.aspx
• 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
April 2018 47
RAC Issues” – Oct. 2017
• Recovery Audit Contractor (RAC) examples:
– Excessive/Insufficient Drug and Biological Units
– E/M within “0” & “10” Day Global Procedures
– Critical care same day as Emergency room services
April 2018 48
Supplemental Medical Review Contractor
(SMRC)
• Strategic Health
Solutions, LLC
• Conducts medical
review based on
analysis
– Part A/B or DME “fee
for service”
– Claims,
services/provider
specialties
April 2018 49
SMRC Current Projects
• Website
– https:current-smrc-projects//strategichs.com/smrc/
• Current Projects:
– 3/16/17 Outpatient Drugs - Completed
– 4/7/17 Incorrect Place of Service - Completed
– 4/11/17 Bone Marrow and Stem Cell Transplant
– 7/10/17 Cardiac Rehabilitation - Completed
April 2018 50
Office of Inspector General (OIG) https://oig.hhs.gov/
• Compliance with
Nation's fraud and
abuse laws
• Educate public
• Monthly reporting
– https://oig.hhs.gov/rep
orts-and-
publications/workplan/i
ndex.asp#current
April 2018 51
Targeted Probe & Educate (TPE)
• Noridian Pilot review
process - June 2017
– https://med.noridianme
dicare.com/web/jfb/
cert-reviews/targeted-
probe-educate
• Medical Review (MR)
conducting reviews
– One-on-one education
April 2018 52
TPE Key Elements
• Noridian selects topics and providers based on
current data analysis
– 1-3 rounds of prepayment probe review
• Goal to lower provider error rates
– Learn from education/improve results in next "round“
• IOM 100-08, Chapter 2
– https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/pim83c02.
April 2018 53
Subsequent Hospital Codes
• Procedure codes 99223,99232,99233
• Requested 2,754
• Denied 2,485
• Rational services were not received with in 45 days 49.91 %
• Services were downcoded two levels
• Failure to support levels billed
• Signatures missing
• - 70.78%
April 2018 54
Resources and Educational
Tools
Look to Noridian Website https://med.noridianmedicare.com/
Part A Part B
April 2018 56
Updated Medicare Secondary
Payer (MSP) Calculator • Tool determines line by
line claim payment calculations when Medicare is secondary
• Noridian Website – https://med.noridianmedica
re.com/
• Jurisdiction F
• Medicare Part A/B
• Browse by Topic – Medicare Secondary
Payer (MSP)
April 2018 57
New Enrollment
Application Search Tool
• Noridian Website
– https://med.noridianme
dicare.com/
• Jurisdiction F
• Medicare Part A/B
• Enrollment
– Enrollment Application
Status Search
April 2018 58
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
April 2018 59
Find Us On Utube!
April 2018 60 Noridian Healthcare Solutions, LLC
April 2018 61
Download Google Play
April 2018 62 Noridian Healthcare Solutions, LLC
Education on Demand Recordings
• View self-paced recordings at your convenience
• Certificate emailed upon completion
• Part B Topics:
April 2018
• Claim Submission
• Endoscopies
• Chronic Care
Management (CCM)
• Transitional Care
Management (TCM)
• Medically Unlikely Edits
(MUEs)
• Incident To
• Correct Coding Initiative
(CCI)
• Annual Wellness Visit
(AWV)
• Initial Preventive Physical
Exam (IPPE)
• FLU/PPV Roster Billing
63 Noridian Healthcare Solutions, LLC
CMS Educational Materials
• MLN products downloadable or request copy free of charge – Brochures, Fact sheets
– Web-based training
• MLN dedicated web pages
• General Information – http://www.cms.gov/MLNGe
nInfo
• Matters Articles – http://www.cms.gov/MLNMat
tersArticles
• Products – http://www.cms.gov/MLNPro
ducts
April 2018 64
Locating Quarterly Provider Updates https://www.cms.gov/Regulations-and-Guidance/Regulations-and-
Policies/QuarterlyProviderUpdates/index.html
• CMS website
– https://www.cms.gov/
• Regulations &
Guidance
– Regulations & Policies
– Quarterly Provider
Updates
65 April 2018
Questions?
Thank you!
