Woodland hills aapc medicare seminar
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Woodland Hills AAPC Medicare Seminar. Presented by Kathy A. Montoya Senior Provider Relations Representative Palmetto GBA.

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Woodland hills aapc medicare seminar

Woodland Hills AAPCMedicare Seminar

Presented by

Kathy A. Montoya

Senior Provider Relations Representative

Palmetto GBA


Woodland hills aapc medicare seminar

The information provided in this presentation was current as of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Objectives

Objectives

  • To enhance the knowledge base of Medicare coverage and billing guidelines

  • To decrease the National Paid Claims Error Rate

  • To protect the Medicare Trust Fund

  • To ensure the delivery of quality care to our Medicare beneficiaries


Agenda

Agenda

  • Updates/Reminders

    • JE bid

    • Fee Schedule changes

    • Therapy Services

    • Ordering/Referring


Agenda1

Agenda

  • Documentation

    • Principles of documentation

    • Common Errors

    • Amendments


A b mac jurisdiction e

A/B MAC Jurisdiction E

May 2013


Jurisdiction e awarded

Jurisdiction E Awarded

  • Announced September 20, 2012

  • Noridian Administrative Services (NAS)


Jurisdiction e

Jurisdiction E

  • Noridian launched JE website April 16, 2013

    • https://www.noridianmedicare.com/je/

    • Outlines implementation timeline

    • Presents calendar of transition events

    • States physical presence in California


Https www noridianmedicare com je

https://www.noridianmedicare.com/je/


Implementation dates

Implementation Dates

  • Noridian will be the MAC for Jurisdiction E:

    • Part A – August 26, 2013

    • Part B –September 16, 2013


Communication resources

Communication Resources

  • Website/Listserv: www.noridianmedicare.com/JE

  • Contact provider organizations/associations

  • Meet and Greet meetings with providers

  • Mailings to providers

  • Web based provider workshops/ACTs


Listserv 2

Listserv2

  • For providers not registered with J1 prior to March 1, 2013

    • Go to: https://www.noridianmedicare.com and select “E-mail Newsletter Sign Up” at the bottom of the left hand navigation menu.

    • Instructions listed in Listserv article on JE website


Key website items

Key Website Items

  • Contact Information

    • phone numbers and mailing addresses

    • implementation questions

  • Current news and relevant changes

  • IVR

  • Schedule of Events


Key website items1

Key Website Items

  • Cutover dates

  • Payment cycles

  • FAQs

  • EDI - focus on vendors and direct submitters

  • Provider Portal


Contact information

Contact Information

  • Single Toll-free number after JE Implementation

    • Provider Contact Center (PCC)

    • Electronic Data Interchange Support Services (EDISS)

    • Telephone Reopenings

    • Provider Enrollment

    • User Security


Contact information1

Contact Information

  • Questions regarding implementation

    • Email to [email protected] or

    • Call Implementation Hotline at 1-800-361-8289

      • Hot Line available 8:00 am to 5:00 pm (PT), Monday-Friday


Welcome

Welcome

  • Noridian is proud to be your Medicare Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1. They look forward to working with you in the near future to serve your Medicare needs.


New costs

New Costs


2013 part b deductible and coinsurance rates

2013 Part B Deductible and Coinsurance Rates

Deductible-$147.00

Coinsurance

20% of eligible charges


2013 part a deductible and co pays

2013 Part A Deductibleand Co-Pays

  • $1,184 deductible

    • 1st 60 days of hospitalization

  • $296 co-pay

    • Days 61-90

  • $592 co-pay

    • Days 91 – 150 Lifetime Reserve

  • $148 co-pay

    • SNF days 21 - 100


2013 part b premiums

2013 Part B Premiums


2013 part a premium

2013 Part A Premium

  • Fewer than 30 quarters

    • $441.00 per month

  • 30 to 39 Quarters

    • $243.00 per month


Updates

Updates


Payment reduction april 1 2013

Payment ReductionApril 1, 2013

  • The Budget Control Act of 2011

    • Requires Federal spending reductions, sequestration

  • The American Taxpayer Relief Act of 2012 postponed sequestration for two months

    • President Obama issued a sequestration order on March 1, 2013


Payment reduction april 1 20131

Payment ReductionApril 1, 2013

  • Medicare FFS claims

    • Part B - dates-of-service ≥ April 1, 2013

    • Part A - dates-of-discharge ≥ April 1, 2013

    • Two percent reduction

  • CR7825


Transitional care management services tmc

Transitional CareManagement Services (TMC)

  • New codes 99495 and 99496

    • Established patient

    • Moderate to high complexity medical decision making


Transitional care management services tmc1

Transitional CareManagement Services (TMC)

  • Transition period from an inpatient setting (IP, LTC, SNF, rehab) to the patient’s community setting

  • TMC begins on date of discharge + 29 days

  • One face-to-face visit combined with non FTF services provided by physician or clinical staff


Transitional care management services tmc2

Transitional CareManagement Services (TMC)

  • Medical decision making/date of the first face-to-face visit are used to select the code

    • 99495 TMC service

      • Communication with patient/caregiver within 2 business days

      • Moderate complexity

      • Face to face within 14 calendar days of discharge


Transitional care management services tmc3

Transitional CareManagement Services (TMC)

  • 99496 TMC service

    • Communication with patient/caregiver within 2 business days

    • High complexity

    • Face to face with 7 calendar days of discharge


Transitional care management service tmc

Transitional CareManagement Service (TMC)

  • Date of Service = 30th day

  • Place of Service = POS for face to face visit

  • What if patient dies during the 30 day period

    • Bill E/M code only


Psychiatry

Psychiatry

  • Initial Psychiatric Evaluation

    • 90801 and 90802 were deleted

    • Distinction made between service by MD and one by non physician


Psychiatry new codes

Psychiatry – New Codes

  • 90782 = Initial evaluation with physician services

  • 90791 = Initial evaluation done by a non physician

  • 90785 = New add on code for interactive complexity


Multiple procedure payment reduction mpprs

Multiple Procedure Payment Reduction (MPPRs)

  • CR7848

  • Effective January 1, 2013

  • Reduction to Technical Component (TC)

    • Diagnostic Cardiovascular

    • Ophthalmology procedures


Multiple procedure payment reduction

Multiple Procedure Payment Reduction

  • Multiple services to same patient, same date

  • Affected codes

    • http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

  • Remittance Advice

    • Adjustment Reason Code 59


Multiple procedure payment reduction1

Multiple Procedure Payment Reduction

  • Cardiovascular Services

  • Same physician, or multiple physicians in same group

    • Full TC payment with highest value

    • Subsequent TC paid at 75%


Multiple procedure payment reduction2

Multiple Procedure Payment Reduction

  • Ophthalmology services

  • Same physician, or multiple physicians in same group

    • Full TC payment with highest value

    • Subsequent TC paid at 80%


Mpprs cardiovascular payment reduction example

MPPRs Cardiovascular Payment Reduction Example


Mpprs ophthalmology payment reduction example

MPPRs Ophthalmology Payment Reduction Example


Cr7260

CR7260

  • Health Insurance Claim Number (HICN) and Name Mismatch

  • Effective October 1, 2012

  • Claims will reject MA 130 and MA61

  • Take information exactly as shown on Medicare card


Woodland hills aapc medicare seminar

MEDICARE HEALTH INSURANCE

SOCIAL SECURITY ACT

NAME OF BENEFICIARY

JOHN D. DOE

MEDICARE CLAIM NUMBER SEX

123-45-6789A MALE

IS ENTITLED TO EFFECTIVE DATE

HOSPITAL INSURANCE (PART A) 1/1/98

MEDICAL INSURANCE (PART B)

John D. Doe

SIGN

HERE


Therapy services

Therapy Services


Multiple procedure payment reduction mppr for selected therapy services

Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services

  • CR 8206

  • Effective April 1, 2013

  • MPPR increased to 50% from 20% for all settings

    • Applies to the practice expense

    • Applies to HCPCS codes on the “always therapy” list


2013 financial limitation for outpatient therapy services

2013 Financial Limitation for Outpatient Therapy Services

  • Effective January 1, 2013

  • 2013 Therapy Cap amounts:

    • $1,900 for OT

    • $1,900 combined PT and SLP


2013 financial limitation for outpatient therapy services1

2013 Financial Limitation for Outpatient Therapy Services

  • Section 603 of American Taxpayer Relief Act of 2012

  • Outpatient Therapy claims cap

    • Extended through DOS December 31, 2013

    • $3,700 for PT and SLP

    • $3,700 for OT

  • Manual Review of claims > $3,700


Changes for therapy services in 2013

Changes for Therapy Services in 2013

  • Reporting requirements

    • Use Functional status codes

    • Use Functional Limitation modifiers

    • Every 10 treatments or 30 calendar days, whichever is earlier


Functional reporting g codes

Functional Reporting G-Codes


Functional reporting g codes1

Functional Reporting G-Codes


Functional status codes

Functional Status Codes

  • Three codes

    • Current status

    • Goal status

    • Discharge status


Severity complexity modifiers

Severity Complexity Modifiers


Functional reporting

Functional Reporting

  • Use of G codes and modifiers is required

    • At the onset of therapy episode of care

    • At least once every 10 treatment days


Functional reporting1

Functional Reporting

  • Same date of service that an evaluation/re-evaluation procedure

  • At the time of discharge from therapy episode of care

  • On the same date of service the reporting of a functional limitation is ended


Claim reporting

Claim Reporting

  • Onset of therapy and each reporting period

    • Report two G codes with modifiers

      • Current status, goal status

  • Discharge

    • Report two G codes with modifiers

      • Current status, discharge status


Manual medical review

Manual Medical Review

  • CMS Update March 21, 2013

  • Recovery Auditors (RA) to conduct MMR at $3,700 thresholds (PT and SLP, OT)

    • Prepayment Review Demo – California

    • Pos-tpayment Review – Nevada, Hawaii


Manual medical review1

Manual Medical Review

Reference

http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html


Manual medical review2

Manual Medical Review

  • Prepayment Review

    • California

      • Palmetto GBA to send a Additional Documentation Request (ADR) to provider

        • Request documentation be sent to the RA

      • The Recovery Auditor will conduct prepayment review

        • Within 10 business days of receiving documentation

        • Will notify Palmetto of payment decision


Manual medical review3

Manual Medical Review

  • Postpayment Review

    • Hawaii and Nevada

      • Palmetto GBA to send a Additional Documentation Request to the provider

        • Request documents be sent to the RA

      • The Recovery Audition will conduct a post payment review

        • Will notify Palmetto GBA of the payment decision


Ordered and referred services

Ordered and Referred Services

Reminders and Updates


Phase 1 ordering referring rejects

Phase 1Ordering/Referring Rejects

  • Affordable Care Act §6405

    • Required Ordering/Referring providers to be enrolled in Medicare

    • Name and NPI needed on claim

  • Phase 1

    • Began October 5, 2009

    • Incorrect, Missing information – rejected claim

    • Informational messaging on Remittance Advices


New edit phase 2

New EditPhase 2

  • Planned Effective/Implementation May 1, 2013 - Delayed

  • Claims will be denied when Ordering/Referring provider needed

    • Provider not enrolled in Medicare

    • No NPI on claim

    • Wrong specialty for service/supply

  • Denied as Non-covered


  • Denial reason codes

    Denial Reason Codes

    • N264 = Missing/incomplete/invalid ordering provider name

    • N265 = Missing/incomplete/invalid ordering provider primary identifier


    New edit resources

    New EditResources

    • SE1305

    • CRs 6421, 6417, 6696, 6856

    • Ensure your in PECOS

      • Look up your NPI

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html


    Order or referral must include

    Order or ReferralMust Include

    • Specific services requested

      • CPT/HCPCS code

      • Indicate preventive or diagnostic

      • Use appropriate gender specific codes if applicable


    Order or referral must include1

    Order or ReferralMust Include

    • Applicable ICD-9-CM code

      • Screening versus diagnostic codes

      • Sign or symptoms

      • Patient diagnosis

      • Use appropriate gender specific codes if applicable


    Order or referral must include2

    Order or ReferralMust Include

    • Ordering/Referring Provider’s Name and NPI number

    • Ordering/Referring Provider’s signature if necessary

    • Plan of Care if applicable


    Reporting ordering referring information

    Reporting Ordering/Referring Information

    • Don’t use nicknames

    • Don’t enter credentials (Dr.)

    • First name first, Second name second

      • John Smith

    • Use individual not group information


    Resources

    Resources

    • Fact Sheet

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

    • NPI registry

      • https://www.nppes.cms.hhs.gov/NPPES/Welcome.do


    Resources1

    Resources

    • Enrollment

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html


    Documentation important for billing important for audits

    DocumentationImportant for BillingImportant for Audits


    Basic coverage rule

    Basic Coverage Rule

    • Social Security Act in Section 1862 (A) 1

      • No payment for expenses not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member


    855 i section 15 bullet 4

    855 I, Section 15, Bullet 4

    • Abide by Medicare laws, regulations and program instructions

      • Provider must know

    • Claim payment based upon

      • Claim

      • Underlying transaction

      • Supplier’s compliance with conditions of participation


    Medicare audits

    Medicare Audits

    • They happen

    • Be prepared

      • Create thorough documentation

      • Read request carefully

      • Use Medicare Self Help tools

      • Learn from mistakes


    Medicare audits1

    Medicare Audits

    • Medical Review of Palmetto GBA

    • Comprehensive Error Rate Testing (CERT) program

    • Recovery Audit Contractors (RACs)

    • Zone Program Integrity Contractors (ZPICs)


    Audits

    Audits

    • Pre-payment or post payment

    • Documentation

      • Follow industry, specialty, CMS and Palmetto GBA guidelines


    Additional documentation request adr

    Additional DocumentationRequest (ADR)

    • Outlines requested information

    • Indicates date of service(s)

    • Outlines timeline for return of documents

    • Provides return address


    Use medicare self help tools and articles

    Use Medicare Self HelpTools And Articles

    • www.PalmettoGBA.com/J1B

      • CERT section

      • Articles section

      • ADR Checklists


    Learn from mistakes

    Learn From Mistakes

    • Review results

      • Medical review audits

      • CERT and RAC audits

      • Office of Inspector General (OIG)


    Code of federal regulations 42 cfr 424 5 a 6

    Code of Federal Regulations42 CFR 424.5 (a) (6)

    • Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.


    Medical record documentation

    Medical RecordDocumentation

    • Thorough proper documentation

      • Verifies service/level provided

      • Key to audit success

      • Ensures payment for services rendered

      • Protects patients and provider


    Documentation should paint a picture

    Documentation ShouldPaint a Picture

    CHOOSE A NORMAN ROCKWELL OR ANDREW WYETH PAINTING

    NOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE


    Medical record documentation1

    Medical RecordDocumentation

    • Evaluate, plan and monitor

    • Communication, coordination and continuity

    • Claims payment and review

    • Utilization and quality evaluations

    • Research and education


    Principles of documentation

    Principles of Documentation

    • Complete and legible

      • Transcribe if necessary

    • Reason for encounter

    • Relevant history

    • Physical examination


    Principles of documentation1

    Principles of Documentation

    • Diagnostic test

      • Rationale for ordering

      • Results

    • Assessment, clinical impression or diagnosis

    • Plan for care

    • Date and legible signature


    Principles of documentation2

    Principles of Documentation

    • Past and present diagnoses

    • Identify health risk factors

    • Patient's progress

    • Response to and changes in treatment

    • Revision of diagnosis

    • Support CPT and ICD-9-CM code selection


    General documentation tips

    General Documentation Tips

    • Patient name on each page and date of service

    • Templates/forms OK, but must be individualized

    • Computerized notes OK, but must be individualized


    General documentation tips1

    General Documentation Tips

    • Document time when coding is based on time (face to face)

    • Must be legible, when in doubt transcribe

    • Each entry must be signed (first, middle, last) with credentials

      • Signature log O.K. to use

      • Electronic signature O.K. to use


    Illegibility

    Illegibility

    • Read by others for treatment/care

    • Proof of services rendered

    • Illegibility leads to denials

    • ‘If it isn’t documented it didn’t happed’

    • Auditors cannot use inference in evaluation of records


    Missing provider signatures

    Missing Provider Signatures

    • Acceptable signature required

      • Each entry

      • First, middle and last name

      • Include credentials

      • Date

    • Use signature log or attestation statement

    • (CR) 6698

      • www.cms.gov/transmittals/downloads/R327PI.pdf


    Insufficient documentation

    Insufficient Documentation

    • Documentation should answer

      • What was wrong?

      • How was it manifested?

      • What did it look like?

      • What was the procedure to fix it?

      • What was the plan of care


    Insufficient documentation1

    Insufficient Documentation

    • Paint picture of need for service

    • Vague statements not detailed enough

      • ‘Status quo’, ‘no change’ or ‘patient stable’

      • Give details


    Insufficient documentation2

    Insufficient Documentation

    • Medical documentation submitted does not include pertinent patient facts (e.g., patient’s overall condition, diagnosis, extent of services performed)

  • Use narrative with chart templates

  • Document need for a complete or comprehensive services


  • Incorrect date of service

    Incorrect Date Of Service

    • Incorrect date of service received

    • Read ADR letter carefully

    • Check before responding

    • Send multiple dates if asked


    Missing patient name

    Missing Patient Name

    • Missing patient name on documentation

    • Check copies before mailing

      • Both sides

      • Beware of photocopies


    New patient versus established patient denials

    New Patient VersusEstablished Patient Denials

    • ‘New patient’

      • Not seen within the previous three years

      • From physician or physician group practice (same physician specialty)

      • Hospital services count


    Combined billing

    Combined Billing

    • Physicians in same group, different specialties

      • Bill and paid regardless of group


    Combined billing1

    Combined Billing

    • Physician in same group, same specialties

      • Bill and paid as single physician

      • Only one E/M per day

      • Unless unrelated problems

      • Select E/M level to incorporate all


    Documenting services

    Documenting Services

    • Comments Field – NTE 02

      • Provide explanation of multiple physician treatment

      • Identify subspecialty if applicable

    • Send documentation when requested or for appeals

      • Show need for1+ visits per day

      • Identify subspecialty if applicable


    E m guidelines

    E & M Guidelines

    • “1995 Documentation Guidelines for Evaluation and Management Services”

    • “1997 Documentation Guidelines for Evaluation and Management Services.”

    • Use either set

    • Use only one per E & M service


    E m guideline resources

    E & M Guideline Resources

    • IOM 100-04, Chapter 12, §30.6

      • http://www.cms.gov/manuals/downloads/clm104C12.pdf

    • CMS “Evaluation and Management Services Guide”

      • http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp


    Http www cms gov mlnproducts downloads eval mgmt serv guide pdf

    http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    E m services

    E & M Services

    • Grouped by categories and subcategories

      • Setting

      • Type of service

      • 3 to 5 levels of service


    Components of e m services

    Components of E/M Services

    Chief complaint

    History

    Exam

    Decision making


    Components of e m services1

    Components of E/M Services

    Counseling

    Coordination of care

    Nature of presenting problem

    Time


    Evaluation and management scoresheet tool

    Evaluation and Management Scoresheet Tool


    Basic patient information

    Basic Patient Information


    History components

    History Components


    Review of systems

    Review of Systems


    Physical examination

    Physical Examination


    Medical decision making

    Medical Decision Making


    Amount and complexity of data reviewed

    Amount and Complexity of Data Reviewed


    Assessment of risk

    Assessment of Risk


    Counseling and or coordination of care

    Counseling and/orCoordination of Care


    Selection of code

    Selection of Code

    Select ‘Update”

    for CPT code

    selection

    Select ‘Print’

    to print a copy

    of scoresheet


    Common e m documentation coding errors

    Common E/M Documentation/Coding Errors


    Common e m documentation errors

    Common E/MDocumentation Errors

    • Missing documentation

      • Beneficiary’s name

      • Date of Service

      • Rendering physician’s/NPP’s signature

      • Supporting documentation (referred to ROS, PFSH, or orders)

    • Minimum documentation requirements not met (down coded)


    Common e m documentation errors1

    Common E/MDocumentation Errors

    • Medical necessity/reasonableness was not established

    • Illegible documentation

    • Billed in error (per physician/NPP)

    • Cloned records


    Common e m documentation errors2

    Common E/MDocumentation Errors

    • The chief complaint/reason for visit was not clearly documented

    • Billed higher level services

    • Extensive PFSH was documented for lower-level services


    Common e m documentation errors3

    Common E/MDocumentation Errors

    • Complete PFSH was missing

      • New patient or initial services

  • Expansive ROS was documented for lower-level services

  • Missing ROS for the system(s) related to the presenting problem or system(s) related to the presenting problem were “negative”


  • Common e m documentation errors4

    Common E/MDocumentation Errors

    • Documented diagnoses under ROS

    • Extensive examination was documented for lower level services

    • Unable to determine if diagnosis/problem is stable or worsening


    Common e m documentation errors5

    Common E/MDocumentation Errors

    • The assessment contained a list of diagnoses/problems that were not addressed during the encounter

    • Documented “labs reviewed” without further information

    • Unable to determine if the physician/NPP independently reviewed image, tracing, or specimen


    Common e m documentation errors6

    Common E/MDocumentation Errors

    • Didn’t summarize old records/history from others

    • Ancillary staff/scribe documentation requirements were not met

    • Counseling/coordination of care missing time/documentation

    • Incident to requirements were not met


    Medical record amendments

    Medical Record Amendments


    Medical record amendments1

    Medical RecordAmendments

    • General Medicare requirements

      • After medical records are sign & dated

        • Additional information can be added in form of an appropriate Amendment or addendums

        • On rare occasions & not used as common practice


    Accepted as an appropriate addendum to medical records

    Accepted as an Appropriate Addendum to Medical Records

    • Must be added timely within a few days/one week

    • Must contain individualized, patient-specific clinical information for each date of service amended.

      • Blanket statements, declarations or attestations not accepted


    Accepted as an appropriate addendum to medical records1

    Accepted as an Appropriate Addendum to Medical Records

    • Should be chronological in records

    • Must be legible, signed and dated

    • Should address additional, clinically relevant information

      • Not added to meet regulatory requirements

      • Not added to support downcoded claim


    Making corrections to the medical record

    Making Correctionsto the Medical Record

    • Follow legal requirements

      • Never write over, erase, or obliterate an entry

      • Draw a single line through incorrect information

        • Write correction near deletion

        • All information should still be legible

        • Should be signed and dated


    Making corrections to the medical record1

    Making Correctionsto the Medical Record

    • A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed

      • A full explanation of why the record was in error

      • Practitioner should sign and date the correction


    Questions

    Questions?

    Please fill out Evaluations


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