March 2015 J11 Home Health and Hospice
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here. J11 HHH Medicare Advisory Latest Medicare News for J11 Home Health & Hospice What’s Inside... General Information......................................................................................................2 Provider Contact Center (PCC) Training and Holiday Closure Schedule.................2 CMS e-News...................................................................................................................3 Extension of Temporary Moratoria on Enrollment of New HHAs, HHA Sub-units and Part B Ambulance Suppliers..............................................................4 Home Health and Hospice Information.......................................................................4 Reporting Force Balance Claim Payment on the Electronic Remittance Advice (ERA) 835 and Cross Over Beneficiary 837 Claim Transactions.............................4 Corrections to Processing Service Facility Information on Hospice Claims............5 Continuation of Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessments...........................................6 Payment Codes on Home Health Claims Will Be Matched Against Patient Assessments...............................................................................................................8 Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers............................................................................. 11 Preventing Inappropriate Payments on Home Health Low Utilization Payment Adjustment (LUPA) Claims....................................................................................14 Fee Schedule Information...........................................................................................17 April 2015 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files.........................17 ICD-10 Information.....................................................................................................18 Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) - A Re-Issue of MM7492..................................................................................................................18 Learning and Education Information........................................................................27 March Quarterly Updates, Changes, and Reminders Webcast – March 12, 2015........................................................................................................27 2015 Jurisdiction 11 (J11) Home Health Medicare Workshop Series – The Golden Years – Medicare at 50!.......................................................................28 2015 Jurisdiction 11 (J11) Hospice Medicare Workshop Series – The Golden Years – Medicare at 50!.......................................................................30 Medical Affairs Information.......................................................................................32 J11 HHH Local Coverage Determinations (LCDs) Updates..................................32 J11 HHH Local Coverage Determinations (LCDs) Article Updates.......................35 palmettogba.com/hhh The J11 HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction 11 HHH. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The J11 HHH Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/Medicare. CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable 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 Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved. March 2015 Volume 2015, Issue 03 Medical Review Information......................................................................................37 New Timeframe for Response to Additional Documentation Requests..................37 Tools That You Can Use...............................................................................................38 Claims Submission Error Help................................................................................38 Interactive UB-04 Form..........................................................................................40 Helpful Information.....................................................................................................43 Contact Information for Palmetto GBA Home Health and Hospice.......................43 Don’t Forget to Register for the Quarterly Updates, Changes, and Reminders Webcast on March 12, 2015, and the 2015 Home Health and Hospice Workshop Series Please go to the Learning and Education section begining on Page 27 of this issue for more information about this Webcast and the Home Health and Hospice Workshops. GENERAL INFORMATION Provider Contact Center Training and Holiday Closure Schedule The Palmetto GBA Provider Contact Center (PCC) will continue to close up to eight hours per month for customer service advocate (CSA) training and staff development. Please note that our Interactive Voice Response (IVR) unit will be available during these scheduled training sessions for automated customer service transactions. The 2015 training closure dates and times are listed below. Date March 6, 2015 March 27, 2015 April 10, 2015 April 24, 2015 May 8, 2015 May 22, 2015 May 25, 2015 June 12, 2015 June 26, 2015 July 3, 2015 July 10, 2015 July 24, 2015 PCC/Office Closed PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00a.m. to 12:00 p.m. Office closed/ Memorial Day PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. Office closed/Independence Day PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 2 03/2015 August 7, 2015 August 21, 2015 September 4, 2015 September 7, 2015 September 18, 2015 October 12, 2015 November 11, 2015 November 26-27, 2015 December 4, 2015 December 18, 2015 December 24, 2015 December 25, 2015 January 1, 2016 PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. Office closed/ Labor Day PCC closed 8:00 a.m. to 12:00 p.m. PCC closed/Training Day PCC closed/Training Day Office Closed/ Thanksgiving (2days) PCC closed 8:00 a.m. to 12:00 p.m. PCC closed 8:00 a.m. to 12:00 p.m. Office closed/Christmas Eve Office closed/ Christmas Day Office closed/ New Year’s Day CMS E-NEWS CMS e-News will contain a week’s worth of Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recently issues, please copy and paste the following links in your Web browser: February 19, 2015 http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-02-19-eNews. pdf February 12, 2015 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-02-12-eNewsfile.pdf CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 3 03/2015 February 5, 2015 http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-02-05-eNews. pdf January 29, 2015 http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-01-29-Message. pdf Extension of Temporary Moratoria on Enrollment of New HHAs, HHA Sub-units and Part B Ambulance Suppliers On January 29, 2015, CMS displayed a notice in the Federal Register (CMS-6059-N2 (https:// s3.amazonaws.com/public-inspection.federalregister.gov/2015-01696.pdf)) announcing that the temporary moratoria on the enrollment of new Home Health Agencies (HHAs), HHA Sub-units and Part B ambulance suppliers is being extended for an additional six months in certain geographic areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse. For more information see MLN Matters Article #SE1425 (http://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1425.pdf), ‘Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers.’ HOME HEALTH AND HOSPICE INFORMATION Reporting Force Balance Claim Payment on the Electronic Remittance Advice (ERA) 835 and Cross Over Beneficiary 837 Claim Transactions MLN Matters® Number: MM 9050 Related Change Request (CR) #: CR 9050 Related CR Release Date: February 13, 2015 Effective Date: July 1, 2015 Related CR Transmittal #: R1467OTN Implementation Date: July 6, 2015 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 4 03/2015 Provider Types Affected This MLN Matters® Article is intended for physicians, providers, and suppliers that submit claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and Durable Medical Equipment (DME) MACs for services provided to Medicare beneficiaries. What You Need to Know The Centers for Medicare & Medicaid Services (CMS) issued CR 9050 to alert providers that Claim Adjustment Reason Code (CARC) A7 will be replaced on July 1, 2015, by CARC 121 to report force balancing of Out of Balance (OOB) claims payment/adjudication. Background CR9050 modifies the way MACs report force balancing of OOB claim payment/adjudication. Currently, MACs are using CARC A7− Presumptive Payment Adjustment to report the balancing of OOB payments. CR9050 instructs MACs to use CARC 121−Indemnification adjustment− compensation for outstanding member responsibility in place of A7. This will be effective July 1, 2015. In addition, MACs will use Group Code OA (Other Adjustment) as the required Group Code. Finally, MACs will report offsetting of Veterans Affairs claims at the provider level using PLB code J1 “Non-Reimburseable” and an offsetting dollar amount. Additional Information The official instruction for CR9050 issued to your MAC regarding this change is available at http://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1467OTN.pdf on the CMS website. If you have questions, please contact your MAC at their toll-free number. The number is available at http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ index.html under - How Does It Work? Corrections to Processing Service Facility Information on Hospice Claims MLN Matters® Number: MM9042 Related Change Request (CR) #: CR 9042 Related CR Release Date: January 30, 2015 Effective Date: January 1, 2014 Related CR Transmittal #: R1455OTN Implementation Date: July 6, 2015 Provider Types Affected This MLN Matters® Article is intended for hospice agencies submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 5 03/2015 What You Need to Know Change Request (CR) 9042 informs providers that MACs have reported that the Medicare system is incorrectly replacing the billing facility ZIP code with the service facility location ZIP code, resulting in inaccurate billing provider information and incorrect payments. The hospice benefit does not make payment based on the service facility location and CR9042 will require the Medicare system to correctly use the billing facility location and not to replace the billing facility location with the service facility location. Background In compliance with the Health Insurance Portability and Accountability Act (HIPAA), the Centers for Medicare & Medicaid Services (CMS) issued instructions for optional reporting effective January 1, 2014 and mandatory reporting effective April 1, 2014, for hospice agencies billing Medicare for services provided in a facility other than their billing location to report the facility location information in the 5010 electronic claim transaction loop 2310E. Under the requirements of the 5010 electronic claim, this field has situational usage and must be reported when appropriate. For hospice claims, this data is informational only and not used for payment purposes. The MACs that process hospice claims have reported that the Medicare system is applying the service facility location zip code to the billing facility record, resulting in inaccurate billing provider information and inaccurate payments for some physician services. CR9042 requires the Medicare system to stop using the service facility location for the billing facility. MACs are required to correct provider records and claim payments when an error is brought to their attention by the billing facility within 6 months of the implementation date of CR9042. MACs may override timely-filing edits as necessary to correct claims. Additional Information The official instruction, CR9042, issued to your MAC regarding this change, is available at http://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1455OTN.pdf on the CMS website. If you have questions, please contact your MAC at their toll-free number. The number is available at http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ index.html under - How Does It Work? Continuation of Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessments MLN Matters® Number: MM9016 Related Change Request (CR) #: CR 9016 Related CR Release Date: January 30, 2015 Effective Date: July 1, 2015 Related CR Transmittal #: R1459OTN Implementation Date: July 6, 2015 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 6 03/2015 Provider Types Affected This MLN Matters® Article is intended for Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs) submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need to Know Change Request (CR) 9016 informs MACs about the changes needed to implement the Fiscal Intermediary Standard System (FISS) changes required to refine the interface between FISS and the Quality Improvement and Evaluation Service. These changes include new fields to house an Assessment Identification Number (AIN) for each Health Insurance Prospective Payment System (HIPPS) Revenue Code line on submitted claims. Make sure your billing staffs are aware of these changes. Background The PPS case-mix groups used to determine payments under Home Health (HH) PPS, SNF PPS, and the IRF PPS are based on clinical assessments of the beneficiary. In all three payment systems, the assessments are entered into software at the provider site that encodes the data from the individual assessments into a standard transmission format and transmits the assessments to the State survey agency or a national repository. In addition, the software runs the data from the individual assessments through grouping software that generates a case-mix group to be used on Medicare PPS claims via a Health Insurance PPS (HIPPS) code. Although the Centers for Medicare & Medicaid Services (CMS) provides grouping software, many providers create their own software due to their need to integrate these data entry and grouping functions with their own administrative systems. Currently, the transmission of assessment data and transmission of HIPPS codes on claims to MACs are an entirely separate processes. The FISS has limited matching access to the assessment databases. Based on current business needs in order to more accurately match assessments, this process needs further refinement. Providers sending the AIN will provide more accurate matching. Providers may report the AIN for each HIPPS Revenue Code line in various manners based on the type of claim submission that individual providers use. When providers choose to submit assessment identification using the 837I claims submission, they are to report the AIN for each HIPPS Revenue Code line as follows: NTE*UPI*123456789012345~ The AIN submitted in the NTE02 segment must be right-justified and zero-filled. Repeat this segment for each HIPPS Revenue code Line (that is, a SNF claim with multiple Revenue Code lines [0022] with a HIPPS code that has a different assessment indicator (positions 4 and 5 of the HIPPS code) as necessary, as follow:. NTE*UPI*123456789012345~NTE*UPI*123456789012345~NTE*UPI*12345678 9012345~NTE*UPI*123456789012345~ CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 7 03/2015 If there is more than one AIN for each HIPPS Revenue Code line (that is, IRF Revenue Code line [0024] Inactivation/Modification), when providers choose to submit, they must report multiple assessments up to two (2) per each HIPPS Revenue code line in the 837I claim submission as follows: NTE*UPI*123456789012345223456789012345~ In this example, the first AIN will represent the most current original/modified assessment and the second AIN (which is in italics beginning with “223” represents a prior original inactivation/modified assessment. For Direct Data Entry (DDE) claims, providers using DDE should enter the AIN into these newly created fields on the DDE screens. Providers submitting paper claims should use Form Locator 43 to provide this information. Additional Information The official instruction, CR 9016 issued to your MAC regarding this change is available at http://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1459OTN.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/index.html under - How Does It Work. Payment Codes on Home Health Claims Will Be Matched Against Patient Assessments MLN Matters® Number: SE1504 Related Change Request (CR) #: 7760 Related CR Release Date: July 18, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2495CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters® Special Edition Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need to Know Beginning on April 1, 2015, Medicare systems will compare the Health Insurance Prospective Payment System (HIPPS) code on a Medicare home health claim to the HIPPS code generated by the corresponding Outcomes and Assessment Information Set (OASIS) assessment before the claim is paid. If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated HIPPS code for payment. At this time, if no corresponding OASIS assessment is found the claim will process normally. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 8 03/2015 Background Original Medicare determines payments of Home Health (HH) claims using case-mix groups based on the OASIS assessment of the beneficiary. OASIS assessments are entered into software at the HHA that transmits the data to a national quality data repository. In addition, the software runs the data from each assessment through a grouping program that generates a case-mix group. The HHA submits the case-mix group on their claim as a HIPPS code. Although the Centers for Medicare & Medicaid Services (CMS) provides free grouping software, many providers create their own software to integrate these data entry and grouping functions with their own administrative systems. Previously, the transmission of assessment data and the submission of claims were entirely separate processes. The Fiscal Intermediary Shared System (FISS), which processes all Original Medicare HH claims, did not have access to the quality data repository. As a result, FISS could not validate the submitted HIPPS code against the associated OASIS assessment. This created a payment vulnerability for the Medicare program which the Office of Inspector General (OIG) identified in several studies. Implementing the Change In 2012, CMS issued Change Request (CR) 7760, which required the FISS system to create a file exchange interface with the national quality data repository, the Quality Information Evaluation System (QIES). This interface provided the infrastructure to validate HIPPS codes against OASIS assessments and to also perform similar validations of Inpatient Rehabilitation Facility (IRF) and Skilled Nursing Facility (SNF) claims. The interface was implemented October 1, 2012. The QIES required additional changes to perform the matching of the claim data to its corresponding assessment and to return to the FISS the HIPPS code calculated from the assessment. In order to best manage risk, CMS decided to test and implement the matching process in phases. The MACs tested the IRF matching process during 2013 and implemented it in claims processing in February 2014. The MACs successfully tested the HH matching process during the remainder of 2014. For HH PPS claims received on or after April 1, 2015, Medicare will validate the submitted HIPPS code against the OASIS-calculated HIPPS code present in QIES. Impact on Home Health Agencies HHAs do not need to make any changes to their billing systems. HH PPS claims will be suspended temporarily during processing to allow for the file exchange between FISS and QIES. The claims will be suspended with FISS reason code 37071 in status/locations SMFRX0-SMFRX4. This will occur during the 14 day payment floor period and should not delay payments to HHAs. If the matching process determines that the OASIS-calculated HIPPS code is different from the one submitted on the claim, the OASIS-calculated HIPPS code will be used for payment. If the HIPPS code matches or if an OASIS assessment corresponding to the claim is not found, the claim will process normally at this time. If the matching process changes the HIPPS code used for payment, special coding on the remittance advice will notify the HHA. Claim Adjustment Reason Code 186 (Level of care change adjustment) and Remittance Advice Remark Code N69 (PPS code changed by claims processing system) will identify the recoded claims. These are the same codes used to identify claims recoded due to changes in therapy services. The electronic remittance advice will also return to the HHA the HIPPS code used for payment. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 9 03/2015 Understanding Changed HIPPS Codes in FISS The FISS will display a new field in Direct Data Entry (DDE) that will contain the OASIS-calculated HIPPS code. The field will be named “RETURN-HIPPS1.” When the OASIS-calculated HIPPS code is used for payment, the code in this field will match the code on the electronic remittance advice. It is also possible that an OASIS-calculated HIPPS code may be re-coded further by Medicare systems. The OASIS-calculated HIPPS code will be sent to the HH PPS Pricer program which may change the code based on changes in therapy services or whether the claim is for an early or later episode. In this case, the Pricer re-coded HIPPS code will be used for payment and will continue to be recorded in the APC-HIPPS field. HHAs will be able to recognize this case because there will be three HIPPS codes on the claim record in DDE: Field in DDE HCPC RETURN-HIPPS1 APC-HIPPS DDE Map MAP171E MAP171E MAP171A Represents HHA-submitted HIPPS code OASIS-calculated HIPPS code Pricer re-coded HIPPS code Next Steps Per the Code of Federal Regulations (CFR) at 42 CFR 484.210(e), submission of an OASIS assessment for all HH episodes of care is a condition of payment. If the OASIS is not found during medical review of a claim, the claim is denied. At this time, if no corresponding OASIS assessment is found by the claims matching process Medicare will release the claim to process normally, unless the claim is selected for medical review. However, the OIG recommended that the Medicare program use this claims matching process to further enforce the condition of payment. CMS plans to use the claims matching process to enforce this condition of payment in the earliest available Medicare systems release. At that time, Medicare will deny claims when a corresponding assessment is past due in the QIES but is not found in that system. CMS will provide notice to HHAs as soon as possible after we determine the implementation date. Additional Information The official instructions (CR7760 and CR8950) issued to your MAC regarding this change are available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2495CP.pdf and at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3151CP.pdf, respectively. The recommendations of the OIG regarding this project are available at http://oig.hhs.gov/oei/reports/oei01-10-00460.asp on the OIG website. If you have questions, please contact your MAC at their toll-free number. The number is available at http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ index.html under - How Does It Work? CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 10 03/2015 Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers MLN Matters® Number: SE1425 Revised Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A Note: This article was revised on January 30, 2015, to reflect an extension of the moratoria for another 6 months, as noted in the article. Provider Types Affected This MLN Matters® Article is intended for Home Health Agencies, Home Health Agency Sub-units, and Part B ambulance suppliers in parts of Florida, Illinois, Michigan, Texas and New Jersey that provide services to Medicare, Medicaid and CHIP beneficiaries. Provider Action Needed STOP – Impact to You Effective January 29, 2015, the temporary moratoria on new Home Health Agencies, Home Health Agency Sub-units, and Part B ambulance suppliers are being extended for an additional 6 months in certain geographic locations. CAUTION – What You Need to Know During the 6-month temporary moratorium, initial provider enrollment applications and change of information applications to add additional practice locations, received from Home Health Agencies, Home Health Agency Sub-Units and Part B Ambulance suppliers in the listed counties will be denied. Application fees that are paid for applications that are denied due to this temporary moratorium will be refunded. GO – What You Need to Do Effective January 29, 2015, Home Health Agencies, Home Health Agency Sub-units, and Part B Ambulance suppliers should not submit initial enrollment applications or change of information applications to add additional practice locations until the 6-month moratoria has expired. CMS will announce in the Federal Register when the moratorium has been lifted or if it will be extended. Background In accordance with 42 CFR §424.570(c), the Centers for Medicare & Medicaid Services (CMS) may impose a moratorium on the enrollment of new Medicare providers and suppliers of a specific type or the establishment of new practice locations in a particular geographic area. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 11 03/2015 On January 29, 2015, CMS announced, in a Federal Register notice (https://s3.amazonaws.com/publicinspection.federalregister.gov/2015-01696.pdf), the extension of temporary moratoria on the enrollment of new Home Health Agencies, Home Health Agency Sub-units and Part B Ambulance suppliers in designated geographic locations. The moratoria initially became effective on January 30, 2014, and its implementation was announced in the Federal Register, which may be accessed at https://www.federalregister.gov/ articles/2014/02/04/2014-02166/medicare-medicaid-and-childrens-health-insurance-programsannouncement-of-new-and-extended-temporary#page-6475 on the Internet. Moratoria Extension Effective January 29, 2015, the temporary moratoria on new Home Health Agencies and Home Health Agency Sub-units is being extended for an additional 6 months in the areas stated in Table 1, below. Table 1: Home Health Agencies and Home Health Agency Sub-units under Temporary Moratorium City and State Fort Lauderdale, FL Miami, FL Detroit, MI Dallas, TX Counties Broward Miami-Dade Monroe Macomb Monroe Oakland Washtenaw Wayne Collin Dallas Denton Ellis Kaufman Rockwall Tarrant CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 12 03/2015 Houston, TX Chicago, IL Brazoria Chambers Fort Bend Galveston Harris Liberty Montgomery Waller Cook DuPage Kane Lake McHenry Will In addition, the temporary moratorium on new Part B ambulance suppliers is being extended for an additional 6 months in the areas stated in Table 2, below. Table 2: Part B Ambulance Suppliers Under 6-month Temporary Moratoria City and State Houston, TX Philadelphia, PA Counties Harris Brazoria Chambers Fort Bend Galveston Liberty Montgomery Waller Bucks (PA) Delaware (PA) Montgomery (PA) Philadelphia (PA) Burlington (NJ) Camden (NJ) Gloucester (NJ) Initial provider enrollment applications and change of information applications to add additional practice locations received from Home Health Agencies, Home Health Agency Sub-Units and Part B Ambulance suppliers in the above listed counties will be denied in accordance with 42 CFR §424.570(c). Application fees that are paid for applications that are denied due to this temporary moratorium will be refunded. Note: Home Health Agencies, Home Health Agency Sub-Units and Part B Ambulance suppliers are afforded appeal rights. However, the scope of review will be limited to whether the temporary moratorium applies to the provider or supplier appealing the denial. CMS’ basis for imposing a temporary moratorium is not subject to review. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 13 03/2015 Additional Information For more information regarding CMS’ use of temporary moratoriums, please review MLN Matters® article MM7350 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM7350.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number, which is available at http:// www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-complianceinteractive-map/index.html on the CMS website. Preventing Inappropriate Payments on Home Health Low Utilization Payment Adjustment (LUPA) Claims MLN Matters® Number: MM 9027 Related Change Request (CR) #: CR 9027 Related CR Release Date: January 30, 2015 Effective Date: July 1, 2015 Related CR Transmittal #: R3176CP Implementation Date: July 6, 2015 Provider Types Affected This MLN Matters® Article is intended for providers and Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries in a Home Health period of coverage. Provider Action Needed The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9027 to notify providers of new edits in Original Medicare systems to ensure Low Utilization Payment Adjustment (LUPA) payments under the Home Health Prospective Payment System (HH PPS) are made appropriately. CR9027 clarifies billing instructions for HH PPS claims. No new policy is created by CR9027; these new requirements improve the enforcement of existing Original Medicare payment policies. Make sure your billing staffs are aware of these changes. Background Since January 2008, the HH PPS has included an additional payment when HH PPS episodes subject to LUPAs are the first episode in a sequence of adjacent episodes or are the only episode of care received by a beneficiary. This payment is often referred to as the “LUPA add-on.” Medicare systems apply the LUPA add-on only when certain coding is present on a claim. Medicare systems ensure that if this coding is present, earlier adjacent episodes have not been processed for the same beneficiary. This coding and enforcement is described in CR5877, which was implemented July 7. 2008, and a related MLN Matters® article is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/mm5877.pdf on the CMS website. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 14 03/2015 MACs have reported that in two limited circumstances, Medicare systems may allow more than one LUPA add-on payment during a sequence of adjacent episodes. Those circumstances are: 1. Cases where an incoming claim coded for a LUPA add-on overlaps an earlier episode for the same beneficiary which was also paid a LUPA add-on. When this occurs, Medicare systems currently autocancel the earlier episode and trigger the unsolicited response process that ensures the earlier episode’s statement dates are adjusted. (This is the same unsolicited response that ensures Partial Episode Payment (PEP) adjustments are applied correctly, though no PEP adjustment is triggered in this case.) Because the earlier episode is canceled and has not yet been re-processed, the incoming claim appears to be the first episode and the LUPA add-on is allowed. The requirements of CR9027 change Medicare systems to identify the duplicate LUPA add-on payment before the earlier episode is canceled and to ensure the add-on is not paid. 2. Cases where two adjacent episodes coded for a LUPA add-on for the same beneficiary by the same provider are processed out of sequence. When the later dated episode is received first, it may appear to Medicare systems to be the first episode and the LUPA add-on is allowed. When the earlier dated episode is received later, Medicare systems look for an earlier episode and find none, so this also appears to be the first episode and the LUPA add-on is allowed. Medicare systems do not currently check to see if a LUPA add-on for a later date has already been paid. The requirements of CR9027 change Medicare systems to identify that a LUPA add-on has already been paid and return the earlier dated claim to the provider. The provider must then correct the admission date on the claim for the later dated episode before the earlier dated claim can be paid. Finally, per Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, to be eligible to receive Medicare Home Health services the beneficiary must have a skilled need (that is, require intermittent Skilled Nursing (SN) services, Physical Therapy (PT), and/or Speech-Language Pathology (SLP) services or have a continuing need for Occupational Therapy (OT) services). The first OT service, which is a dependent service, is covered only when preceded by an intermittent SN visit, PT visit, or SLP visit. The requirements below change Medicare systems to return to the provider any claims for episodes subject to LUPAs that are the first episode in a sequence of adjacent episodes or are the only episode of care received by a beneficiary for which patient eligibility for the Medicare Home Health benefit has not been established (i.e., no SN, PT, or SLP visits reported on the claim). The following summarizes the “Medicare Claims Processing Manual” revisions that highlight the requirements of CR9027: 1. Chapter 10/Section 10.1.17/Adjustments of Episode Payment –LUPAs • One criterion that Medicare uses to determine whether a LUPA add-on payment applies is that the claim Admission Date matches the claim “From” Date. HHAs should take care to ensure that they submit accurate admission dates, especially if episodes are submitted out of sequence. Inaccurate admission dates may result in Medicare systems returning LUPA claims where an add-on payment applies, but the add-on was paid inappropriately on a later dated episode in the same sequence of adjacent episodes. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 15 03/2015 • Medicare systems may return to the provider LUPA claims if the claim meets the criteria for a LUPA add-on payment but it contains no qualifying skilled service. In these cases, the HHA may add the skilled visit to the claim if it was omitted in error and re-submit the claim. Otherwise, the HHA may only re-submit the claim using condition code 21, indicating a billing for a denial notice. 2. Chapter 10/Section 40.1/Request for Anticipated Payment (RAP) and Section 40.2/HH PPS Claims • For initial episodes, the HHA reports on the 0023 revenue code line the date of the first covered visit provided during the episode. For subsequent episodes, the HHA reports on the 0023 revenue code the date of the first visit provided during the episode line, regardless of whether the visit was covered or non-covered. As a result of CR9027, Providers should note that a claim will be rejected for repricing if the following conditions are met: • The Type of Bill is 032x, • Pricer return code 14 is present, indicating a LUPA add-on, • The claim “From” date falls within the “From” and “Through” dates of a paid • claim in history for the same beneficiary, and • Pricer return code 14 is also present on the paid claim in history. As a result of CR9072, claims will be returned to the provider if any of the following conditions are met: • The Type of Bill is 032x; • There are 4 or fewer covered visits (occurrences of revenue codes 042x, 043x, 044x, 055x, 056x and 057x); • The Admission Date matches the From Date; • The first position of the HIPPS code is 1 or 2; or • Condition code 47 is not present, and there is no qualifying skilled service (at least one covered occurrence of revenue codes 042x, 044x or 055x). Additional Information The official instruction for CR9027 issued to your MAC regarding this change is available at http://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3176CP.pdf on the CMS website. If you have questions please contact your MAC at their toll-free number. The number is available at http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ index.html under - How Does It Work? CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 16 03/2015 FEE SCHEDULE INFORMATION April 2015 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files MLN Matters® Number: MM9084 Related Change Request (CR) #: CR 9084 Related CR Release Date: January 30, 2015 Effective Date: April 1, 2015 Related CR Transmittal #: R3180CP Implementation Date: April 6, 2015 Provider Types Affected This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs and Durable Medical Equipment MACs for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9084 informs Medicare MACs to download and implement the April 2015 ASP drug pricing files and, if released by the Centers for Medicare & Medicaid Services (CMS), the January 2015, October 2014, July 2014, and April 2014, ASP drug pricing files for Medicare Part B drugs. Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after April 6, 2015, with dates of service April 1, 2015, through June 30, 2015. MACs will not search and adjust claims that have already been processed unless you bring such claims to their attention. Make sure that your billing staffs are aware of these changes. Background The Medicare Modernization Act of 2003 (MMA; Section 303(c)) revised the payment methodology for Part B covered drugs and biologicals that are not priced on a cost or prospective payment basis. The Average Sales Price (ASP) methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare contractors with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in the “Medicare Claims Processing Manual” (Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 50 (Outpatient PRICER); see http://www.cms.gov/manuals/downloads/clm 104c04.pdf on the CMS website.) CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 17 03/2015 The following table shows how the quarterly payment files will be applied: Files April 2015 ASP and ASP NOC January 2015 ASP and ASP NOC October 2014 ASP and ASP NOC July 2014 ASP and ASP NOC April 2014 ASP and ASP NOC Effective Dates of Service April 1, 2015, through June 30, 2015 January 1, 2015, through March 31, 2015 October 1, 2014, through December 31, 2014 July 1, 2014, through September 30, 2014 April 1, 2014, through June 30, 2014 NOTE: The absence or presence of a Healthcare Common Procedure Coding System (HCPCS) code and its associated payment limit does not indicate Medicare coverage of the drug or biological. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The local MAC processing the claim shall make these determinations. Additional Information The official instruction, CR 9084 issued to your MAC regarding this change is available at http://www.cms. gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R3180CP.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/index.html under - How Does It Work. ICD-10 INFORMATION Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) – A Re-Issue of MM7492 MLN Matters® Number: SE1408 Revised Related Change Request (CR) #: 7492 Related CR Release Date: N/A Effective Date: October 1, 2014 Related CR Transmittal #: N/A Implementation Date: N/A Note: This article was revised on February 20, 2015, to add a question and answer at the bottom of page 2 regarding dual processing of ICD-9 and ICD-10 codes. All other information remains the same. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 18 03/2015 Provider Types Affected This article is intended for all physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), and Durable Medical Equipment MACs (DME MACs)) for services provided to Medicare beneficiaries Provider Action Needed For dates of service on and after October 1, 2015, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the ICD-10 code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2015. As a result of CR7492 (and related MLN Matters® Article MM7492), guidance was provided on processing certain claims for dates of service near the original October 1, 2013, implementation date for ICD-10. This article updates MM7492 to reflect the October 1, 2015, implementation date. Make sure your billing and coding staffs are aware of these changes. Key Points of SE1408 General Reporting of ICD-10 As with ICD-9 codes today, providers and suppliers are still required to report all characters of a valid ICD10 code on claims. ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time. Please refer to http://www.cms.gov/Medicare/Coding/ICD10/index.html for more information on the format of ICD-10 codes. In addition, ICD-10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is currently the case with ICD-9 procedure codes. General Claims Submissions Information ICD-9 codes will no longer be accepted on claims (including electronic and paper) with FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2015. Institutional claims containing ICD-9 codes for services on or after October 1, 2015, will be Returned to Provider (RTP) as unprocessable. Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or after October 1, 2015, will also be returned as unprocessable. You will be required to re-submit these claims with the appropriate ICD-10 code. A claim cannot contain both ICD-9 codes and ICD-10 codes. Medicare will RTP all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim. For dates of service prior to October 1, 2015, submit claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1, 2015, submit with the appropriate ICD-10 diagnosis code. Likewise, Medicare will also RTP all claims that are billed with both ICD-9 and ICD-10 procedure codes on the same claim. For claims with dates of service prior to October 1, 2015, submit with the appropriate ICD-9 procedure code. For claims with dates of service on or after October 1, 2015, submit with the appropriate ICD-10 procedure code. Remember that ICD-10 codes may only be used for services provided on or after October 1, 2015. Institutional claims containing ICD-10 codes for services prior to October 1, 2015, will be Returned to Provider (RTP). Likewise, professional and supplier claims containing ICD-10 codes for services prior to October 1, 2015, will be returned as unprocessable. Please submit these claims with the appropriate ICD-9 code. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 19 03/2015 Will the Centers for Medicare & Medicaid Services (CMS) allow for dual processing of ICD-9 and ICD-10 codes (accept and process both ICD-9 and ICD-10 codes for dates of service on and after October 1, 2015)? No, CMS will not allow for dual processing of ICD-9 and ICD-10 codes after ICD-10 implementation on October 1, 2015. Many providers and payers, including Medicare have already coded their systems to only allow ICD-10 codes beginning October 1, 2015. The scope of systems changes and testing needed to allow for dual processing would require significant resources and could not be accomplished by the October 1, 2015, implementation date. Should CMS allow for dual processing, it would force all entities with which we share data, including our trading partners, to also allow for dual processing. In addition, having a mix of ICD-9 and ICD-10 codes in the same year would have major ramifications for CMS quality, demonstration, and risk adjustment programs. Claims that Span the ICD-10 Implementation Date CMS has identified potential claims processing issues for institutional, professional, and supplier claims that span the implementation date; that is, where ICD-9 codes are effective for the portion of the services that were rendered on September 30, 2015, and earlier and where ICD-10 codes are effective for the portion of the services that were rendered October 1, 2015, and later. In some cases, depending upon the policies associated with those services, there cannot be a break in service or time (i.e., anesthesia) although the new ICD-10 code set must be used effective October 1, 2015. The following tables provide further guidance to providers for claims that span the periods where ICD-9 and ICD-10 codes may both be applicable. Bill Type(s) 11X 12X Facility Type/Services Claims Processing Requirement Inpatient Hospitals (incl. If the hospital claim TERFHA hospitals, has a discharge and/or Prospective Payment through date on or after System (PPS) hospitals, 10/1/15, then the entire Long Term Care Hospitals claim is billed using (LTCHs), Critical Access ICD-10. Hospitals (CAHs) Inpatient Part B Hospital Split Claims - Require Services providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Use FROM or THROUGH Date THROUGH FROM CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 20 03/2015 13X 14X 18X 21X Outpatient Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Non-patient Laboratory Split Claims - Require Services providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Swing Beds If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10. Skilled Nursing (Inpatient If the [Swing bed Part A) or SNF] claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10. FROM FROM THROUGH THROUGH CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 21 03/2015 22X Skilled Nursing Facilities (Inpatient Part B) 23X Skilled Nursing Facilities (Outpatient) 32X Home Health (Inpatient Part B) 3X2 Home Health – Request for Anticipated Payment (RAPs)* Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span 10/1/2015, but require those claims to be submitted using ICD-10 codes. * NOTE - RAPs can report either an ICD9 code or an ICD-10 code based on the one (1) date reported. Since these dates will be equal to each other, there is no requirement needed. The corresponding final claim, however, will need to use an ICD-10 code if the HH episode spans beyond 10/1/2015. FROM FROM THROUGH *See Note CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 22 03/2015 34X Home Health – (Outpatient ) 71X Rural Health Clinics 72X End Stage Renal Disease (ESRD) 73X Federally Qualified Health Clinics (prior to 4/1/10) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. N/A – Always ICD-9 code set. FROM FROM FROM N/A CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 23 03/2015 74X Outpatient Therapy 75X Comprehensive Outpatient Rehab facilities 76X Community Mental Health Clinics 77X Federally Qualified Health Clinics (effective 4/4/10) Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. FROM FROM FROM FROM CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 24 03/2015 81X 82X 83X 85X Hospice- Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Hospice – Non hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. Hospice – Hospital Based N/A Critical Access Hospital Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later. FROM FROM N/A FROM CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 25 03/2015 Table B - Special Outpatient Claims Processing Circumstances Scenario Claims Processing Requirement 3-day /1day Payment Window Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on or after 10/1/2015, the claim must be billed with ICD-10 for those bundled outpatient services. Use FROM or THROUGH Date THROUGH Table C – Professional Claims Type of Claim Claims Processing Requirement All anesthesia claims Anesthesia procedures that begin on 9/30/2015 but end on 10/1/2015 are to be billed with ICD-9 diagnosis codes and use 9/30/2015 as both the FROM and THROUGH date. Use FROM or THROUGH Date FROM Table D –Supplier Claims Supplier Type Claims Processing Requirement DMEPOS Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the ICD-10 compliance date of 10/1/2015 (i.e., the FROM date of service occurs prior to 10/1/2015 and the TO date of service occurs after 10/1/2015). Use FROM or THROUGH/TO Date FROM Additional Information You may also want to review SE1239 at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/SE1239.pdf on the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2015. You may also want to review SE1410 at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/index.html under - How Does It Work. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 26 03/2015 LEARNING AND EDUCATION INFORMATION March Quarterly Updates, Changes, and Reminders Webcast – March 12, 2015 Palmetto GBA will host the J11 Home Health and Hospice Quarterly Updates Webcast on Thursday, March 12, 2015, at 10 a.m. ET. This 60-minute webcast is designed to provide pertinent updates, changes and reminders to assist the provider community in staying compliant with Medicare rules and regulations and will include: • Comprehensive Error Rate Testing (CERT) • Medicare Updates and Changes • Hot Topics • Reminders • News to Use! • Resources Registration is required. To register for this webcast, please go to the Event Registration Portal under the Learning & Education section of Palmetto GBA website at www.PalmettoGBA.com/hhh. Note: A Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI) are required to register. You should only enter ‘n/a’ if you do not have an NPI or PTAN. Audio The audio for this presentation will be broadcasting through your computer. For best results, it is recommended that you utilize/headphones. You should not use your telephone to dial into the conference. Handouts A copy of the presentation will be available through the event portal once the session begins. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 27 03/2015 2015 Jurisdiction 11 (J11) Home Health Medicare Workshop Series – The Golden Years – Medicare at 50! Palmetto GBA is pleased to announce our 2015 Home Health workshop series, ‘The Golden Years – Medicare at 50!’ These workshops are designed for home health providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements. These workshops will provide insight for home health agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend our online learning courses for beginners at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section under the Learning and Education link on the left navigation. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices! Home Health Topics: • Statistics o Length of Stay (LOS) o Disbursement • Review Findings – Palmetto GBA and CERT Reviews • Improving Your Practice o Health Information Supply Chain (HISC) • Home Health (HH) Plans of Care (POCs) o Diabetes and the Home Health (HH) Benefit • Medicare Program Changes for 2015 o Reporting Principal Diagnosis Code(s) Etiology vs. Manifestation codes • Data Analysis o Appeals o Provider Contact Center (PCC) o Claims CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 28 03/2015 • Tying It All Together o Define, Measure, Analyze, Improve, and Control (DMAIC) Process • Provider Resources Note: CMS requires that Medicare contractors track all educational activities, which consists of capturing the provider’s six-digit Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI). Attendees are asked to be prepared to provide this information when they attend the workshop. For workshops that are sponsored by Palmetto GBA, attendees can provide the information during the registration process. Attendees are also encouraged to dress in layers or bring a sweater or jacket to ensure comfort. As a reminder, providers are encouraged to telephone the Provider Contact Center (PCC) at 855-696-0705 with any claim specific questions they may have as these will not be able to be addressed in the workshop Featured speakers will be the Provider Outreach and Education (POE) staff that specializes in clinical, as well as billing and coverage experience. The schedule of workshops and registration information listed below. To reserve your seat or find out more about the workshops in your area, please make sure you: 1. Create a profile at the new Event Registration Portal to create an account. Your existing Workshops database profile is not linked to the new portal as the profile creation process is different. 2. Log in your Event Registration Portal account and you will be able to register yourself or other people for any workshops hosted in the portal before registration closes. Each workshop will have a separate registration link. For the workshops that Palmetto GBA sponsors, Palmetto GBA’s registration page will be displayed. If the state Association is sponsoring the workshop, the link will take you directly to the Association’s registration page. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 29 03/2015 2015 Jurisdiction 11 (J11) Hospice Medicare Workshop Series – The Golden Years – Medicare at 50! Palmetto GBA is pleased to announce our 2015 Hospice workshop series, ‘The Golden Years – Medicare at 50!’ These workshops are designed for hospice providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements. These workshops will provide insight for hospice agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend online learning courses for beginners offered at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section under the Learning and Education link on the left navigation. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices! Hospice Topics: • Related versus Non-Related Conditions • Hospice Data • Improving Your Practice o Health Information Supply Chain (HISC) • Identifying Improper Payments – Palmetto GBA and CERT Reviews • General Inpatient Care (GIP) • Pulmonary Patients • Medicare Program Changes for 2015 o Principal Diagnoses Coding o Hospice Notice of Election (NOE) Submission • Data Analysis • Tying It All Together o Define, Measure, Analyze, Improve, and Control (DMAIC) • Provider Resources CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 30 03/2015 Note: CMS requires that Medicare contractors track all educational activities, which consists of capturing the provider’s six-digit Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI). Attendees are asked to be prepared to provide this information when they attend the workshop. For workshops that are sponsored by Palmetto GBA, attendees can provide the information during the registration process. Attendees are also encouraged to dress in layers or bring a sweater or jacket to ensure comfort. As a reminder, providers are encouraged to telephone the Provider Contact Center (PCC) at 855-696-0705 with any claim specific questions they may have as these will not be able to be addressed at the workshop. Featured speakers will be Provider Outreach and Education (POE) staff that specializes in clinical, as well as billing and coverage experience. How to Register The schedule of workshops and registration information listed below. To reserve your seat or find out more about the workshops in your area, please make sure you: 1. Create a profile at the new Event Registration Portal to create an account. Your existing Workshops database profile is not linked to the new portal as the profile creation process is different. 2. Log in your Event Registration Portal account and you will be able to register yourself or other people for any workshops hosted in the portal before registration closes. Each workshop will have a separate registration link. For the workshops that Palmetto GBA sponsors, Palmetto GBA’s registration page will be displayed. If the state Association is sponsoring the workshop, the link will take you directly to the Association’s registration page. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 31 03/2015 MEDICAL AFFAIRS INFORMATION J11 HHH Local Coverage Determinations (LCDs) Updates Revised ICD-9 LCDs The table below provides a summary of recent J11 Part HHH ICD-9 LCD revisions/updates. To view the revised LCDs go to www.PalmettoGBA.com/j11a/lcd. Select “Active”. Select “All LCDs” under the “Document types to further refine your search by:” section and click on the “Submit” button. The LCDs are listed in alphabetical order. Title LCD ID Number Revision Number Home-based Fall Evaluations and Interventions LCD Number: L31607 Revision Number: 4 Changes/Additions/Deletions Effective Date Under CMS National Coverage Policy changed all Manual 02/12/2015 Systems to read Internet-Only Manual. Under Coverage Indications, Limitations and /or Medical Necessity removed “and 33X” from Home health benefit bill types per Change Request 8244. Under the Part B Outpatient Benefit heading removed “noted below” and re-worded to read as listed in Publication 100-02, Chapter 7, Section 40.2.1.Under Bill Type Codes removed 033x per Change request 8244. Under Associated Information in the Utilization Guidelines, reworded the Palmetto GBA statement to read Whether the therapy is rehabilitative, restorative or maintenance should be documented on the Plan of Care and the OASIS. Under Sources of Information and Basis for Decision corrected all sources to AMA formatting and corrected source links where appropriate. Home Health-Surface Under CMS National Coverage Policy, added the citation for 01/23/2015 Electrical Stimulation CMS Internet-Only Manual, 100-04, Medicare Claims Processing in the Treatment of Manual to reference CR8244.Under Bill Type Codes removed Dysphagia Code 033x per CR8244. Under Sources of Information and LCD Number: L31534 Basis of Decision added citations for Blumenfeld, Hahn, Revision Number: 4 LePage, et al; Burnett, Mann, et al; Chaudhuri, Brady, Caldwell; Crary, Carnaby-Mann, Faunce; D’Souza, Krieger, Kobe; Empi recovery sciences; Humbert, Poletto, et al; Kong; Leelamanit, Limsakul; and Permsirivanich. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 32 03/2015 Under CMS National Coverage Policy changed all Manual 02/05/2015 Systems to read Internet-only Manual; added citation for Pub 100-02 Chapter 7 section 30.1.2; added citation for change request 8244 and added citation for Pub 100-04 Chapter 5 sections 20 and 20.1. Under Bill Type Codes removed 033x per Change Request 8244.Under CPT/HCPCS Codes removed “or 33x” in the paragraph. Under Associated Information in the Evaluation/Reevaluation section, number 11 removed “when they provide further information to supplement measurement tools”; Number 12 was removed completely as it was a repeat of number 11; changed number 13 to 12 in order to maintain number sequencing. Under Plan of Treatment and Certification/ Recertification made some grammatical and punctuation corrections. Removed section titled Utilization Guidelines. Under Sources of Information and Basis for Decision corrected source for Nicolosi to AMA formatting and update edition, added citations for Ben-Yashay/Diller and Lawton/Brody. Hospice – HIV Disease Revisions were made to the Hospice HIV Policy L31535. Under 02/05/2015 LCD Number: L31535 CMS National Coverage Policy removed Title XVIII Section Revision: 4 1861 (dd).Under Associated Information corrected the section title references to read “Coverage Indications, Limitations and / or Medical Necessity”. Under Sources of Information and Basis for Decision corrected all sources to meet AMA compliance and added source for CDC guidelines for performing CD4+ determinations. Home Health SpeechLanguage Pathology LCD Number: L31533 Revision Number: 6 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 33 03/2015 Revised ICD-10 LCDs The table below provides a summary of recent J11 HHH ICD-10 LCD revisions/updates. To view the revised LCDs go to www.PalmettoGBA.com/hhh/lcd. Select “Active”. Select “Future LCDs/Future contract number LCDs” under the “Document types to further refine your search by:” section and click on the “Submit” button. The LCDs are listed in alphabetical order. Title LCD ID Number Revision Number Home-based Fall Evaluations and Interventions LCD Number: L34546 Revision Number: 1 Changes/Additions/Deletions Effective Date Under CMS National Coverage Policy changed all Manual 10/01/2015 Systems to read Internet-Only Manual. Under Coverage Indications, Limitations and /or Medical Necessity removed “and 33X” from Home health benefit bill types per Change Request 8244. Under the Part B Outpatient Benefit heading removed “noted below” and re-worded to read as listed in Publication 100-02, Chapter 7, Section 40.2.1.Under Bill Type Codes removed 033x per Change request 8244. Under Associated Information in the Utilization Guidelines, reworded the Palmetto GBA statement to read Whether the therapy is rehabilitative, restorative or maintenance should be documented on the Plan of Care and the OASIS. Under Sources of Information and Basis for Decision corrected all sources to AMA formatting and corrected source links where appropriate. Home Health-Surface Under CMS National Coverage Policy, added the citation for 10/01/2015 Electrical Stimulation CMS Internet-Only Manual, 100-04, Medicare Claims Processing in the Treatment of Manual to reference CR8244.Under Bill Type Codes removed Dysphagia Code 033x per CR8244. Under Sources of Information and LCD Number: L34565 Basis of Decision added citations for Blumenfeld, Hahn, Revision Number: 1 LePage, et al; Burnett, Mann, et al; Chaudhuri, Brady, Caldwell; Crary, Carnaby-Mann, Faunce; D’Souza, Krieger, Kobe; Empi recovery sciences; Humbert, Poletto, et al; Kong; Leelamanit, Limsakul; and Permsirivanich. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 34 03/2015 Home Health SpeechLanguage Pathology LCD Number: L34563 Revision Number: 1 Under CMS National Coverage Policy added citation for Pub 100-02 Chapter 7 section 30.1.2; added citation for change request 8244 and added citation for Pub 100-04 Chapter 5 sections 20 and 20.1. Under Bill Type Codes removed 033x per Change Request 8244.Under CPT/HCPCS Codes removed “or 33x” in the paragraph. Under Associated Information in the Evaluation/Reevaluation section, number 11 removed “when they provide further information to supplement measurement tools”; Number 12 was removed completely as it was a repeat of number 11; changed number 13 to 12 in order to maintain number sequencing. Under Plan of Treatment and Certification/ Recertification made some grammatical and punctuation corrections. Removed section titled Utilization Guidelines. 10/01/2015 Under Sources of Information and Basis for Decision corrected source for Nicolosi to AMA formatting and update edition, added citations for Ben-Yashay/Diller and Lawton/Brody. Hospice- HIV Disease Revisions were made to the Hospice HIV Policy 10/01/2015 LCD Number: L34566 L 34566. Under CMS National Coverage Policy removed Title Revision Number: 1 XVIII Section 1861 (dd) and Internet-Only Manual reference to 100-08, Chapter 13.Under Associated Information corrected the section title references to read “Coverage Indications, Limitations and /or Medical Necessity”. Under Sources of Information and Basis for Decision corrected all sources to meet AMA compliance and added source for CDC guidelines for performing CD4+ determinations. J11 HHH Local Coverage Determinations (LCDs) Article Updates Revised ICD-9 LCD Article Updates The table below provides a summary of J11 HHH MAC ICD-9 LCD article revisions/updates. To view these articles, go to www.PalmettoGBA.com/hhh/lcd. Select “LCD articles”. The LCD articles are listed in alphabetical order. Title LCD Article ID Number CPT Code 97755-Assistive Technology Assessment LCD Article Number: A50421 Changes/Additions/Deletions Effective Date Under Associated Contract Numbers added the Part A contactor numbers 11201, 11301, 11401, and 11501. Under Article Text deleted “by provider” in the first paragraph. The home health local coverage determinations titles listed in the first paragraph were corrected. In the second paragraph, the description was cited for CPT code 97535. The title of the reference cited in the fourth paragraph was corrected. Under CPT/HCPCS Codes deleted CPT code 97535. 01/29/2015 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 35 03/2015 Coding Guidelines for Home Health SpeechLanguage Pathology LCD Article Number: A50420 Under Bill Type Codes removed 033x Bill Type. Under Revenue 02/05/2015 Codes clarified 044x into 0440, 0441, 0444. Under CPT/HCPCS Codes added all CPT codes from policy. Under Covered ICD-9 Codes added all ICD-9 codes from policy. Home-based Fall Evaluations and interventions LCD Article Number: A50489 Removed Bill Type Code 033x per Change request 8244. 02/12/2015 Revised ICD-10 LCD Article Updates The table below provides a summary of a recent J11 HHH MAC ICD-10 LCD article revision/update. To view this revised LCD article, go to www.PalmettoGBA.com/hhh/lcd. Select “LCD articles” and then “Future Effective Documents”. Click on the “Submit” button. The LCD articles are listed in alphabetical order. Title LCD ID Number Revision Number CPT Code 97755-Assistive Technology Assessment LCD Article Number: A53053 Coding Guidelines for Home Health SpeechLanguage Pathology LCD Article Number: A53052 Home-based Fall Evaluations and Interventions LCD Article Number: A53055 Changes/Additions/Deletions Effective Date Under Associated Contract Numbers added the Part A contactor 10/01/2015 numbers 11201, 11301, 11401, and 11501. Under Article Text deleted “by provider” in the first paragraph. The home health local coverage determinations titles listed in the first paragraph were corrected. In the second paragraph, the description was cited for CPT code 97535. The title of the reference cited in the fourth paragraph was corrected. Under CPT/HCPCS Codes deleted CPT code 97535. Under Bill Type Codes removed 033x Bill Type. Under Revenue 10/01/2015 Codes clarified 044x into 0440, 0441, 0444. Under CPT/HCPCS Codes added all CPT codes from policy. Under Covered ICD-10 Codes added all ICD-10 codes from policy. Removed Bill Type Code 033x per Change Request 8244. 10/01/2015 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 36 03/2015 MEDICAL REVIEW INFORMATION New Timeframe for Response to Additional Documentation Requests MLN Matters® Number: MM8583 Revised Related Change Request (CR) #: CR 8583 Related CR Release Date: February 4, 2015 Effective Date: April 1, 2015 Related CR Transmittal #: R567PI Implementation Date: April 6, 2015 Note: This article was revised on February 9, 2015, to reflect the revised CR8583 issued on February 4. In the article, the CR release date, transmittal number, and the Web address for accessing the CR are revised. All other information remains the same. Provider Types Affected This MLN Matters® Article is intended for physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to Medicare beneficiaries. What You Need to Know This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of a pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes. Background In certain circumstances, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments or the billing history found in claims processing system (if applicable) or Medicare’s Common Working File (CWF). In those instances, the CMS review contractor will solicit documentation from the provider or supplier by issuing an ADR. The requirements for additional documentation are as follows: • The Social Security Act, Section 1833(e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 37 03/2015 • According to the “Medicare Program Integrity Manual,” Chapter 3, Section 3.2.3.2, (Verifying Potential Errors and Tracking Corrective Actions),when requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to the providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46. Additional Information The official instruction, CR 8583, issued to your MAC regarding this change, is available at http://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R567PI.pdf on the Centers for Medicare & Medicaid Services (CMS) website. If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/index.html under - How Does It Work. TOOLS THAT YOU CAN USE Claims Submission Error Help Understand Reason Codes on Medicare Claims! Preventing and knowing how to resolve Claim Submission Errors by understanding the reason codes will help expedite the processing of your claims and may save time and money. As a Medicare provider you are responsible for ensuring the information submitted on your claims is correct and compliant with Medicare regulations. You should be aware that action may be taken when you demonstrate a pattern of submitting claims inappropriately, incorrectly or erroneously. To assist providers with this effort, the Jurisdiction 11 Part A Claims Submission Error Help tool has been updated. Palmetto GBA created the tool which includes resources for assisting in resolving and preventing the top claim submission errors made by Medicare providers. Providers can access reasons for errors and tips for correcting claims in plain language. Providers may notice that when accessing reason code descriptions in the Fiscal Intermediary Shared System (FISS) or Direct Data Entry (DDE), the narrative may include descriptions for all applicable bill types. The Claims Submission Error Help tool has been tailored to include narrative language applicable to all Part A bill types. Providers can either scroll through reason codes in numerical order or use the Palmetto GBA search engine to search by reason code. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 38 03/2015 Data analysis reports generate the top fifteen claim submission errors made by J11 providers. All codes on the Claims Submission Error Help Tool are reviewed quarterly for accuracy. Codes are added, updated or removed based on data analysis reports. To view the Claim Submission Error Help tool, go to: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20 A~Learning%20Education~Claims%20Submission%20Error%20Help?open&Expand=1 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 39 03/2015 Interactive UB-04 The Uniform Bill (UB-04) is the standardized billing form for institutional services. This interactive guide provides instruction on how to complete the UB-04. A sample UB-04 can be seen below. To view the Interactive UB-04, go to http://palmgba.com/elearn/ub04/ie7/index.html?dhtmlActivation=inplace CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 40 03/2015 Address Changes This advisory should be shared with all health care practitioners and managerial members of the provider/ supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www. PalmettoGBA.com/hhh. Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the CMS website. To obtain the hard copy form plus information on how to complete and submit it, visit the Palmetto GBA website (www.PalmettoGBA.com/hhh). CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 41 03/2015 NOTES CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 42 03/2015 HELPFUL INFORMATION Contact Information for Palmetto GBA Home Health and Hospice Department Appeals Beneficiary Customer Service Center Claims Contact Information Palmetto GBA J11 HHH Appeals Mail Code: AG-630 P.O. Box 100238 Columbia, SC 29202-3238 Fax: (803) 699-2425 Type of Inquiry • Request for Redeterminations • Redetermination Form Fed Ex/UPS/Certified Mail Address Palmetto GBA J11 HHH Appeals Mail Code: AG-630 Building One 2300 Springdale Drive Camden, SC 29020 1-800-Medicare (1-800-633-4227) TTY: 877-486-2048 Visit the Medicare website at www.medicare. gov. Palmetto GBA J11 HHH Claims Mail Code: AG-600 P.O. Box 100238 Columbia, SC 29202-3238 • All questions related to the Medicare Program • Request for reopenings • Clerical Error Reopening Form CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 43 03/2015 Department Cost Report Contact Information Cost Report Filing Type of Inquiry • Cost Reports • Checks Mailing Address Palmetto GBA Attn: Cost Report Acceptance Mail Code: AG-330 P.O. Box 100144 Columbia, SC 29202-3144 Fed Ex/UPS/Certified Mail Address Palmetto GBA Attn: Cost Report Acceptance Mail Code: AG-330 2300 Springdale Drive Building One Camden, SC 29020-1728 Credit Balance Reporting Cost Report Overpayments Address (checks only) Palmetto GBA Medicare Finance Mail Code: AG-260 P.O. Box 100277 Columbia, SC 29202-3277 Regular and Certified Mail Palmetto GBA Attn: Credit Balance Reporting P.O. Box 100277 Columbia, SC 29202-3277 • Questions or concerns regarding credit balance reports Fed Ex/UPS/Overnight Courier Palmetto GBA Credit Balance Reporting 2300 Springdale Drive Building One Camden, SC 29020 Reports may be faxed to: MCBR Receipts Attn: Credit Balance Reporting (803) 419-3277 Telephone Number: (803) 763-6418 All email inquiries may be sent to: Credit. [email protected] CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 44 03/2015 Department Electronic Data Interchange (EDI) Contact Information Type of Inquiry Palmetto GBA J11 HHH Part A EDI Mail Code: AG-420 P.O. Box 100145 Columbia, SC 29202-3145 Provider Contact Center: 855-696-0705 DDE Hours of Availability Freedom of Information Act (FOIA) Requests Medical Affairs Medical Review • EDI enrollment • Administrative Simplification and Compliance Act (ASCA) • Electronic Remittance Advice (ERA) • PC-ACE Pro 32 (billing software) • Direct Data Entry (billing software) • Other EDI-related issues • Monday to Friday 6 a.m. - 9 p.m. ET • Saturday 6 a.m. - 4 p.m. ET • Sunday** 6 a.m. - 8 a.m. and 12 - 4 pm ET **Not available on Quarterly Release weekends • FOIA requests Palmetto GBA - J11 HHH FOIA Coordinator Mail Code: AG-615 P.O. Box 100190 Columbia, SC 29202-3190 Palmetto GBA J11 HHH Medical Affairs Mail Code: AG-300 P.O. Box 100238 Columbia, SC 29202-3238 • Local coverage determinations (LCDs) Send emails to [email protected]. Palmetto GBA • Responding to Additional J11 HHH Medical Review Documentation Requests Mail Code: AG-230 (ADRs) P.O. Box 100238 • Responses to our requests for Columbia, SC 29202-3238 medical records Please call the Provider Contact Center (PCC) at 855-696-0705 for Medical Review questions. Fed Ex/UPS/Overnight Courier Palmetto GBA - J11 MAC Mail Code: AG-230 2300 Springdale Drive, Building One Camden, SC 29020 Fax: (803) 699-2436 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 45 03/2015 Department Contact Information Type of Inquiry Medicare Secondary Payer For Coordination of Benefits Contractor (COBC) (MSP) questions, call 800-999-1118 or TTY/TDD at 800-318-8782 for the hearing and speech impaired. Customer Service Representatives are available to provide you with quality service Monday through Friday from 8 a.m. to 8 p.m. ET, except holidays. Overpayments Address for general written inquiries: Medicare - Coordination of Benefits P.O. Box 33847 Detroit, MI 48232 Palmetto GBA J11 HHH Overpayments Mail Code: AG-340 P.O. Box 100277 Columbia, SC 29202-3277 • MSP questions • Questions regarding beneficiary’s primary or secondary records The COB Contractor’s trained staff will help you with COB questions • Overpayments • Checks for cost reports and credit balances Provider Inquiries For inquiries regarding overpayments, please call the Provider Contact Center at 855-696-0705. Provider Audit Fax Numbers • To send any financial correspondence to the overpayment department by fax, please fax this information to (803) 419-3275 To request an immediate offset, fax your request to (803) 462-2574 Palmetto GBA Provider Audit Mail Code: AG-320 P.O. Box 100144 Columbia, SC 29202-3144 Palmetto GBA Cost Report Appeals and Reopenings Mail Code: AG-380 P.O. Box 100144 Columbia, SC 29202-3144 • Issues related to cost reports, desk reviews, audits and settlements • Issues related to the filing of cost report appeals and reopenings Email: Filing of Cost Report Appeals [email protected] Filing of Cost Report Reopenings [email protected] CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 46 03/2015 Department Provider Contact Center (PCC) Contact Information Type of Inquiry Palmetto GBA J11 HHH PCC Mail Code: AG-840 P.O. Box 100238 Columbia, SC 29202-3238 Provider Contact Center: 855-696-0705 Our PCC representatives are ready to answer your questions about billing problems and other issues. J11 HHH PCC Hours: 8 a.m. to 5 p.m. ET Provider Enrollment Email J11 HHH to have your inquiry answered. Please do not include any Protected Health Information. Palmetto GBA J11 HHH Provider Enrollment Mail Code: AG-331 P.O. Box 100144 Columbia, SC 29202-3144 For inquiries regarding provider enrollment, please call the Provider Contact Center at 855-696-0705. Provider Outreach and Education (POE) Palmetto GBA J11 HHH POE Mail Code: AG-830 P.O. Box 100238 Columbia, SC 29202-3238 • General coverage and Medicare-related questions • Crossover questions • Questions regarding claim filing requirements • Explanation of denial reasons • IVR resources • MSP resources • Modifier guidelines • Medical record documentation questions • Enrollment (credentialing) questions • Request CMS-855 B, I or R forms • Change address, add a location, add a new member to a provider group • Independent Diagnostic testing facility (IDTF) enrollment • Electronic Funds Transfer (EFT) CMS 588 form • Medicare Participating Physician or Supplier Agreement (PAR) CMS 460 form • How to obtain a National Provider Identifier (NPI) • Participation corrections • IRS 1099 tax form corrections • Consent forms • Educational training requests • Request a speaker for association meetings in your state For education, please complete the Education Request Form. To access this document, go to the Forms Web Page at www.PalmettoGBA. com/hhh/forms. CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 47 03/2015 Department Provider Reimbursement Contact Information Type of Inquiry Palmetto GBA Provider Reimbursement Mail Code: AG-330 P.O. Box 100144 Columbia, SC 29202-3144 • Submission of interim rate information • Reimbursement issues • Reimbursement specialist • Submission of certificates Provider inquiries, please call (803) 382-6104. Zone Program Integrity Contractor (ZPIC) Fax updated certificates for diabetes education to the reimbursement department at (803) 9350262. Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee home health and hospice providers • Fraud • Abuse • Questionable billing practices AdvanceMed, an NCI Company 520 Royal Parkway, Suite 100 Nashville, TN 37214 Phone Number: (615) 871-2361 Website: www.nciinc.com/about-us/ advancemed New Mexico, Oklahoma and Texas home health and hospice providers Health Integrity, LLC Website: www.healthintegrity.org Phone Number: (972) 383-0000 Florida home health and hospice providers SafeGuard Services 3450 Lakeside Drive, Suite 201 Miramar, FL 33027 Phone Number: (954) 433-6000 CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. 48 03/2015
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