10/28/2014 Medical Oncology Association Southern CA Medicare Updates
10/28/2014 Medical Oncology Association Southern CA Medicare Updates Presented by Cheryl Bradley Provider Outreach and Education (POE) November 4, 2014 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. 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 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. November 2014 2 Agenda • • • • • New Costs Medicare Hot Topics Avoiding Common Errors Appeals Resources November 2014 3 1 10/28/2014 New Costs 4 November 2014 2015 Part B Deductible and Coinsurance Rates Unchanged • Deductible-$147.00 • Coinsurance – 20% of eligible charges November 2014 5 2015 Part B Premiums Income Parameters for Part B Premiums Premium/ Mthly Individual Income Combined Income (Married) Married Filing Separate <$85,000 $104.90 < $85,000 < $170,000 $146.90 $85,000.01 to $107,000 $170,000.01 to $214,000 $209.80 $107,000.01 to $160,000 $214,000.01 to $320,000 $272.70 $160,000.01 to $214,000 $320,000.01 to $428,000 $85,001.00 to $129,000 $335.70 $214,000.01 > $428,000.01 > $129,001.00 > November 2014 6 2 10/28/2014 2015 Part A Deductible and Co-Pays • $1,260 deductible – 1st 60 days of hospitalization • $315 co-pay – Days 61-90 • $630 co-pay – Days 91 – 150 Lifetime Reserve • $157.50 co-pay – SNF days 21 - 100 November 2014 7 2015 Part A Premium • Fewer than 30 quarters – $407.00 per month • 30 to 39 Quarters – $224.00 per month November 2014 8 Beneficiary Open Enrollment • Review cost and coverage for 2015 – October 15 – December 7, 2014 • Compare medical plans & make changes • Questions – 1-800-MEDICARE – http://www.medicare.gov/ November 2014 9 3 10/28/2014 Medicare Hot Topics November 2014 10 2015 MPFS Proposed Rule • The current conversion factor is $35.8228 – 0% Update January 1, 2015-March 31, 2015 – Protecting Access to Medicare Act • Without Congressional Action – 20.9 percent reduction (April 1st) – Due to Sustainable Growth Rate – Hematology/Oncology Impact = + 1% • CMS will finalize Physician Payment – Publishes in Federal Register December – Watch Noridian Website for 2015 MPFS! November 2014 Proposed Chronic Care Management 11 : • Non-face-to-face care coordination – 2 (or 4) or more chronic conditions expected to last at least 12 months, or until death, – Pose significant risk of death, decline in function, or acute exacerbation or decompensation • 20 min. of services / 30-day billing cycle – By clinical staff (directly or contract) – Provide general supervision at all times, not just after hours. • Also: 24-hour coverage, med review, ongoing post institution coordination, and patient-centered care plans will continue • Fee: $43.67 PMPM in an office; $32.58 in a facility, November 2014 12 4 10/28/2014 Revalidation: Phase III • September 2013 through March 2015 • Continuing with the revalidation process for all remaining providers/suppliers required by ACA prior to March 25, 2015 • www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidation s.html • CMS continued focus Working with large chains/organizations November 2014 13 Revalidation: Phase III 2 • When you receive notice to revalidate – Update your enrollment through internetbased PECOS or complete CMS 855 – Sign the certification statement on the application – If applicable, pay the fee $542 • https://pecos.cms.hhs.gov/pecos/feePayment Welcome.do – Mail supporting documents to Noridian 14 November 2014 Meaningful Use – New Hardship Deadline • CMS extending hardship exception deadline to November 30, 2014 by 11:59 Eastern Time • Avoid 2015 payment adjustments, by demonstrating meaningful use of Certified Electronic Health Record Technology (CEHRT) • Hardship application found at http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/ PaymentAdj_Hardship.html November 2014 15 5 10/28/2014 PQRS Incentive Payment and Payment Reductions • Eligible professionals that do not satisfactorily report data on quality measures for the January 1, 2014-December 31, 2014 reporting period, will be subject to the 2.0% adjustment in their fee schedule amount in 2016. •http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/PaymentAdjustment-Information.html November 2014 16 PQRS Incentive Payment and Payment Adjustments Program Year Incentive Payment Adjustment 2011 1.0% None 2012 0.5% None 2013 0.5% None 2014 0.5 None 2015 None 1.5% Based on 2013 participation 2016 > None 2.0 % Based on 2014 participation 17 November 2014 PQRS Assistance • If providers have any Physician Quality Reporting System (PQRS) questions, please contact • QualityNet Help Desk at 1-866-288-8912 or via email at [email protected] November 2014 18 6 10/28/2014 ICD-10 Will change everything October 1, 2015! November 2014 19 • CMS invites Family Practice/Internal Medicine providers to view new webcast @ cms.gov/ICD10 “Road to 10” • Click “Webcast” tab located in left-hand navigation – Physician perspective/clinical impact of ICD-10 – Documentation changes and new concepts – Use of "unspecified" codes in ICD-10 • Other specialty webcasts previously available (orthopedics, cardiology, etc.) November 2014 20 Plan Your Journey to ICD-10 • • • • • Assess staff training needs Educate and Train Staff Review Clinical Documentation Practices Contact practice management system vendor Contact clearinghouses, billing services and payers • Budget time and costs • Conduct testing – Trading Partners and clearinghouses – Allow time for approval November 2014 21 7 10/28/2014 • CMS National Provider Call – Transition to ICD-10 • When: Wednesday, November 5, 2014 • Time: 1:30 PM - 3:00 PM Eastern Time • Registration – http://www.eventsvc.com/blhtechnologies November 2014 22 CPT Modifier 59 • Distinct Procedural Service – Indicate a procedure or service was distinct or independent from other services performed on the same day • Most widely used modifier – Considerable abuse and high level of manual audit – Lead to even civil fraud and abuse cases • Siphons off funds that should be available to legitimate providers November 2014 23 Modifier 59 Misuse • 2013 CERT Report – Part B claims • $2.4 Billion in payment made – $320 million projected in errors – Part A claims • $11 Billion billed – $450 million projected in errors November 2014 24 8 10/28/2014 Distinct Procedural Service New Modifiers for 2015 November 2014 CR 8863- Specific Modifiers for Distinct Procedural Services (Modifier 59) Update • Effective January 1, 2015 • Four new HCPCS modifiers – Subset of Modifier 59 • Defines a subset of the work of the first code • Used to identify – A separate encounter – A separate anatomic site – A distinct service November November2014 2014 26 Subset Modifiers • XE Separate encounter • XS Separate Structure • Performed on a separate organ/structure • XP Separate Practitioner • Performed by a different practitioner • XU Unusual non-overlapping service • Does not overlap usual components of the main service November 2014 27 9 10/28/2014 Modifier 59 and Subset Modifiers • Modifier 59 still recognized – Should not be used when a more descriptive modifier is available • Subset modifiers – To be used with certain codes at high risk for incorrect billing – More selective versions of modifier 59 – Not to be used with modifier 59 on the same line November 2014 28 Modifier 59 Update • Check NCCI edit tables on CMS website – Indicator 1 allows for unbundling – Indicator 0 cannot unbundle codes • To avoid repeat procedure denials, bill – Modifier 76 - Repeat procedure by same physician or – Modifier 91 - Repeat clinical diagnostic laboratory test to obtain multiple results November 2014 29 Avoiding Common Errors 10 10/28/2014 Avoid and Prevent Duplicate Claim Submissions CR 8121 • Fraud and Abuse monitoring – Post to patient’s account appropriately – Verify payment prior to submission – Identify duplicate claim submissions internally – Eliminate processes which may be causing duplicate submissions November 2014 31 Top Claim Errors • Procedure with modifier inconsistent/missing – Check Fee Schedule, Indicator List, Local Coverage Determination (LCD) policies and CPT/HCPCS books • Missing/invalid referring or ordering provider • Patient or Insured HIC #/name do not match • Patient cannot be identified as our insured November 2014 32 Correct Patient/HIC# Errors • Check patient’s Red, White, Blue Medicare card • Two last names – With space = bill with space – Without space = bill without space • Hyphenated name – With hyphen = bill with hyphen – Patient may need to contact local SSA to remove hyphen • Check for alpha-prefix vs. alpha-suffix – Ex. A123-45-6789 – Railroad Medicare – Palmetto GBA • Need Details? Scroll down to Claim Submission workshop – JE • https://med.noridianmedicare.com/web/jeb/education/eventmaterials November 2014 33 11 10/28/2014 Item 17 – Name of Referring or Ordering Physician Paper: Electronic: Loop •Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. Segment Description NM103 DN= Referring Provider Last Name NM104 Referring Provider First Name NM103 DK= Ordering Provider Last Name NM104 Ordering Provider First Name 2310A 2420E November 2014 34 Item 17a & 17b – NPI of Referring or Ordering Physician Paper: Electronic: Item 17a •Leave Blank Loop Segment Description 2310A NM109 DN= Referring Provider Primary ID 2420E NM109 DK= Ordering Provider Primary ID Item 17b •Enter NPI of referring/ordering physician November 2014 35 Item 11 (possible MSP) DENIAL SOLUTION CO16 Claim/service lacks information which is needed for adjudication Add NONE (if no primary •Verify Primary insurance to Medicare) Insurance information •Verify patient’s eligibility before billing COMMENTS MA83 Did not indicate whether Medicare is primary or secondary payer •If Medicare Secondary Payer (MSP), MUST fill out items 11 – 11C •Check dates of service correctly entered •MSP incorrect? Contact Coordination of Benefits Contractor (COBC) •800-999-1118 •Need details? Scroll down to MSP workshop JE https://med.noridianmedicare.com/web/jeb/education/event-materials November 2014 36 12 10/28/2014 Top Adjudication issues • Unlisted codes or NOC • J3490, J9999, and J3590 – Name of the drug, NDC number and dosage must – Block 19 – Electronic equivalent • Claims not providing information deny unprocessable. November 2014 37 Patients Supplying Their Own Drugs • Providers can bill Medicare only when such drugs are purchased by physician, from the pharmacy and administered in physician’s office – Providers NOT allowed to instruct patients to purchase drugs themselves and then bring to provider’s office for administration • Drug charge, if any, must be included in physician’s bill and cost represents expense to physician – Pharmacies can not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary – Pharmacies, suppliers and providers can not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service, such as refilling an implanted drug pump November 2014 38 Patients Supplying Their Own Drugs2 • Donated or Free of Charge Patient Supplied Drug – To avoid chemotherapy/other drug administration denial, drug code must be on same/prior claim Item Description 19 (Narrative) “Drug Donated” with description, strength and dosage when billing Not Otherwise Classified (NOC) HCPCS 24D Drug (J code) HCPCS 28 Billed amount of $0.00 or $0.01 • If the drug is not donated/free of charge, then provider must provide the drug under incident to guidelines • IOM Publication 100-02, Chapter 15, Sections 50/50.3 November 2014 39 13 10/28/2014 Medical Review (MR) Modifier 25 • If a significant separately identifiable E/M service is performed, the appropriate E/M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or non- chemotherapy injection and infusion service (96360–96549). For an E/M service provided on the same day, a different diagnosis is not required. • http://www.cms.gov/manuals/downloads/clm1 04c12.pdf November 2014 41 CPT 99211 • CPT code 99211 is not allowed with or without the modifier 25 on the same day as nonchemotherapy or chemotherapy administration codes. • CPT 99211 not allowed: • Phone calls to patients • Drawing of blood for laboratory analysis or when performing other diagnostic tests • Administration of medications when an injection or infusion code is submitted separately November 2014 42 14 10/28/2014 99213-25 • Insufficient Documentation Submitted – Does not support beneficiary was seen for a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service” – Submitted progress note states: “Patient is here for chemo. No new problems. Same as last visit” November 2014 43 Signature Requirements Signatures: – Services provided/ordered must be authenticated by the author – Must be legible and should include the practitioner’s first and last name – Handwritten or Electronic – No Stamps November 2014 44 Electronic Signature Guidelines • Systems and software products must include protections against modification and should apply administrative safeguards that correspond to standards and laws; • The individual whose name is on alternate signature method and provider bears responsibility for authenticity of information being attested to; • Physicians are encouraged to check with their attorneys and malpractice insurers in regard to use of alternative signature methods; • Part B providers must use qualified electronic prescribing (eprescribing) system; and • Prescriptions for drugs incident to Durable Medical Equipment (DME) must be made via qualified e-prescribing system November 2014 45 15 10/28/2014 For an attestation statement to be valid, it must be signed by the performing provider JE – https://med.noridianmedicare.co m/documents/10525/78978/Sig nature+Attestation+Statement/ November 2014 46 Unique Signature Situations Situation: Performed by: Signature Requirement: Ancillary Staff Must be signed by billing provider NPP (Non-Physician Practitioner) May be signed by the NPP or the supervising physician NPP and Physician Must be signed by billing provider NPP and Physician Must be signed by billing provider Ancillary staff The scribes name must be listed in the medical record and identified as scribe. Provider must sign Incident to Split/Shared Office/Clinic Split/Shared hospital inpatient/outpatient/ Emergency dept. setting Scribe 47 November 2014 Medical Record Cloning • Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. November 2014 48 16 10/28/2014 Amended Medical Records 2 • Provider may add “late” entry within a few days • Medical reviewers give less weight when making review determinations to documentation created >30 days following date of service. • If pattern of “late” entries identified, may be referred to Zone Program Integrity Contractor (ZPIC) November 2014 49 Comprehensive Error Rate Testing (CERT) Post Pay Audit Review Program Who is Reviewing my Claims? • Multiple post pay contractors are able to review facility claims – Comprehensive Error Rate Testing (CERT) – Noridian Medical Review (MR) – Recovery Auditor (RA) – Office of the Inspector General (OIG) – Zone Program Integrity Contractor (ZPIC) November 2014 51 17 10/28/2014 Receive Part B CERT Request? • CERT post pay audit review random documentation sampling on previous claims • Need Part B CERT assistance? Please email: – [email protected] or [email protected] • Follow email steps: – “Subject” line enter CERT Claim Identification (CID#) (seven-digit number starting with “1”) – “Body of email”, provider office contact information (name, phone/fax number, CID#, city/state) November 2014 52 Noridian CERT Checklists • • • • • • • • • Ambulance Documentation Checklist Chiropractic Documentation Checklist Dialysis Documentation Checklist Evaluation and Management (E/M) Documentation Checklist Laboratory Documentation Checklist Physical, Occupational and Speech Therapies Documentation Checklist Psychiatric-Mental Health Documentation Checklist Radiation Oncology Documentation Checklist Radiology Documentation Checklist November 2014 53 Checklist: E/M Documentation Requests November 2014 54 18 10/28/2014 Documentation Tips • Documentation is important – “If it is not documented, it did not happen” • Good documentation practice protects you – Fraudulent billing results in stiff penalties • Medical record should be complete and legible • Coding and billing – CPT and ICD-9 codes supported • Appropriate health risk factors identified • Proper signatures November 2014 55 Recent Recovery Auditor Issues Relevant to Physicians Region D • Aldesleukin wastage • Observation codes for inpatients • Bevacizumab 1 unit per 10 mg • Observation codes for less than 8 hours • Multi-use vials for HERCEPTIN • MUE edits • Rituximab 1 unit per 100 mg • Reclast once per year @ 1 mg • Initial hospital E/M once per day includes all E/M • Neulasta the same day as chemo • Only one hospital visit per day per specialty • Region D – https://racinfo.healthdatainsights.com November 2014 56 Recovery Auditor Update • August 27, 2014 – A contract modification, allowing the current Recovery Auditors to restart some reviews has been completed for Regions A, B, and D. Most reviews will be done on an automated basis, but a limited number will be complex reviews of topics selected by CMS. November 2014 57 19 10/28/2014 2014 OIG Part B Focus** • Evaluation and Management (E&M) – During global surgery periods • • • • “Incident To” services Laboratory services Diagnostic Radiology Anesthesia Services – Personally Performed Services **Not all inclusive http://oig.hhs.gov/reports-andpublications/archives/workplan/2014/WorkPlan-2014.pdf November 2014 58 Compliance Program • A proactive program incorporating fundamental elements – Written policies and procedures – Compliance professionals – Effective training – Effective communication – Internal monitoring – Enforcement of standards – Prompt response November 2014 59 You Have Appeal Rights! November 2014 60 20 10/28/2014 Appeal Level Time limit for Filing Request Monetary Threshold (AIC) - 2013 Redetermination 120 days from date of receipt of notice initial determination None Noridian 60 days from date of receipt 180 days from Reconsideration date of receipt of Redetermination None QIC 60 days from date of receipt Administrative Law Judge (ALJ) Hearing 60 days from date of receipt of Reconsideration $150 Effective 1/1/15 Departmental Appeals Board (DAB) Review 60 days from date of receipt of the ALJ hearing decision None Federal Court Review 60 days from date of receipt of DAB decision or declination of review by DAB $1,460 Effective 1/1/15 Where to File Appeal Contractor Time Limit to Complete MAC or HHS OMHA field 90 days from office, if heard date of receipt by a QIC DAB or ALJ None Hearing Office November 2014 None 61 Redetermination Reminders • Complete appropriate request form • Submit all pertinent medical records to support services provided – Include documentation of physician’s intent and/or order – Records include physician’s legible signature • Check for correct DOS on records • Check records are for correct beneficiary • Ensure signature on request form November 2014 62 Resources 21 10/28/2014 Medicare Quarterly Provider Compliance Newsletter July 2014 • Includes RA Findings – – – – – CERT Bariatric Surgery Obesity Counseling E/M services Recovery Auditor Findings – Archive of Previously Issued Newsletters http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909012.PDF November 2014 64 CMS Educational Materials • • • • • 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://www.cms.gov/MLNProducts MLN Web Guides http://www.cms.gov/MLNEdWebGuide November 2014 65 Endeavor Online Provider Portal • Free to providers with Internet – – – – – – Beneficiary Eligibility Claim Status including Reviewer Comments Payment Floor / Prior Checks Issued Single Claim / Entire Remittance Advice Reopening & Redetermination Submission Appeal Status • Additional resources include – – – – Self-Paced tutorial for Part B System availability alerts on the Medicare website User Manual; valuable, many screen images and guides Workshops and presentations • Eligibility “Main Menu” page next slide November 2014 66 22 10/28/2014 Part B Web-Based Workshops Date Time (CT) 11/12/14 1:00 PM Quarterly Release Workshop Title 11/18/14 1:00 PM Recovery Auditor (RA) Program with HDI 11/19/14 1:00 PM Compliance Program 11/20/14 1:00 PM Protecting Your Practice from Fraud and Abuse Register Now! JE https://med.noridianmedicare.com/web/jeb/education/training-events November 2014 67 Resources • CMS Change Request (CR) 6698 – www.cms.gov/MLNMattersArticles/downloads/MM6698. pdf • MLN Fact Sheet Signature Requirements – www.cms.gov/MLNProducts/downloads/Signature_Req uirements_Fact_Sheet_ICN905364.pdf • CMS Internet Only Manual (IOM) Publication1008;Chapter 3, Section 3.4.1.1 – www.cms.gov/manuals/downloads/pim83c03.pdf • CERT Report – www.cms.gov/CERT/Downloads/CERT_Report.pdf November 2014 68 Resources • https://med.noridianmedicare.com/web/jeb/po licies/coverage-articles/chemotherapyadministration • CMS IOM Pub. 100-04, Chapter 17. Section 20.5.7 – www.cms.gov/manuals/downloads/clm104c17.pdf • 96360–96549 are not intended to be reported by the physician in the facility setting – www.cms.gov/Regulations-and-Guidance /Guidance/Manuals/Downloads/ clm104c04.pdf November 2014 69 23
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