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

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Presentation Transcript

Woodland Hills AAPCMedicare Seminar

Presented by

Kathy A. Montoya

Senior Provider Relations Representative

Palmetto GBA

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.


  • 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


  • Updates/Reminders

    • JE bid

    • Fee Schedule changes

    • Therapy Services

    • Ordering/Referring


  • Documentation

    • Principles of documentation

    • Common Errors

    • Amendments

A/B MAC Jurisdiction E

May 2013

Jurisdiction E Awarded

  • Announced September 20, 2012

  • Noridian Administrative Services (NAS)

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


Implementation Dates

  • Noridian will be the MAC for Jurisdiction E:

    • Part A – August 26, 2013

    • Part B –September 16, 2013

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


  • 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

  • Contact Information

    • phone numbers and mailing addresses

    • implementation questions

  • Current news and relevant changes

  • IVR

  • Schedule of Events

Key Website Items

  • Cutover dates

  • Payment cycles

  • FAQs

  • EDI - focus on vendors and direct submitters

  • Provider Portal

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 Information

  • Questions regarding implementation

    • Email to JEQuestions@noridian.com or

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

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


  • 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

2013 Part B Deductible and Coinsurance Rates



20% of eligible charges

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 A Premium

  • Fewer than 30 quarters

    • $441.00 per month

  • 30 to 39 Quarters

    • $243.00 per month


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 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 CareManagement Services (TMC)

  • New codes 99495 and 99496

    • Established patient

    • Moderate to high complexity medical decision making

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 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 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 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


  • Initial Psychiatric Evaluation

    • 90801 and 90802 were deleted

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

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)

  • CR7848

  • Effective January 1, 2013

  • Reduction to Technical Component (TC)

    • Diagnostic Cardiovascular

    • Ophthalmology procedures

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 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 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 Ophthalmology Payment Reduction Example


  • 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






123-45-6789A MALE




John D. Doe



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

  • Effective January 1, 2013

  • 2013 Therapy Cap amounts:

    • $1,900 for OT

    • $1,900 combined PT and SLP

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

  • 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 Status Codes

  • Three codes

    • Current status

    • Goal status

    • Discharge status

Severity Complexity Modifiers

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 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

  • 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

  • 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 Review



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 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

Reminders and Updates

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 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

    • N264 = Missing/incomplete/invalid ordering provider name

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

    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 ReferralMust Include

    • Specific services requested

      • CPT/HCPCS code

      • Indicate preventive or diagnostic

      • Use appropriate gender specific codes if applicable

    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 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

    • Don’t use nicknames

    • Don’t enter credentials (Dr.)

    • First name first, Second name second

      • John Smith

    • Use individual not group information


    • 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


    • Enrollment

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

    DocumentationImportant for BillingImportant for Audits

    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

    • 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

    • They happen

    • Be prepared

      • Create thorough documentation

      • Read request carefully

      • Use Medicare Self Help tools

      • Learn from mistakes

    Medicare Audits

    • Medical Review of Palmetto GBA

    • Comprehensive Error Rate Testing (CERT) program

    • Recovery Audit Contractors (RACs)

    • Zone Program Integrity Contractors (ZPICs)


    • Pre-payment or post payment

    • Documentation

      • Follow industry, specialty, CMS and Palmetto GBA guidelines

    Additional DocumentationRequest (ADR)

    • Outlines requested information

    • Indicates date of service(s)

    • Outlines timeline for return of documents

    • Provides return address

    Use Medicare Self HelpTools And Articles

    • www.PalmettoGBA.com/J1B

      • CERT section

      • Articles section

      • ADR Checklists

    Learn From Mistakes

    • Review results

      • Medical review audits

      • CERT and RAC audits

      • Office of Inspector General (OIG)

    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 RecordDocumentation

    • Thorough proper documentation

      • Verifies service/level provided

      • Key to audit success

      • Ensures payment for services rendered

      • Protects patients and provider

    Documentation ShouldPaint a Picture



    Medical RecordDocumentation

    • Evaluate, plan and monitor

    • Communication, coordination and continuity

    • Claims payment and review

    • Utilization and quality evaluations

    • Research and education

    Principles of Documentation

    • Complete and legible

      • Transcribe if necessary

    • Reason for encounter

    • Relevant history

    • Physical examination

    Principles of Documentation

    • Diagnostic test

      • Rationale for ordering

      • Results

    • Assessment, clinical impression or diagnosis

    • Plan for care

    • Date and legible signature

    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

    • 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 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


    • 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

    • 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

    • 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 Documentation

    • Paint picture of need for service

    • Vague statements not detailed enough

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

      • Give details

    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 received

    • Read ADR letter carefully

    • Check before responding

    • Send multiple dates if asked

    Missing Patient Name

    • Missing patient name on documentation

    • Check copies before mailing

      • Both sides

      • Beware of photocopies

    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

    • Physicians in same group, different specialties

      • Bill and paid regardless of group

    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

    • 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

    • “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

    • 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


    E & M Services

    • Grouped by categories and subcategories

      • Setting

      • Type of service

      • 3 to 5 levels of service

    Components of E/M Services

    Chief complaint



    Decision making

    Components of E/M Services


    Coordination of care

    Nature of presenting problem


    Evaluation and Management Scoresheet Tool

    Basic Patient Information

    History Components

    Review of Systems

    Physical Examination

    Medical Decision Making

    Amount and Complexity of Data Reviewed

    Assessment of Risk

    Counseling and/orCoordination of Care

    Selection of Code

    Select ‘Update”

    for CPT code


    Select ‘Print’

    to print a copy

    of scoresheet

    Common E/M Documentation/Coding 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/MDocumentation Errors

    • Medical necessity/reasonableness was not established

    • Illegible documentation

    • Billed in error (per physician/NPP)

    • Cloned records

    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/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/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/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/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 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

    • 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 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 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 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


    Please fill out Evaluations

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