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SDMGMA SDMGMA Third Party Payer and TPA Day
Noridian Updates
Noridian Medicare Part BProvider Outreach and Education
September 2014
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DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not beLLC (Noridian). 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 http://www.noridianmedicare.com and the CMS website at http://www.cms.gov
The identification of an organization or product in this information does not
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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 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
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CMS News
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Recovery Auditors New AddressHealthDataInsights, Inc.
9275 West Russell Road, Ste 100
• CMS delay in awarding
new RA contracts
• Automated reviews restarted in August
Las Vegas, NV 89148
– Limited number of complex reviews as selected by CMS
• Review New Issues Approved by CMShttps://racinfo healthdatainsights com/Public1/– https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx
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Medically Unlikely Edit (MUE) MUE Adjudication
MAI Description HowMAI is EditedIndicator (MAI)
MAI Description How MAI is Edited
1 Adjudicated as claim line editWill continue to be adjudicated as claim line edit
2 Date of service edit Per day edits based on policy
3 Date of service editPer day edits based on clinical b h kbenchmarks
Two columns added
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CMS Educational Materials• MLN products downloadable• MLN products downloadable
– Free of charge/free shipping• Brochures• Fact sheets• Quick reference charts• Web-based training
MLN dedicated web pages• MLN General Information
http://www.cms.gov/MLNGenInfo• MLN Matters Articles
http://www.cms.gov/MLNMattersArticles• MLN Products
http // cms go /MLNProd ctshttp://www.cms.gov/MLNProducts• MLN Web Guides
http://www.cms.gov/MLNEdWebGuide
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ICD-10• All covered entities must be fully compliant on• All covered entities must be fully compliant on
October 1, 2015• ICD-10 Acknowledgement Testing with
trading partners during three separate testing weeksweeks– November 17 – 21, 2014 – March 2 – 6, 2015 – June 1 – 5, 2015
K t d t ith N idi d CMS• Keep up-to-date with Noridian and CMS websites
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Noridian News
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Top Reasons Appeals Remain Denied
Appeals
• Duplicate claim
• Documentation does not support services
• No documentation submitted with appealpp
• Frequency
• Unprocessable reasons– Incomplete/invalid information (MA130)
• Bundling
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Top Reasons Appeals Remain Denied 2
Appeals
• Missing/Illegible/invalid signature
• Patient in Skilled Nursing Facility (SNF) or inpatient on date of service
• Claims lacks information for adjudication (CO-16)– Submit new claim with needed information
• Items/services statutorily excluded from Medicare coverage
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Top Reasons Appeals Reversed
Appeals
• Modifier added to CPT– Modifier 25
– Modifier 57
• Procedure code change– Most common CPT 92004 to 92014
• Provider enrollment issue
• Two providers from different specialties providing care on same DOS
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Appeal Request Form Completion Errors
Appeals
• Redetermination requests not signed by requestor
• Action request not specific
• Form sent to incorrect PO Box– Delays processing
• Required elements not completed– Must complete elements marked with *
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Avoid completion errors by submitting through Endeavor
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Missing Documentation to Support Appeal
Appeals
• Submit all pertinent medical records to support services provided– Include documentation of physician’s intent
and/or order• Utilize documentation checklists
– Records include physician’s legible signature• Submit signature log or attestation, if needed
• Check for correct DOS on records• Check that beneficiary name and
redetermination form match
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Example Medical DocumentationItem Documentation Required
Appeals
Adding Modifiers Office notes, operative reports, progress reports. (If you are adding modifier GA, a copy of the Advance Beneficiary Notice of Noncoverage [ABN] is also required)
Ambulance Services Trip report (when possible include the hospital records, such as the emergency room (ER) report, history and h i l di h i f ti f thphysical, discharge summary or information from the
nursing home, such as chart notes)
Chiropractic Services Medical necessity denials require office notes and a copy of signed disclaimer form, if applicable
Critical Care Progress notes, nurse’s notes, physician’s orders
Diagnostic Written interpretation/report and office notes/order fromDiagnostic Tests/Procedures
Written interpretation/report and office notes/order from ordering physician
Duplicate Denials Documentation for all services must be submitted to support separate services
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Check Production Alerts
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14503.2%H4 Not on File (3 2% of Total)
Top Inquiries to Provider Contact Center
PCC
1611
1581
1554
1450
3.5%
3.4%
3.4%
P2 Misrouted Telephone Call/Written …
F5 CWF Rejects (3.4% of Total)
E1 Status/Explanation/Resolution (3.4% of …
H4 Not on File (3.2% of Total)
2153
2065
1986
1896
4.7%
4.5%
4.3%
4.1%
H6 Payment Explanation/Calculation (4.7% …
F1 Claim Overlap with Dates of Service …
P1 Issue Not Identified/Incomplete …
F8 Duplicate (4.1% of Total)
4696
2567
2153
10.2%
5.6%
F2 Coding Errors/Modifiers (10.2% of Total)
G5 MSP (5.6% of Total)
y p / (
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Emergency Room Visits – CPT 99285
Medical Medical Review
52%
58%
50%
42%
55%
50%
39% 38%
43%
31%
AK 59 AZ 115 ID 50 MT 5 ND 163 OR 74 SD 140 UT 7 WA 98 WY 136
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80%
Ground Ambulance ‐ CPT A0428
Medical Medical Review
50%
60%
70%
10%
20%
30%
40%
AK AZ ID MT ND OR SD UT WA WY
Percentage 67% 69% 58% 70% 45% 65% 56% 65% 70% 74%
0%
10%
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Reviewing Contractors
Medical Medical Review
• Comprehensive Error Rate Testing (CERT)• Noridian Medical Review (MR)• Recovery Auditor (RA)• Office of the Inspector General (OIG)• Zone Program Integrity Contractor (ZPIC)• Supplemental Medical Review Contractor
(SMRC)(SMRC) • Quality Improvement Organization (QIO)
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Other Noridian News
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New FunctionView Claim Comments
Endeavor
Click on link to view
comments on claim decision
Comments shown here
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Revalidation
Enrollment
• Submit enrollment application and supporting documentation only when requested
• Utilize checklist to ensure all requirements• Utilize checklist to ensure all requirements completed
• Enrollment status can be verified in PECOS
• EFT information will not change if currently matching
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Utilize PECOS
Enrollment
• Submit initial Medicare enrollment application
• View or change enrollment information
• Track enrollment application
• Add or change reassignment of benefits
• Reactivate existing enrollment record
• Withdraw from Medicare Program
• Submit Change of Ownership of Medicare enrolled provider
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Part B Web-Based WorkshopsD t Ti (CT) W k h Titl
Education
Date Time (CT) Workshop Title
9/23/14 1:00 PM Care Plan Oversight (CPO) Services
9/24/14 1:00 PM Mental Health Services
9/25/14 1:00 PM Compliance
9/29/14 1 00 PM A b l S C (ASC)9/29/14 1:00 PM Ambulatory Surgery Center (ASC)
9/30/14 1:00 PM Climbing the Ladder to Success Part 1
10/1/14 1:00 PM Climbing the Ladder to Success Part 2
10/2/14 1:00 PM Climbing the Ladder to Success Part 3
10/15/14 3:00 PM Ask the Contractor Teleconference (ACT)‐General
10/29/14 11:00 AM DME Documentation
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Questions? Stop by and see me!p y
