WPS MEDICARE UPDATES

Aileen K. Sigler, Analyst and Mary E. Muchow, AnalystProvider Outreach & Education

American Association of Healthcare Administrative ManagementAksarben Spring Conference

April 23, 2015

Audio or Video Recording is Prohibited

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DisclaimerThis presentation is a tool to assist providers. Every reasonable effort was made to ensure the accuracy of the information. However, providers have the ultimate responsibility for correct submission of claims. WPS Medicare bears no liability for results or consequences of any misuse of the information.

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• ICD-101

• Comprehensive Error Rate Testing (CERT) Program

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• Medicare Signature Requirements3

Today’s Agenda

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• Nuggets4

• Questions5

Today’s Agenda

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ICD-10 and Policy

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Local Coverage Determination (LCD) Transition to ICD-10• LCD policies containing ICD-9 are end dated

– Discontinue use on 09/30/15• LCDs with ICD-10 are available now for

preview – Effective 10/01/2015

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ICD-10 Testing

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ICD-10 Resources

• SE1409– Outlines CMS testing approach

• SE1435– End-to-End testing FAQs

• SE1501– Compares Acknowledgement and End-to-End

testing • MM8867

– Direction for 2015 End-to-End testing

What’s the Difference?

Acknowledgement Testing• No registration• Open to all submitters• Claim is accepted or

rejected • Submit any # of claims• Use current dates of service

End-to-End Testing• Registration during specific

times• 50 volunteers selected • Complete adjudication and

RA generated• Limit of 50 claims• Dates of service > October

1, 2015

End-to-End Testing Results

• 1,400 registered– 661 participated

• 14,929 claims received– 12,149 accepted 81%

Types of Claims Tested

Professional 56%Institutional 38%Supplier 6%

Upcoming Testing Events

• Acknowledgement testing – Ongoing

• April 27 – May 1– Volunteers have been selected

• July 20 – July 24– Form available beginning March 13

• January testers are automatically eligible

Comprehensive Error Rate Testing (CERT) Program

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Why did CMS implement the CERT review program?

• To improve the processing and medical decision making involved with payment of Medicare claims

• Goal: to reduce the National Paid Claims Error Rate

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CERT Process

• Random Claim Selection• Medical Record Requests• Review of Claims• Assignment of Improper Payment Categories• Calculation of the Improper Payment Rate

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“Why should I care?”

• Many entities use CERT identified improper payments to target medical review activities and strategies– Common denominator to identify program vulnerabilities

• Includes reviews by– Office of Inspector General (OIG)– Recovery Auditor– MACs– Supplemental Medicare Review Contractor– Zone Program Integrity Contractors– Program Safeguard Contractors– CMS

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Corrective Actions

• CMS and contractors analyze improper payment rate data and develop Error Rate Reduction Plans to reduce improper payments

• Corrective actions include:– Refining improper payment rate measurement

processes – Improving system edits– Updating coverage policies and manuals – Conducting provider education efforts

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National Improper Payment: Fiscal Year (FY) 2014

Service Type Improper Payment Rate

Improper Payment Amount

Inpatient Hospitals 9.2% $10.4B

Durable Medical Equipment 53.1% $5.1B

Physician/Lab/Ambulance 12.1% $11.0B

Non-Inpatient Hospital Facilities 13.1% $19.2B

Overall 12.7% $45.8B

Reporting period for this improper payment rate is July 1, 2012-June 30, 2013 19

Errors Assessed

• Handouts– Details on errors assessed for Nebraska providers

• Available on WPS website• Details on errors assessed for various provider types

and specialties and how to avoid those errors• Quarterly error finding summary reports• Mapping of errors

– J5/J8 MAC Part A>Departments>CERT>CERT Identified Errors>CERT Identified Errors Map

– J5/J8 MAC Part B>Departments>CERT>CERT Error Analysis>CERT Identified Errors Map

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Forecasted Errors

• Handout– Forecasting of errors provided by CERT

contractor; based on historical data and trending

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CMS/WPS Medicare CERT Web Pages

• CMS CERT web page– Research, Statistics, Data and Systems>Medicare

Fee-for-Service Compliance Programs>Comprehensive Error Rate Testing (CERT)

• WPS Medicare CERT web page– J5/J8 MAC Part A/B>Departments>Comprehensive

Error Rate Testing (CERT)

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Obtaining CERT Review Results• E-mail WPS Medicare CERT Point of Contact

– Part A – medicare.cert.part.a@wpsic.com– Part B – medicareadmin@wpsic.com

• Include“CERT Review Results” in Subject Line

Requester’s full name, address, and telephone number

Provider Transaction Access Number (PTAN)

Claim Identification Number (CID)

Details on requested information For Part A only, Facility Name

• Please do not include protected health information23

Medicare Signature Requirements

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Authentication by Author Required

• Payment may be impacted for absence of acceptable signature

• CMS’ MLN offers a variety of educational products to help understand signature requirements for Medicare-covered services

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Attestation Statement

• Can be used in cases of illegible or missing provider signatures (excluding physician orders)

• Must be signed and dated by the author of the medical record entry

• Must contain sufficient information to identify the beneficiary

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Nuggets

nug·get/ˈnʌgɪt/ Show Spelled [nuhg-it] noun 1. a lump of something, as of precious metal. 2. a lump of native gold. 3. anything of great value, significance, or the like: nuggets of wisdom.

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Amendments, Corrections and Delayed Entries in Medical Documentation

• Publication 100-08, Chapter 3, Section 3.3.2.5– Also referenced in MLN Matters SE1237

• Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents must:

1. Clearly and permanently identify any amendment, corrections or addenda, and

2. Clearly indicate the date and author of any amendment, correction or addenda, and

3. Clearly identify all original content (do not delete)

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Protocols

• If using a protocol or referring to a protocol in medical record documentation, a copy should be included when sending documentation to the Medicare contractor

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Misunderstood Modifiers

• Used to add information or change the description of service in order to improve accuracy or specificity

• Documentation must support use• Information issued by CMS may differ from

the American Medical Association’s (AMA) coding advice regarding the use of modifiers

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Specific Modifiers for Distinct Procedural Services• CMS created four new –X Modifiers to define

specific subsets of the –modifier, a modifier used to define a “distinct procedural service”

• Medicare Learning Network (MLN) Matters Article – MM8863

• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf

– SE1503• https://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1503.pdf

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National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits

• PTP edits define when two HCPCS/CPT codes should not be reported together either in all situations or in most situations– Correct Coding Modifier Indicators (CCMI)

indicate when code pairs may be reported together only in defined circumstances

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CCMI

• 0 – Not Allowed– There are no modifiers associated with NCCI that

are allowed to be used with this code pair• There are no circumstances in which both procedures of

the code pair should be paid for the same beneficiary on the same day by the same provider

• 1 – Allowed– The modifiers associated with NCCI are allowed

with this code pair when appropriate• 9 – Not Applicable

– An NCCI edit does not apply to this code pair• The edit for this code pair was deleted retroactively

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CMS-Secure Net Access Portal (C-SNAP)

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• Secure web site for patient and claim data• www.medicareinfo.com

WPS Nerve Conduction Velocity Presentation - October 4, 2013 • Page 35

C-SNAP – A Continuing Evolution*

Jan ‘13 Apr ‘13 June ‘13 Oct ‘13 Dec ‘13 Jan ‘14 June ‘14 Summer ‘14 Fall ‘14

External Users Can Locate NPI

Administrator

Help Center Added

Part A Appeals Status

Clerical Error Reopenings

(CER)

Part A Discharge

Status

Live Chat C-SNAP Call

Center Automation

ICD-10 Preparedness

Part B Appeals Status

Overpayment Claim

Adjustment (OCA)

*Latest enhancement is ability to upload documentation in response to an Additional Documentation Request (ADR) letter received for medical review purposes

Striving For Best Website

• Continuous Enhancements• Weekly Updates Posted

– J5/J8 MAC Part A/B>Resources>Website Updates• Please continue to complete the ForeSee

Website Customer Satisfaction Survey

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Top Inquiries and FYI Database

• Quarterly telephone correspondence FAQs and written correspondence FAQs are available on our website– J5/J8 MAC Part A/B>FAQs>Departmental>Customer

Service• FYI Database

– Accessible from every page

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Education Opportunities• Live Training

– J5/J8 Part A/B>Training>Live Training>Live training event catalog

• “A Day with Medicare” – June 11 in Overland Park, Kansas– July 22 in St. Charles, Missouri– 20 breakout sessions

• Part A and Part B

– No registration fee

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Education Opportunities

• On Demand Training – J5/J8 Part A/B>Training>On Demand Training– Organized by topic– Audio and handouts from past teleconferences– Self-paced educational modules

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QUESTIONS?

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THANK YOU

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