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HOW TO STAY INFORMED: MEDICARE UPDATES & REMINDERS FROM CGS NATIONAL ASSOCIATION FOR HOME CARE & HOSPICE 2014 ANNUAL MEETING & EXPOSITION PHOENIX, AZ| OCTOBER 19-22, 2014 RECENT MEDICARE CHANGES Home Health September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 2 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 1 SPECIAL EDITION ARTICLE (SE) 1305 “Full Implementation of Edits on the Ordering/Referring Providers in ed ca e… o e Health ea t Agency ge cy C Claims” a s Medicare…Home http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1305.pdf Effective January 6, 2014, claims will be denied if claim fails ordering/referring edit • 37236 – home health claim (type of bill 329) • 37237 – home h h health lth adjustment dj t t (type (t off bill 327)) 3 September 2, 2014 SPECIAL EDITION ARTICLE (SE) 1305 If appropriate, may “appeal” claim denials for ordering/referring edits Ex: NPI /name mis-keyed mis keyed or PECOS file was incorrect and has been corrected To “appeal,” must submit: Reopening Request Form, http://www.cgsmedicare.com/hhh/appeals/pdf/hhh_reopening_form. pdf and Adjustment claim on hardcopy UB-04 See “Ordering/Referring Denial Reopening” on ‘Reopenings’ webpage, http://www.cgsmedicare.com/hhh/appeals/Reopenings.html September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 4 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 2 CHANGE REQUEST 8441 “Home Health Agency Reporting Requirements for the Certifying Physician and a d the t e Physician ys c a W Who oS Signs g s tthee Plan a o of Ca Care” e http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8441.pdf Effective for episodes beginning on/after July 1, 2014 Requires NPI and name of physicians who: Signs the home health plan of care (POC) and Certifies/recertifies the patient’s eligibility for home health services • Note: Only when different than certifying physician September 2, 2014 5 CHANGE REQUEST 8441 Example #1: Certifying physician and POC physician are different ATT PHYS = Physician who signed POC REF PHYS = Physician who certified/recertified home health eligibility ESRD HOURS ATT PHYS OPR PHYS OTH OPR REN PHYS REF PHYS ADJUSTMENT REASON CODE REJECT CODE NPI XXXXXXXXXX L SMITH NPI L NPI L NPI L NPI XXXXXXXXXX L JONES F A F F F F B NONPAY CODE M SC M SC M SC M SC M SC p #2: Certifying y gp physician y and POC p physician y are same Example ATT PHYS = Physician who certified HHA eligibility and signed POC ESRD HOURS ATT PHYS OPR PHYS OTH OPR REN PHYS REF PHYS September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 ADJUSTMENT REASON CODE REJECT CODE NPI XXXXXXXXXX L SMITH NPI L NPI L NPI L NPI L F A F F F F NONPAY CODE M SC M SC M SC M SC M SC 6 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 3 CHANGE REQUEST 8699 “Preventing Duplicate Payments When Overlapping Inpatient and Home ea t ((HH)) C Claims a s Aree Received ece ed Out o of Seque Sequence” ce Health http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8699.pdf Effective dates of service on/after January 1, 2015 Current edits reject a HH claim with service dates that overlap a posted inpatient stay CR 8699 will implement additional edits: • To recoup HH PPS payment when inpatient stay billed after paid HH episode • To include swing bed (type of bill 18X) as an inpatient claim September 2, 2014 7 CHANGE REQUEST 8699 To resolve issue, adjust HH claim to remove line item dates of service that overlap o e ap inpatient pat e t stay See Top Claim Submission Errors C7080 webpage, http://www.cgsmedicare.com/hhh/education/materials/C7080.html Use beneficiary eligibility file to look for overlapping inpatient stays • If overlapping dates cannot be determined, contact CGS Provider Contact Center 1.877.299.4500 (Option 1) September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 8 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 4 CHANGE REQUEST 8710 “Preventing Payment on Requests for Anticipated Payment (RAPs) When o e Health ea t Beneficiaries e e c a es a aree Enrolled o ed in Medicare ed ca e Advantage d a tage ((MA)) Home Plans” http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8710.pdf Effective dates of service on/after January 1, 2015 Implements edits to prevent RAP payments when final claim not payable due to MA plan RAPs will reject when • “FROM” date falls on/after start of MA plan enrollment • “FROM” date falls before end of MA plan enrollment September 2, 2014 9 CHANGE REQUEST 8710 Reminders about home health and MA plans If a beneficiary is enrolled in MA plan, plan and OPT Code = C C, claims must be submitted to MA plan; not CGS • Exception: If beneficiary elects hospice, claims are submitted to CGS Additional guidance available on MA Plans – Claim Filing Tips webpage, http://www.cgsmedicare.com/hhh/education/materials/Medicare_Ad vantage Plans html vantage_Plans.html September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 10 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 5 CHANGE REQUEST 8813 “Diagnosis Reporting on Home Health Claims” http://www http://www.cms.gov/Outreach-and-Education/Medicare-Learningcms gov/Outreach and Education/Medicare Learning Network-MLN/MLNMattersArticles/Downloads/MM8813.pdf Effective for dates of service on/after January 1, 2015 Implements edits to prevent manifestation codes as primary diagnosis on home health claims Principal diagnosis on HH claim should be ICD-9 code most related to current HH plan of care (POC) RAPs and claims reporting a manifestation code as principal diagnosis will be returned to provider (RTPd) September 2, 2014 11 RECENT MEDICARE CHANGES Home Health & Hospice September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 12 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 6 MEDICARE SECONDARY PAYER (MSP) CHANGES Reminder: Change Request 6426 requires MSP claims to be submitted eelectronically, ect o ca y, us using g 50 5010 0 format o at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R70MSP.pdf For Group Health Plans (GHPs), must submit electronically, even when services were applied to deductible or benefits exhausted • Claims submitted direct data entry (DDE) will be returned to provider (RTP) with reason code 31265 For Non-group Health Plans (NGHPs), if services are unrelated, claims may be submitted DDE with Medicare as primary if claim does not include any related diagnosis codes September 2, 2014 13 ICD-10-CM/PS ICD-10 compliance date is October 1, 2015 CGS ICD-10-CM/PCS ICD 10 CM/PCS webpage, webpage http://www.cgsmedicare.com/hhh/claims/5010.html CMS ICD-10 webpage, http://www.cms.gov/Medicare/Coding/ICD10/index.html Medicare Fee-for-Service Provider Resources webpage, http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-ForService Provider Resources html Service-Provider-Resources.html September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 14 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 7 ICD-10-CM/PS For Home Health: Special Edition article SE1410, ttp:// .c s.go /Out eac a d ducat o / ed ca e ea g http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1410.pdf RAPs - report ICD-9 or ICD-10 code based on “TO” date Claims – report ICD-9 or ICD-10 code based on “TO” date HH claims cannot be split HH claims cannot report both ICD-9 and ICD-10 CMS states: HHAs will be allowed to use payment group code derived from ICD-9 codes on claims that span 10/1, but claims must report ICD-10 codes September 2, 2014 15 RECENT MEDICARE CHANGES Hospice September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 16 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 8 CHANGE REQUEST 8358 “Additional Data Reporting Requirements for Hospice Claims”, ttp:// .c s.go /out eac a d educat o / ed ca e ea g et o http://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnmattersarticles/downloads/MM8358.pdf Effective for dates of service April 1, 2014 Additional hospice data to support hospice payment reform 1. Line item visit data for hospice staff provided under general inpatient care (GIP) in skilled nursing facilities or hospitals 2 National Provider Identifier (NPI) of facility where beneficiary resides 2. 3. Post-mortem visits (on date of death) to capture visits and duration for hospice employed nurses, aides, social workers and therapist 4. Injectable and non-injectable prescription drugs 5. Infusion pumps and medication refills 17 September 2, 2014 CHANGE REQUEST 8358 GIP visits Appropriate revenue and HCPCS code, code units (15 (15-min min. increments) when site of service is Q5004, Q5005, Q5007 or Q5008 Facility NPI Required with Q5003, Q5004, Q5005, Q5007, and Q5008 Required with Q5006 if different than billing hospice Post-mortem visits A Appropriate i revenue and d HCPCS code, d PM modifier, difi units i ((15-min. i increments) Exception: PM visits under GIP in hospice inpatient facility (Q5006) cannot be reported September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 18 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 9 CHANGE REQUEST 8358 Injectable drugs Line item reporting per fill Revenue code 0636 and HCPCS, units (amount filled, according to HCPCS definition) Non-injectable prescriptions Line item reporting per fill 5 and National Drug g Code (NDC),, units Revenue code 0250 Infusion pump Line item reporting per pump and per medication refill Revenue code 029X (equipment), 0294 (drug) and HCPCS 19 September 2, 2014 CHANGE REQUEST 8358 Additional resources 2014 Table of Drugs (HCPCS), (HCPCS) http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha -Numeric-HCPCS-Items/2014-DrugsTable.html?DLPage=1&DLSort=0&DLSortDir=descending NDC directory, http://www.fda.gov/drugs/informationondrugs/ucm142438.htm Hospice Prescription Drug Reporting Table, Table http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_ presdrugreportingtable.pdf FAQs, http://www.cgsmedicare.com/hhh/education/faqs/index.html (under Hospice Billing) September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 20 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 10 CR 8877 “Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election o ect o (NO (NOE)) a and d Termination e at o o or Revocation e ocat o o of Election”, ect o , http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3032CP.pdf Effective for dates of service on/after October 1, 2014 1. Prohibits use of “Symptoms, Signs, and Ill-defined Conditions” diagnosis codes as principal diagnosis 2 Mandates filing of Notice of Election (NOE) within 5 calendar days 2. after hospice admission date 3. Must submit Notice of Termination/Revocation (NOTR) within 5 calendar days after effective date of live discharge/revocation 4. Clarification of Q5003 and Q5004 21 September 2, 2014 CR 8877 Codes prohibited as principal diagnosis 799.3 799 3 and 780 780.79 79 (Debility) 783.7 (Adult failure to thrive) Multiple dementia codes • See Attachment A for complete list Claims with prohibited codes will be returned to provider (RTPd) with reason code 30727 Note: Editing will be updated with implementation of ICD-10 September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 22 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 11 CR 8877 Timely filing of NOEs Defined as “a a NOE that is submitted to the Medicare contractor and accepted by the Medicare contractor within 5 calendar days after the hospice admission date” Providers need to consider • Staff availability to submit NOEs timely • QA process to ensure accuracy of submission of NOE • An NOE that is returned to provider (RTPs) does not constitute an “accepted” NOE • When NOE is corrected (F9’d) out of RTP, it gets new receipt date; this will be receipt date used to determine timely filing of NOE Untimely NOEs will still process and post beneficiary’s hospice election 23 September 2, 2014 CR 8877 Example of timely/untimely NOE calculation Admission date = 10/10/14 Day 1 = 10/11/14 Day 2 = 10/12/14 Day 3 = 10/13/14 Day 4 = 10/14/14 Day 5 = 10/15/14 NOE due date If NOE received on/after 10/16/14, it is untimely Example: NOE received 10/16/14 OSC 77 reported with 10/10/14 – 10/15/14 September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 24 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 12 CR 8877 If the NOE is untimely, provider must submit claim with: An occurrence span code 77 with noncovered dates • Noncovered dates = admission date / day before NOE received MAP1711 PAGE 01 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXXX SC INST CLAIM ENTRY C201433P HH:MM:SS HIC TOB 811 S/LOC S B0100 OSCAR SV: UB-FORM NPI TRANS HOSP PROV PROCESS NEW HIC PAT.CNTL#: TAX#/SUB: TAXO.CD: STMT DATES FROM TO DAYS COV N-C CO LTR LAST FIRST MI DOB ADDR 1 2 3 4 CARR: 5 6 LOC: ZIP SEX MS ADMIT DATE HR TYPE SRC D HM STAT COND CODES 01 02 03 04 05 06 07 08 09 10 OCC CDS/DATE 01 02 03 04 05 06 07 08 09 10 SPAN CODES/DATES 01 77 101014 101514 02 03 04 05 06 07 08 09 10 FAC.ZIP DCN 25 September 2, 2014 CR 8877 Noncovered level of care days due to untimely NOE are reported on separate sepa ate revenue e e ue code linee from o co covered e ed days MAP1712 SXB4699 HIC CL PAGE 02 SC CGS J15 MAC - HHH REGION INST CLAIM ENTRY TOB 811 REV HCPC MODIFS 0651 Q5001 0651 Q5001 0551 Q0154 S/LOC S B0100 TOT RATE UNIT 6 16 2 COV UNIT 16 2 ACPFA052 MM/DD/YY C201433P HH:MM:SS REV CD PAGE 01 PROVIDER TOT CHARGE NCOV CHARGE 600.00 600.00 1600.00 50.00 SERV RED DATE IND 101014 101614 101014 “Noncovered” discipline visits and drugs may be reported as noncovered, but not required September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 26 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 13 CR 8877 Four exceptional circumstances 1 1. Fires, flood Fires flood, earthquakes earthquakes, or other unusual events that inflict extensive damage to hospice’s ability to operate 2. An event that produces a data filing problem due to CMS or contractor system issues, beyond control of hospice 3. Newly Medicare-certified hospice that is notified of certification after Medicare certification date, or awaiting user ID from Medicare contractor; or 4. Other circumstances determined by Medicare contractor or CMS to be beyond hospice’s control Examples provided in “Section IV. Supporting Information” section of CR See 8877.3 and 8877.4 27 September 2, 2014 CR 8877 To request an exception: Report ‘KX’ KX modifier on earliest dated level of care line (0651 (0651, 0652 0652, 0655, 0656) CGS will generate non-medical review Additional Development Request (non-MR ADR) • Claim will move to S B6001 • Edit code on FISS Page 08 will be 78877 • ADR narrative will indicate need to submit documentation to support pp exceptional circumstance • FISS Page 08 will provide mailing address to submit documentation • esMD will be accepted • Documentation must be submitted as soon as possible, but no later than day 30 days September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 28 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 14 CR 8877 CGS will review exceptional circumstance documentation If documentation supports exception CGS will remove non-covered days, and pay for days associated with late-filed NOE If documentation does not support exception CGS will process claim as billed (with noncovered days) 29 September 2, 2014 CR 8877 Hospices required to submit Notice of Termination/Revocation (NOTR) within t 5 calendar ca e da days a after te effective e ect e date o of d discharge/revocation sc a ge/ e ocat o Unless final claim already filed Submit direct data entry (DDE) • Use Claims option; instead of NOE option September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 30 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 15 CR 8877 Billing requirements for NOTR Similar to NOEs (8XA) except: • Type of bill (TOB) = 81B or 82B • From date = Start date of hospice benefit period in which termination/revocation is effective • Through date = date of termination/revocation • Admission Date = Effective date of hospice benefit period in which the discharge/revocation is effective – Note: Not initial hospice admission date • Patient status = appropriate patient status code 31 September 2, 2014 CR 8877 Q5003 vs. Q5004 Q5004 used in 4 situations: 1. Beneficiary receiving hospice care in solely-certified SNF 2. Beneficiary receiving general inpatient care in SNF 3. Beneficiary in SNF receiving SNF care under Medicare SNF benefit for condition unrelated to terminal illness/related conditions and under hospice routine home care (rare) 4 4. Beneficiary receiving inpatient respite care in SNF Q5003 used when beneficiary received care in nursing facility that doesn’t meet criteria above September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 32 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 16 COMMON BILLING ERRORS & TOP DENIALS Home Health 33 September 2, 2014 CGS CLAIMS DATA – HOME HEALTH April 1, 2014 – July 31, 2014 Number of “Claims” Submitted 844,984 Total # of “Claim” Submission Errors (CSEs) 98,763 Number of Claims Reviewed by Medical Review 1,957 Number of Claims Denials (Partial/Full) by Medical Review 1,646 September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 34 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 17 CGS BILLING ERRORS – HOME HEALTH April 1, 2014 – July 31, 2014 Reason Code 38107 Billing Error # of Errors FISS can’t find matching RAP 30,011 Duplicate RAP/claim – same beneficiary/same dates of service/same billing provider 12,292 U 8I U538I O l another Overlap th HHA’ HHA’s episode i d 68 6 6,856 31018 Less than 60 days billed on home health claim and patient status code billed equals “30” 3,185 31790 HCPC Q5001, Q5002, or Q5009 not present 2,724 38157, 38200 September 2, 2014 35 CGS BILLING ERRORS RESOURCES – HOME HEALTH Top Claim Submission Errors (Reason Codes) and How to Resolve web page , http://www.cgsmedicare.com/hhh/education/materials/CSEs.html September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 36 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 18 CGS MEDICAL REVIEW DATA – HOME HEALTH April 1, 2014 – July 31, 2014 Denial Denial Reason Reason Code # of Denials Face-to-face documentation missing/incomplete/untimely 675 Medical necessity not supported 537 56900 6 ADR information i f ti nott received/timely i d/ti l 218 8 5HPLN Missing/incomplete/untimely plan of care 73 5HHBD Homebound status not supported 53 5FFTF 5HMED 37 September 2, 2014 CGS MR DENIAL RESOURCES – HOME HEALTH Home Health Denial Fact Sheets 5FFTF - Missing/incomplete/untimely FTF Encounter, http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5FF TF_FactSheet.pdf 5HMED – Medical necessity, http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5H MED_FactSheet.pdf 5HNOA – No OASIS, http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hno a_factsheet.pdf September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 38 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 19 CGS MR DENIAL RESOURCES – HOME HEALTH Home Health Denial Fact Sheets (cont.) 5HPLN/5HORD – Missing plan of care or orders, orders http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HP LN-5HORD_FactSheet.pdf 5HHBD – Homebound status, http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhb d_factsheet.pdf 56900 – No response to ADR ADR Process webpage, http://www.cgsmedicare.com/hhh/medreview/adr_process.html Additional Development Request quick resource tool, http://www.cgsmedicare.com/hhh/education/materials/pdf/ADR_QR T.pdf September 2, 2014 39 COMMON BILLING ERRORS & TOP DENIALS Hospice September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 40 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 20 CGS CLAIMS DATA – HOSPICE April 1, 2014 – July 31, 2014 Number of “Claims” Submitted 277,117 Total # of “Claim” Submission Errors (CSEs) 54,456 Number of Claims Reviewed by Medical Review 2,933 Number of Claims Denials (Partial/Full) by Medical Review 1,994 41 September 2, 2014 CGS BILLING ERRORS – HOSPICE April 1, 2014 – July 31, 2014 Reason Code # of Errors 37402 Sequential billing – no prior processed claim 34952 Service facility NPI not reported 38200 8 D li t claim Duplicate l i 4,114 U5150 No NOE on file for hospice election 3,316 U5106 NOE falls within current hospice election 2,944 September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 Billing Error 6,452 5,020 (May-Jul) 42 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 21 CGS BILLING ERRORS RESOURCES – HOSPICE Top Claim Submission Errors (Reason Codes) and How to Resolve web page , http://www.cgsmedicare.com/hhh/education/materials/CSEs.html 43 September 2, 2014 CGS MEDICAL REVIEW DENIAL DATA – HOSPICE April 1, 2014 – July 31, 2014 Denial Reason Code # of Denials 5PTER Six-month terminal prognosis not supported 1032 5PPOC POC does not meet requirements 252 5PCER PCER Missing/incomplete/untimely certification/recertification 203 56900 No response to ADR 161 5PRLM Reduced level of care 97 September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 Denial Reason 44 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 22 CGS MR DENIAL RESOURCES – HOSPICE Hospice Denial Fact Sheets 5PTER 5 – Six-month p prognosis g not supported, pp , http://www.cgsmedicare.com/hhh/education/materials/pdf/Hospice_ 5PTER_FactSheet.pdf 5PPOC – Plan of care does not meet requirements, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_ 5ppoc_factsheet.pdf 5PCER – Missing/incomplete/untimely certification/recertification, http://www cgsmedicare com/hhh/education/materials/pdf/hospice http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_ 5pcer_factsheet.pdf 5PRLM/5PRLT – Reduced level of care, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_ 5prlm_factsheet.pdf 45 September 2, 2014 CGS MR DENIAL RESOURCES – HOSPICE 56900 – No response to ADR ADR Process webpage, webpage http://www.cgsmedicare.com/hhh/medreview/adr_process.html Additional Development Request quick resource tool, http://www.cgsmedicare.com/hhh/education/materials/pdf/ADR_QR T.pdf September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 46 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 23 CGS HH&H WEBSITE RESOURCES Home Health & Hospice September 2, 2014 47 CGS HH&H WEBSITE http://www.cgsmedicare.com/hhh/index.html Join/Update ListServ Contact Us link Search engine September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 48 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 24 CGS HH&H WEBSITE http://www.cgsmedicare.com/hhh/index.html Click “+” for Quick Links Main navigation menu Links to Hot Topics 49 September 2, 2014 CGS HH&H WEBSITE: MYCGS PORTAL http://www.cgsmedicare.com/hhh/myCGS/index.html myCGS: Login, FAQs, User Manual, Help Desk September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 50 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 25 CGS HH&H WEBSITE: APPEALS http://www.cgsmedicare.com/hhh/appeals/index.html Appeals: Overview, FAQs, Timeliness Calculator, Appropriate Requests, Reopenings, Redeterminations September 2, 2014 51 CGS HH&H WEBSITE: CLAIMS http://www.cgsmedicare.com/hhh/claims/index.html Claims: ADRs, Checking Claim Status, FAQs, FISS, MSP, Timely Filing, RTPs, Transfer Dispute September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 52 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 26 CGS HH&H WEBSITE: CUSTOMER SERVICE http://www.cgsmedicare.com/hhh/cs/index.html Customer Service: Contact Info, Site Map, Website Feedback, IVR User Guide September 2, 2014 53 CGS HH&H WEBSITE: EDUCATION & RESOURCES http://www.cgsmedicare.com/hhh/education/index.html Education & Resources: CMS Educational Resources, Educational Materials, FAQs September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 54 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 27 CGS HH&H WEBSITE: EDUCATIONAL MATERIALS http://www.cgsmedicare.com/hhh/education/materials/index.html September 2, 2014 55 CGS HH&H WEBSITE: FINANCIAL http://www.cgsmedicare.com/hhh/financial/index.html Financial: Cost Reports, p , PS&R, Rates & Fee Schedules, RA/ERA September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 56 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 28 CGS HH&H WEBSITE: LCDS/COVERAGE http://www.cgsmedicare.com/hhh/coverage/index.html LCDs/Coverage: Home Health Coverage, Hospice Coverage, OASIS September 2, 2014 57 CGS HH&H WEBSITE: MEDICAL REVIEW http://www.cgsmedicare.com/hhh/medreview/index.html Medical Review: ADRs, esMD, CERT, Overview of MR, Reopenings September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 58 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 29 CGS HH&H WEBSITE: NEWS & PUBLICATIONS http://www.cgsmedicare.com/hhh/pubs/index.html News & Publications: Recent News (listservs), CGS Bulletin, Join Listserv September 2, 2014 59 QUESTIONS? CGS Provider P id C Contact t tC Center: t 1 8 299 4 00 (O 1.877.299.4500 (Option ti 1) CGS EDI Department: 1.877.299.4500 (Option 2) September 2, 2014 NAHC Annual Meeting October 19‐22, 2014 60 Disclaimer: This resource is not a legal document. Any regulations, policies, and/or guidelines cited in this publication are subject to change without notice. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Current Medicare regulations can be found on the CMS Web site, www.cms.gov Reproduction of this material for profit is prohibited. CPT codes, related data © 2014 AMA. ICD‐9‐CM codes, descriptors © 2014. 30
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