1. No category

Coalition of
Hematology/Oncology
Practices
September 11, 2014
Disclaimer
•
All Current Procedural Terminology (CPT) only copyright 2013 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 (MAC) Jurisdiction L (JL) include: Delaware,
District of Columbia, Maryland, New Jersey, and Pennsylvania
• Education specific to providers in Medicare Administrative
Contractor Jurisdiction H (JH) include: Arkansas, Colorado,
Louisiana, Mississippi, New Mexico, Oklahoma, and Texas
• 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
•
•
•
•
Quarterly Updates
Novitas Initiatives
LCD/CAC Process
Comprehensive Error Rate Testing
Program (CERT)
• Self Service Options
Objectives
• Identify and understand the current
Medicare changes
• Provide a basic understanding of the Local
Coverage Determination (LCD) process.
• Identify and utilize the educational
resources and information
Quarterly Updates
Fiscal Year 2015 Physician
Fee Schedule Proposed Rule
• Proposed policy and payment changes to
the Medicare Physician Fee Schedule for
Calendar Year 2015 CMS Fact Sheet
• Reference:
o
http://www.cms.gov/Newsroom/MediaRelease
Database/Fact-sheets/2014-Fact-sheetsitems/2014-07-03-1.html
ICD-10 Conversion/Coding Infrastructure
Revisions/ICD-9 Updates to National Coverage
Determinations (NCDs) - Maintenance CR
• Change Request # 8691
o
o
Effective: July 1, 2014 (ICD-9) October 1, 2015 (ICD-10)
Implementation: July 7, 2014 (ICD-9) October 6, 2015
(ICD-10)
• Key Points
o
o
o
Create and update NCD editing
Update associated coding infrastructure
Provide pertinent policy/coding information necessary to
implement ICD-10 for 9 NCDs
• Reference
o
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/MM8691.pdf
Updates to International Classification of
Diseases, 10th Edition (ICD-10) Local
Coverage Determinations
• Special Edition Article SE1421
• Key Points
o
Advises how to access ICD-10 Local Coverage
Determinations (LCDs) in the Centers for
Medicare & Medicaid Services (CMS) Medicare
Coverage Database (MCD)
• Reference
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1421.pdf
Fluorodeoxyglucose (FDG) Positron
Emission Tomography (PET) for
Solid Tumors
• Change Request # 8739
Effective: June 11, 2013
o Implementation: May 19, 2014
o
• Key Points
o
o
o
Requirement for FDG PET and FDG PET/CT for oncologic indications
Requirements for prospective data collection by the National Oncologic
PET Registry (NOPR) for oncologic indications of FDG (HCPCS A9552)
were removed
Codes 78608, 78811, 78812, 78813, 78814, 78815, 78816, modifier –
PS, and code A9552, for oncologic conditions, no longer require the
following modifier and diagnosis code
 QO
 V70.7
• References
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8739.pdf
Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved.
Medicare National Coverage Determination
(NCD) for Beta Amyloid Positron Emission
Tomography (PET) in Dementia and
Neurodegenerative Disease
• Change Request # 8526
o
o
Effective: September 27, 2013
Implementation: July 7, 2014
• Key Points
o
NCD will only allow coverage for PET Aβ imaging (one PET Aβ
scan per patient) through Coverage with Evidence Development
(CED)
 Develop better treatments or prevention strategies for Alzheimer’s
Disease
 Resolve clinically difficult differential diagnoses where the use of PET
Aβ imaging appears to improve health outcomes, when the patient is
enrolled in an approved clinical study under CED
• Reference
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8526.pdf
Proper Use of Modifier 59
• Special Edition Article SE1418
o
Revise : June 2, 2014
• Key Points
o
o
The Medicare National Correct Coding Initiative (NCCI) includes
Procedure-to-Procedure (PTP) edits that define when two
Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) codes should
not be reported together either in all situations or in most
situations
Modifier 59 is an important NCCI-associated modifier that is
often used incorrectly
 Correct Coding Modifier Indicator (CCMI)
 Examples
• Reference
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1418.pdf
Medicare Signature Requirements Educational Resources for Health
Care Professionals
• Special Edition Article SE1419
• Key Points
o
o
Medicare services provided/ordered must be
authenticated by the author using an acceptable
signature
Links to a variety of educational products to help you
understand signature requirements for Medicarecovered services
• Reference
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1419.pdf
Medically Unlikely Edits (MUE)
and Bilateral Procedures
• Special Edition Article SE1422
• Key Points
Claims filed using noncompliant coding for bilateral
surgical procedures may have been paid in the past
o The purpose of this article is to inform providers that MUE
changes may now render those claim lines unpayable
o Medicare billing instructions require claims for certain
bilateral surgical procedures to be filed using a 50 modifier
and one unit of service
o
• Reference
o
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/SE1422.pdf
Aprepitant for Chemotherapy
Induced Emesis
• Change Request # 8418
o
o
Effective: May 29, 2013
Implementation: July 7, 2014
• Key Points
Extended coverage for the oral antiemetic three-drug
regimen of oral aprepitant
o Coverage for beneficiaries who are receiving highly and
moderately emetogenic chemotherapy
o
• Reference
o
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/MM8418.pdf
Medicare Part B Quarterly
Updates
• Correct Coding Initiative (CCI) edits
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8662.pdf
• Average Sales Price (ASP) Medicare Part B Drug
Pricing Files and Revisions to Prior Quarterly
Pricing Files
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8748.pdf
Local Coverage Determination
(LCD) Development Process
Rationale for Developing
• Reasons for developing a Local Coverage
Determination (LCD) include but are not limited to
o
o
o
o
o
o
A service is identified that is never covered under certain
circumstances
A validated widespread problem demonstrates a significant
risk to the Medicare Trust Fund
An LCD is needed to ensure beneficiary access to care
There are frequent denials for a particular service
Data analysis shows a particular service is reimbursed or
utilized differently compared to other jurisdictions
New technology, service, or procedure becomes available
that has potential to be a risk to the Medicare Trust Fund
Supporting Evidence
• Evidence supporting LCDs
Published authoritative evidence
o General acceptance by the medical
community
o
 Scientific data or research published
 Consensus of expert medical opinion
 Medical opinion derived from consultations with
medical associations or other health care experts
When a Local Coverage
Determination (LCD) is Needed
• When a new LCD or revised LCD is
needed, Novitas will
o
Determine if a policy addressing the issue
already exits
 Adopt or adapt an existing LCD
o
Develop a new policy
Contents of Local Coverage
Determination
• Familiarity with a Local Coverage Determination (LCD)
helps providers and their billing staff gain a full
understanding of the payment/denial of a service
• Novitas encourages providers, billing personnel and
others who may be responsible for filing claims to
Medicare to be aware of all information contained
within an LCD
• There are many components that comprise an LCD
Information Contained in Local
Coverage Determination (LCD)
• Information that may be contained in an LCD
includes
o
o
o
o
o
o
o
Indications and limitations of coverage and/or
medical necessity
Current Procedural Terminology (CPT)
/Healthcare Common Procedure Coding System
(HCPCS) codes
ICD-9-CM codes that support medical necessity
Utilization guidelines
Documentation guidelines
Drug wastage
Individual consideration guidelines, if applicable
Contractor Advisory Committee
(CAC)
Purpose of the Contractor
Advisory Committee (CAC)
• The purpose of the CAC is to provide
A formal mechanism for physicians in the
State to be informed of and participate in the
development of a Local Coverage
Determination (LCD) in an advisory capacity
o A mechanism to discuss and improve
administrative policies that are within the
contractors discretion
o A forum for information exchange between
contractor and physicians
o
Focus of The Contractor
Advisory Committee (CAC)
• The CAC focuses on Local Coverage
Determinations (LCDs) and administrative
policies with the contractor’s discretion. They
do not
o
o
o
o
Discuss issues and policies related to private
insurance
Discuss national policy promulgated by Centers
of Medicare & Medicaid Services (CMS)
Discuss what is “right” or “wrong” with Medicare
Review or discuss of individual cases or
individual providers
Local Coverage Determination
Comment Period
Comment Period
• Newly developed Local Coverage Determinations
(LCDs) and those with significant revisions are posted
for “comment” for 45 days on the Novitas Website
• All comments are considered as the LCD is finalized
• Once finalized, a synopsis of the LCD is published
• Approximately 45 days after it is finalized, the LCD
becomes effective
Local Coverage Article A52018
Approved Drugs & Biologicals…
Cancer Chemotherapeutic
Agents
• Cancer chemotherapeutic agents are covered only
if all of the following requirements are met:
o
o
o
Documentation is present to support that the drug is
safe and effective and is being administered for an
approved indication.
Documentation in the patient’s medical record
supports the medical necessity of administering the
chemotherapy drug to that individual patient.
Documentation in the patient’s medical record
supports that the chemotherapy drug was
administered as billed.
Payment for Chemotherapeutic
Drug or Biologicals
• Payment may be made for an Federal
Drug Administration (FDA)-approved
chemotherapeutic drug or biological, if:
It was injected on or after the date of the
FDA's approval;
o It is reasonable and necessary for the
individual patient; and
o All other applicable coverage requirements
are met
o
Diagnostic Radiopharmaceuticals
Procedures
• Reimbursment for HCPCS Codes A4641, A4642,
A4648, A9500-A9551, A9552, A9553-A9572, A9576A9599, A9600-A9604, and A9698-A9700 are based
on the acquisition cost reported on the claim
• The acquisition cost should be reported in Block 19
or Block 24D of the 1500 claim form and in the 2400
loop NTE segment of an EMC claim.
• Payment allowance will be made at 100% of the
acquisition cost
o
http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pag
ebyid?contentId=00024985
Revised JL/JH Local Coverage
Determinations (LCDs) and Articles
• Effective July 23, 2014
• Revised LCD
o
Biomarkers Overview (L33638)
• Revised Article
o
Biomarkers for Oncology (A52317)
JL/JH Local Coverage
Determinations (LCDs)
•
Effective July 24, 2014
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3D Interpretation and Reporting of Imaging Studies (L34709)
Autonomic Function Tests (L34788)
Barium Swallow Studies, Modified (L34747)
Biomarkers for Oncology (L34796)
Chiropractic Services (L34816)
Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L32237)
Independent Diagnostic Testing Facility (IDTF) (L34792)
Magnetic Pelvic Floor Stimulation (MPFS) (L34612)
Multiple Imaging in Oncology (L34790) (also revised)
Non-Invasive Cerebrovascular Arterial Studies (L34711) (also revised)
Non-Invasive Peripheral Venous Studies (L34714)
Non-Vascular Extremity Ultrasound (L34716) (also revised)
Oximetry Services (L34749)
Pulmonary Function Testing (L34751)
Sacral Nerve Stimulation (L34707)
Spinal Cord Stimulation (Dorsal Column Stimulation) (L34705)
Thrombolytic Agents (L34743)
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L34745)
Novitas Initiatives
Website Improvements
• Based on your feedback we continue to
update the Novitas Solutions website to
better service your needs and to allow for
better navigation
• New features are available
Website content displayed by contract and
line and business
o Improved search functionality
o Enhanced left-side navigation bar
o
Policy Search Application
•
New customized “Policy Search Application”
•
Search current, retired or draft policies
•
Search criteria
o
o
o
o
o
Policy number
Current Procedural Terminology (CPT)
Healthcare Common Procedure Coding System (HCPCS)
Keyword
Local Coverage Determination (LCD) Title
•
Search results based on criteria entered
•
Stayed tuned for additional information and upcoming educational
opportunities
o
http://www.novitas-solutions.com
Medicare Review
• Medical Review Results
o
o
Service Wide Edits
Service Wide Probe Results
• Centers for Medicare & Medicaid Services (CMS) and
Other Related Links
o
o
o
o
CMS Medical Review Site
CMS National Provider Identifier (NPI) Website
Medicare Learning Network (MLN Matters Articles)
Program Integrity Manual (PIM)
• JH
o
http://www.novitassolutions.com/webcenter/spaces/MedicalReview_JH
Novitasphere Part B
What Can You Do With Novitasphere?
• Novitasphere will allow providers, including those providers that use
a billing services or clearinghouse, to connect via the internet
directly to Novitas Solutions to
o Obtain beneficiary eligibility status
o Check claim status
o Submit claims
o Retrieve and print remittance advices
o Perform clerical error reopenings
• Additional information including how to enroll can be found under
the Novitasphere-Portal link on the left side bar of the Novitas
Solutions website
o www.novitas-solutions.com
Novitasphere Registration
• Step 1: Determine who the Security Official or primary person
from your office responsible for accessing the application
• Step 2: Complete the JL Electronic Data Interchange (EDI)
Portal Enrollment form (8292P) found in the Enrollment
section of the Novitasphere Center of our website
• Fax the completed form to 1-877-439-5479
• Step 3: Await instruction for authorized individual access for
the Security Official, your organization and its Users
• JH Electronic Data Interchange (EDI) Portal Enrollment Form
(8292PJH)
• Form is on http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?
contentId=00081061
Novitasphere Help Desk
1-855-880-8424
Novitas Medicare
Learning Center
• Now available!
• Features
o
o
o
o
Create an individualized education account
Register for webinars, teleconferences, and workshops
Download your Continuing Education Unit (CEU) Certificates
Be placed on a waitlist if the educational event you register for is
closed
• Benefits
o
o
o
Centralized location for all educational materials
Track all of the educational events you’ve attended
Access Medicare education 24 hours a day, 7 days a week with
web-based training modules
Calendar of Events
• Our Education and Training Center offers a wide
variety of education
• Join us for Workshops, Teleconferences, and
Webinars
• To view the most current calendar of events, visit:
o
JH Part B
 http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid
?contentId=00008044
Stay Up-to-Date
• Web Updates
o
o
Daily E-mail of the latest Medicare Updates
Subscribe JH
 http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid
?contentId=00007968
• Podcast
o
o
Weekly podcast of the latest Medicare Updates and
other informative topics
Subscribe JH
 http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid
?contentId=00025071
Comprehensive Error Rate Testing
(CERT)
Comprehensive Error
Rate Testing (CERT)
• What is it? A program developed by Centers for Medicare &
Medicaid Services (CMS) to randomly audit claims monthly to
determine if they processed correctly
• Why does it matter? To protect the Medicare trust fund and
determine error rates nationally and regionally
• Who is involved? You. A request for medical records from
AdvanceMed alerts you that one of your claims has been
selected as part of the monthly random sample
• How does it work? A letter will be sent to your office
requesting the medical documentation. You need to comply in
a timely manner with the request
• JH
o
http://www.novitas-solutions.com/webcenter/spaces/CERT_JH
JH Part B Common
Errors
• Insufficient documentation
o
o
o
Missing or illegible documentation and/or
physician signature
Procedure/laboratory service billed
No valid physician’s order
• Incorrect coding errors
o
o
Evaluation and Management (E/M) codes
Units of medication
Self Service Options
Novitas Home Page
Select Line of Business
JH Part B Center
Jurisdiction H Customer
Contact Information
• Provider
1-855-252-8782
o Hours of Operation, Central Time (CT)/Mountain Time (MT)
o
 Monday - Friday: 8:00 am – 4:00 pm CT/MT
• Interactive Voice Response (IVR)
o
Hours of Operation
 Eligibility and General Information
– 24 Hours a day 7 Days a week
 Full IVR Options
– Mondays: 5:00 am – 7:00 pm CT
– Tuesday – Friday: 3:00 am – 7:00 pm CT
– Saturdays: 5:00 am – 3:00 pm CT
o
Step-by-Step Guide
 JH Part A
– http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004409
 JH Part B
– http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004421
Beneficiary Contact
Information
• Patient / Medicare Beneficiary
o
1-800-MEDICARE (1-800-633-4227)
 http://www.medicare.gov/index.html
Postal Mailing Addresses
• Mailing addresses changed in July, 2013
• Effected every mailing address
• Post Office will return mail effective August 26, 2014, if
utilizing the old Camp Hill, PA addresses
• Complete address listing
o
JH Part B
 http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?co
ntentId=00024404
Provider Enrollment
• Provider Enrollment Status Inquiry Tool
o
JH
 http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?con
tentId=00004864
• Release of Information
o
o
Individual Physician or Practitioner
Authorized Delegated Official
• Upcoming Revalidation Mailings
o
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.html
Centers for Medicare &
Medicaid Services (CMS)
• The CMS website offers valuable
resources such as
CMS Internet Only Manuals (IOMs)
o Medicare Learning Network (MLN) Matters
Articles
o Open Door Forum
o
• For additional resources visit
o
http://www.cms.gov/
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 Centers for
Medicare & Medicaid Services (CMS) and
Novitas websites