Medicare Updates

Montgomery County Medical Society

Payor Conference

November 12, 2015

Disclaimer

All Current Procedural Terminology (CPT) only are copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Novitas Solutions does not permit videotaping or audio recording of training events.

Novitas Solutions

Education specific to providers in Medicare Administrative

Contractor Jurisdiction H (JH) include: Arkansas, Colorado,

Louisiana, Mississippi, New Mexico, Oklahoma, and Texas

Education specific to providers in Medicare Administrative

Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of

Columbia, Maryland, New Jersey, and Pennsylvania

This education contains specific contractor guidance

If you are not a provider in JL or JH, please contact your Medicare

contractor for specific guidance

Agenda

ICD-10 Assistance and Advice

Part A/B Updates

Preventive Services

Novitas Initiatives

Comprehensive Error Rate Testing (CERT) Program

Self Service Options

Objectives

Identify and understand the current Medicare changes

Learn how to apply the new guidelines

Identify and utilize the educational resources and information

Acronym List

Acronym Definition

CERT Comprehensive Error Rate Testing

CMS Centers of Medicare & Medicaid Services

EDI Electronic Data Interchange

ICD International Classification of Diseases, 10th Edition

IPPS Inpatient Prospective Payment System

LCD Local Coverage Determination

MLN Medicare Learning Network

NCD National Coverage Determination

OPPS Outpatient Prospective Payment System

ICD-10 Assistance and Advice

ICD-10 Tips

ICD-10 billing tips:

• Use ICD-10 codes with dates of service on and after October 1, 2015

• Use proper qualifiers on the proper codes- ICD-10 qualifiers (ABK/ABF)

• May not use ICD-9 codes with dates after 10/1/15

• Bill separate claims for September and October dates of service

CMS ICD-10 Implementation Page

• http://www.cms.gov/Medicare/Coding/ICD10/index.html

Flexibility to Coding Accuracy for

Physician

No medical review denials the first year related to coding errors as

long as the code is in the “appropriate family” of ICD-10 codes

• Applicable for services paid under the Medicare Fee-for-Service Part B

physician fee schedule

No grace period, codes must be valid, carried out to the highest

level of specificity

Claims subject to LCD/NCD guidelines may deny if not carried out to

the highest level of specificity

No penalties on 2015 quality reports

Reference

• http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedicareProvi

derICD-10.pdf

• https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-

Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-

Announcement.pdf

Part B Appeal/Clerical Error and

Claim Process

No changes with the appeals/clerical error or claim process

• Denied claims continue to follow appeal process

Providers will continue to use the claims corrections line or the Novitasphere

portal to correct clerical errors

i.e. incorrect diagnosis code billed, incorrect units billed, wrong date of service,

incorrect modifier, etc.

Resubmitted claims will deny as duplicates

• Rejected claims need to be rebilled

CMS Communication and

Collaboration Center

Drawing from best practices of other technology implementation

• Monitor the implementation

• Quickly identify issues

• Initiate fixes

Check the validity of ICD-10 codes

• 2016 ICD-10 and GEMs (zip file titled “icd10cm_codes_2016.txt”)

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Code-

Descriptions-in-Tabular-Order.zip

Ombudsman

Ombudsman for physicians and other providers

• Located at the ICD-10 Coordination Center

• Triage and answer questions about claim submissions

• Ask coding questions

• Dr. William Rogers

ICD10_Ombudsman@cms.hhs.gov

AHA Central Office Coding

Questions

Free assistance and advice

• Providing ICD-10 and ICD-10-PCS coding advice

• Does not replace learning how to code

Questions should be submitted via www.codingclinicadvisor.com

• Not limited to AHA members, but registration required

• Review FAQ section for details on how to submit questions

Formulate coding question, not just “what is the code for XYZ”

Provide documentation

Specify whether inquiry refers to a certain setting

Cannot answer questions on payment/coverage

CMS Teleconferences and Videos

CMS sponsored ICD-10 teleconferences

• http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-

Teleconferences.html

MedScape modules

• http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

CMS has created “Road to 10” to help jump start the transition to

ICD-10

• http://www.roadto10.org/

CMS Tools and Fact Sheets

CMS ICD-10 Fact Sheets

• Intro Guide to ICD-10

• The ICD-10 Transition: An Introduction

• ICD-10 Basics for Medical Practices

• Talking to Your Vendors About ICD-10: Tips for Medical Practices

• ICD-10 and CMS eHealth: What’s the Connection?

• ICD-10 Basics for Small and Rural Practices

• Online ICD-10 Implementation Guide

ICD-10-CM/PCS Billing and Payment FAQs

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD-10BillingandPaymentFAQs.pdf

ICD-10 Quick Start Guide

ICD-10 Infographic

ICD-10 Website Wheel Educational Tool

Reference

• http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

CMS Resources

The CMS International Classification of Disease, Tenth Revision

(ICD-10) website

• http://www.cms.gov/icd10

Sign up for Centers and Medicare & Medicare Services (CMS) ICD-

10 Industry Email Updates

• http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-

10_Industry_Email_Updates.html

Subscribe to Latest New Page Watch

• https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_i

d=USCMS_609

Part B Updates

Sequestration Update

Mandatory Payment Reduction of 2% continues through March 31, 2016, for the Medicare Fee For Service Program

For more information• http://www.cms.gov/Outreach-and-

Education/Outreach/FFSProvPartProg/Downloads/2015-03-19-eNews.pdf

Frequently Asked Questions

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00007998

New and Revised Place of Service

Codes (POS) for Outpatient

Hospitals

Change Request # 9231

• Effective: January 1, 2016

• Implementation: January 4, 2016

Key Points

• POS 19 Off Campus-Outpatient Hospital

• POS 22 On Campus-Outpatient Hospital

• POS 17 Walk-in Retail Health Clinic

• POS 26 Military Treatment Facility

Reference

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf

Updates on the Therapy Cap

Exceptions to the therapy cap will remain in effect for claims with

dates of service through December 31, 2017

Hospital outpatient therapy claims will continue to apply to the

therapy cap through December 31, 2017

Suspension for therapy services that exceed $3,700 will remain in

effect for therapy services through December 31, 2017

https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?r

edirect=/TherapyServices

Preventive Services

Medicare Learning Network (MLN)

Products for Preventive Services

Help Keep Your Medicare Patients Healthy In 2015!

Ensure your patients take advantage of Medicare-covered

preventive services

Medicare covers a wide array of preventive services for eligible

beneficiaries, including cancer screenings, certain immunizations,

among others

The Medicare Learning Network (MLN) Preventive Services

Educational Products Web Page provides descriptions and ordering

information for MLN preventive services educational products and

resources for health care professionals and their staff

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/PreventiveServices.html

Preventive Services and Screenings

Covered by Medicare

Abdominal Aortic Aneurysm Screening

Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care

Annual Wellness Visit (Including Personalized Prevention Plan Services)

Bone Mass Measurements

Cancer Screenings o Breast Cancer (mammograms and clinical

breast exam)

o Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])

o Colorectal Cancer Fecal Occult Blood Test

Flexible Sigmoidoscopy

Colonoscopy

Barium Enema

o Prostate (Prostate Specific Antigen blood test and Digital Rectal Exam)

Cardiovascular Disease Screening

Depression Screening in Adults

Diabetes Screening

Diabetes Self-Management Training

Glaucoma Screening

Hepatitis C Screening

Human Immunodeficiency Virus (HIV) Screening

Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)

Intensive Behavioral Therapy for Cardiovascular Disease

Intensive Behavioral Therapy for Obesity

Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)

Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs

Tobacco-Use Cessation Counseling

Influenza Vaccine Payment Allowances-

Annual Update 2015-2016 Season

Change Request #9299

• Effective Date: August 1, 2015

• Implementation : No later than November 24, 2015

Key Points

• These payment allowances are updated on an annual basis

• The pending payment allowances will be updated in the influenza

vaccine pricing webpage

• Providers may visit the webpage for the updated prices

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-

Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

Reference

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM9299.pdf

Preventive Services Resources

Quick Reference Chart for Medicare Preventive Services

o https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads

/MPS_QuickReferenceChart_1.pdf

Improve Your Patients’ Health with the Initial Preventive Physical

Examination (IPPE) and Annual Wellness Visit (AWV)

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/SE1338.pdf

Novitas Initiatives

Increasing Your Bottom Line: How

Much Does Rework Cost?

Cost savings for providers by reducing the need for Clerical Error

Reopening requests:

• Correct minor errors

• Omissions of claim specific information

Education Initiatives:

• Articles published to assist with proper use of specific modifiers

New Web page dedicated to help you reduce rework and increase

your bottom line:

• JL

http://www.novitas-

solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00092539

What is Novitasphere?

Free web-based Portal which allow enrolled users access to

Eligibility, Claim Information and Remittance Advice, Claim

Submission with File Status, Electronic Remittance Advice (ERA),

Claim Correction, and a Mail Box

Available to JH and JL Part B providers, billing services and

clearinghouses servicing Part B practitioners

For demonstrations and more information on Novitasphere visit:

• JL providers:

http://www.novitas-

solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000

24648

Novitasphere Claim Correction

Feature

Common clerical errors can be corrected on finalized claims:

• Number of services or units

• Diagnosis code (Primary)

• Eligible modifiers

• Procedure code

• Date of service

• Place of service

• Billed amount

JL Novitasphere Claims Correction Guide:

• http://novitas-

solutions.com/cs/idcplg?IdcService=GET_FILE&RevisionSelectionMeth

od=LatestReleased&dDocName=00086496&allowInterrupt=1

Novitasphere Help Desk

1-855-880-8424

Comprehensive Error Rate Testing

(CERT) Program

Comprehensive Error Rate Testing

(CERT)

Program developed by Centers for Medicare & Medicaid Services

(CMS) to monitor the accuracy of claims processing

Designed to protect the Medicare trust fund and determine error

rates nationally and regionally

Random audits conducted on a monthly basis

AdvanceMed request medical records for claims selected as part of

the monthly random sample

Medical record documentation supporting claim must be returned in

designated time frame

JL CERT page

• http://www.novitas-solutions.com/webcenter/spaces/CERT_JL

Part B Common Errors

Insufficient documentation:

• Procedure/service billed

• Missing or illegible documentation and/or physician signature

• No valid physician’s order

• No physical therapy certified plan of care/treatment plan

Incorrect coding errors:

• Evaluation and Management (E/M) codes

• Critical care, discharge day management, physical therapy

• Units of medication/infusion services

• Laboratory services

Self-Service Options

Customer Contact Information

Jurisdiction L Providers:

• 1-877-235-8073

• JL Self-Service Tools:

http://www.novitas-

solutions.com/webcenter/portal/CustomerServiceCenter_JL/Self-

Service+Tools

Telecommunication Devices for the Deaf:

• 1-877-235-8074

Patient / Medicare Beneficiary:

• 1-800-MEDICARE (1-800-633-4227)

http://www.medicare.gov/index.html

Centers for Medicare & Medicaid

Services (CMS)

The CMS website offers valuable resources such as

• CMS Internet Only Manuals (IOMs)

• Medicare Learning Network (MLN) Matters Articles

• Open Door Forum

• http://www.cms.gov/

Stay Up-to-Date

Electronic Mailing List

• Daily E-mail of the latest Medicare Updates

• Subscribe

• http://www.novitas-

solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId

=00007968

Podcast

• Podcast of the latest Medicare Updates and other informative topics

http://www.novitas-

solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000

08119

Educational Videos and Tutorials

http://www.novitas-

solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=000

82787

Summary

Discussed the current change requests, giving key points and links

Reviewed the Novitas tools that are needed to keep providers

updated

Gave valuable resources from the CMS and Novitas websites

Thank You For Attending

Questions