Jurisdiction 11 (J11) Part A Medicare Updates and Reminders

HFMA West Virginia Chapter Meeting

January 18, 2012

Disclaimer

This presentation was current at the time it was published or uploaded onto the Palmetto GBA Web site. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Agenda

• J11 Part A Medicare Updates

• J11 Part A Medicare Reminders

J11 Part A Medicare Updates

Additional Way to Submit Medical Record Documentation: Update

MLN Matters® Number: MM7254 Related Change Request (CR) #: 7254MLN Matters® Number: SE1110 Revised Medicare Pilot Project forElectronic Submission of Medical Documentation (esMD). Effective: January 15, 2012

• Palmetto GBA providers will be able to submit medical records via esMD. • In order to send medical documentation electronically to review

contractors, Medicare providers, including physicians, hospitals, and suppliers, must obtain access to a CONNECT-compatible gateway.

• Certain larger providers, such as hospital chains, may choose to build their own gateway.

• Many providers may choose to obtain gateway services by entering into a contract or other arrangement with a Health Information Handler (HIH) that offers esMD gateway services.

• For more information about esmd, see www.cms.gov/esmd

Medicare Fee-For-Service (FFS) Policy Regarding 90 Day Discretionary Enforcement Period for Non-

Compliant HIPAA Covered Entities  • The Centers for Medicare and Medicaid Services (CMS) announced it would notinitiate enforcement action with respect to any HIPAA covered entity that is noncompliant with Version 5010, NCPDP, NCPDP D.0 and 3.0 standards until 90 daysafter the upcoming January 1, 2012 compliance date. • Although compliance will not be enforced for Version 5010 until April 1, 2012, it

isimportant to continue to take the necessary steps to complete your transition to Version5010 as soon as possible. • Medicare FFS is planning to take the following steps for submitters and receivers

of Medicare Part B and Durable Medical Equipment (DME) transactions: – In December 2011, submitters and receivers that have tested and been approved for

5010/D.0 will be notified that they have 30 days to cutover to the 5010/D.0 versions. – Submitters and receivers that have not yet tested will be notified in December 2011 that

they must submit their transition plans and timelines to their MAC within 30 days. – MACs will notify the submitters and receivers, but submitters/receivers have the

responsibility to notify the providers they service. • Note: Submitters and receivers of Medicare Part A transactions will follow the

same action plan starting 30 days after Part B and DME.

New ASC X12 Version 5010 FAQs Posted to the CMS Web site

• CMS has published six FAQ items related to 90 Day Discretionary Enforcement Period for Non-Compliant HIPAA Covered Entities

• These new FAQs can be found at: http://www.cms.gov/Versions5010andD0/Downloads/QandA_for_90_day_announcement.pdf

• For more information on ASC X12 Version 5010, NCPDP D.0, and NCPDP 3.0; please visit www.CMS.gov/Versions5010andD0

Update to Medicare Deductible, Coinsurance and Premium Rates for 2012

MLN Matters® Number: MM7567 RevisedRelated Change Request (CR) #: CR 7567 Effective Date: January 1, 2012 Implementation Date: January 3, 2012 • The 2012 inpatient deductible is $1,156.00. • The coinsurance amounts are shown below in the following table:

Hospital Coinsurance Hospital Coinsurance SNF Coinsurance

Days 61-90 Days 91-150 (Lifetime Reserve Days)

Days 21-100

$289.00 $578.00 $144.00

Update to Medicare Deductible, Coinsurance and Premium Rates for 2012

• 2012 Part B - Supplementary Medical Insurance (SMI)

Standard Premium: $99.90 a month

Deductible: $140.00 a year

Coinsurance: 20%

Screening and Behavioral Counseling Interventions in Primary Care to Reduce

Alcohol Misuse

MLN Matters® Number: MM7633 Related Change Request (CR) #: 7633 Effective Date: October 14, 2011 Implementation Date: December 27, 2011, for local contractorsystem edits; April 2, 2012-for Medicare’s shared system edits,July 2, 2012 for provider inquiry screens & HICR changes

• CMS will cover annual alcohol screening, and for those that screen positive, up to 4, brief, face-to-face behavioral counseling interventions annually for Medicare beneficiaries, including pregnant women.

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)

MLN Matters® Number: MM7636 Related Change Request (CR) #: 7636 Effective Date: November 8, 2011 Implementation Dates: December 27 for local Medicare Contractor systemedits; April 2,  2012, for Medicare shared system edits; and July 2, 2012,

CWFprovider screens and HICR changes 

• CMS covers IBT for CVD, inclusive of one face-to-face CVD risk reduction visit annually.

• The Medicare patient receiving this care must be competent and alert at the time the service is rendered and the service must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting.

Therapy Cap Values for Calendar Year (CY) 2012

MLN Matters® Number: MM7529 Revised Related Change Request (CR) #: 7529 Effective Date: January 1, 2012 Implementation Date: January 3, 2012

• Therapy caps for 2012:

• If Congress extends the therapy cap exceptions process, CMS will provide an update to inform providers of the details of such extension.

PT and SLP Combined: $1880.00

OT: $1880.00

Screening for Depression in Adults

MLN Matters® Number: MM7637 Related Change Request (CR) #: 7637 Effective Date: October 14, 2011 Implementation Date: April 2, 2012 

• Medicare covers annual screening for adults for depression in the primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. 

• Medicare contractors will recognize new Healthcare Common Procedure Coding System (HCPCS) code, G0444, annual depression screening, 15 minutes, as a covered service.  

NOTE: This code will appear on the January 2012 Medicare Physicians Fee Schedule update. TheType of Service (TOS) for HCPCS code G0444 is 1. Effective October 14, 2011, beneficiarycoinsurance and deductibles do not apply to claim lines with annual depression screening, G0444.For Dates of Service on or after October 14, 2011, through December 31, 2011, Medicarecontractors will use their pricing for paying HCPCS code G0444 and update their HCPCS filesaccordingly

 

President Obama Signs the Temporary Payroll Tax Cut Continuation Act of 2011

(TPTCCA)

• On Friday, December 23, 2011, President Obama signed into law the TPTCCA.

• This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect immediately. 

• The negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012.

• CMS Web site for the updated 2012 MPFS Public Use Files at: http://www.cms.gov/PhysicianFeeSched/PFSNPAF/list.asp#TopOfPage. 

Correct Provider Billing of Admission Date and Statement Covers Period

MLN Matters® Number: SE1117 Related Change Request (CR) #: N/A Effective Date: N/A Implementation Date: N/A

• In collaboration with the National Uniform Billing Committee’s (NUBC) definition for reporting of the Admission Date and Statement Covers Period elements on claims, the CMS would like to remind you to review the NUBC definitions for claims submitted on or after October 1, 2011 with a discharge date of July 1, 2011 forward.

• This edit logic change does not apply for claims with a discharge date prior to July 1, 2011.

• The Admission Date (Form Locator 12) is the date the patient was admitted as an inpatient to the facility. It is reported on all inpatient claims regardless of whether it is an initial, interim, or final bill.

• The Statement Covers Period (“From” and “Through” dates in Form Locator 6) identifies the span of service dates included in a particular bill. The “From” Date is the earliest date of service on the bill.

Correct Provider Billing of Admission Date and Statement Covers Period

• Previously, Medicare’s Fiscal Intermediary Shared System (FISS) edits required that the Admission Date not be later than the “From” date on initial provider claims as required to match NUBC UB-92 definitions. In order to pass FISS edits and avoid getting a claim rejected, providers may have engineered workarounds that force the two dates to match.

• CMS has issued instructions to FISS for modifying FISS edits regarding these data elements to match NUBC UB-04 definitions:

• Based on UB-04 definitions of these two data elements, CMS has modified FISS edits so Admission Date and “From” Dates are not required to match.

• Based on UB-04 definitions of these two data elements, CMS has modified FISS edits so as not to compare the number of days in the Statement Covers Period to any other data element (e.g., total accommodation days reported in the revenue code section).

• As a reminder, you should verify your systems edit logic for correct application of these data elements. If you implemented workaround routines, you need to deactivate them. You should contact your trading partners to ensure they are aware of the changes and that they are taking the appropriate steps to correct any edit logic. Please ensure that your staffs are aware of these upcoming changes.

2011 Version of Advance Beneficiary Notice of Noncoverage Must Be Used Beginning

January 1, 2012

– In May 2011, CMS released an updated version of the ABN (form CMS-R-131), which will replace the 2008 version of this form.

– The 2011 version contains no substantive changes from the 2008 version of the notice.

– The 2008 and 2011 ABN notices are identical except that the release date of '3/11' is printed in the lower left hand corner of the new version. 

– The ABN is used by all providers, practitioners and suppliers paid under Medicare Part B, as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A.

2011 Version of Advance Beneficiary Notice of Noncoverage Must Be Used

Beginning January 1, 2012

– Providers and suppliers are allowed to use either the 2008 or 2011 version of the ABN through the end of this year.

– Beginning January 1, 2012, they must begin using the 2011 version. 

– ABNs issued after January 1 that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors.

– 2008 versions of the ABN that were issued prior to January 1 as long-term notification for repetitive services delivered for up to one year will remain effective for the length of time specified on the notice.

– Reference: www.CMS.gov/BNI, under the 'FFS Revised ABN' link.

Hospital Routine Services under Arrangement Requirement

– Per the FY 2012 IPPS final rule:

– Only therapeutic and diagnostic services may be furnished outside of the hospital ‘under arrangement’.

– ‘Routine Services' (for example, bed, board, and nursing services) must be provided by the hospital.

• ‘Routine Services’ that are furnished in the hospital to its inpatients are considered as being provided by the hospital.

• If ‘Routine Services’ are provided outside of the hospital, the services are considered as being provided under arrangement.

– Beginning with the FY 2013, all hospitals will need to be in full compliance with the modified under arrangement provisions.

J11 Part A Medicare Reminders

Provider Contact Center (PCC) Training and Holiday Closure Schedule

• The PCC will continue to close up to eight hours per month for customer service representative (CSR) training and staff development.

• The Interactive Voice Response (IVR) unit will be available during these scheduled training sessions for automated customer service transactions.

• Listed below are training closure dates and times:

January 2, 2012 Office closed/New Year's Day

January 5, 2012 PCC closed 2:30 p.m. - 4:30 p.m

January 12, 2012  PCC closed 2:30 p.m. - 4:30 p.m.

January 16, 2012 Office closed/MLK Day

January 19, 2012 PCC closed 2:30 p.m. - 4:30 p.m.

January 26, 2012 PCC closed 2:30 p.m. - 4:30 p.m.

Reminder - Quarterly Release Temporary Hold

• Each quarter, the Fiscal Intermediary Shared System (FISS) is updated to include new logic for claims processing, pricing, etc.

• Palmetto GBA places a temporary 'hold' to ensure the release is installed properly.

• Claims with dates of service January 1, 2012, or later will be held

• Claims will be released on or about January 13, 2012, to continue processing.

Reason Code Status Location Description

36231 SM6231 ESRD Claims (72X TOB)

37147 SM7147 IRF Claims

37148 SM7148 Swing-Bed PPS SNF Claims

37150 SM7150 PPS Claims

37167 SM7167 LTCH PPS Claims

37181 SMPRIC IPF Claims

IPPS1 SMOPPS OPPS Claims

WW999 SMFISS Holds All Claims

7OUTP SMOUTP TOB 13X, 14X, 12X, 22X, 23X, 34X, 71X, 74X, 75X, 76X, or 85X

Reminder - Quarterly Release Temporary Hold

J11 Part A Claims Processing Issues Log

– www.palmettogba.com/J11A– Select Claims Processing Issues Log

• System Issues Reported to CMS and /or FISS

• Affecting multiple providers and/or large numbers of claims

• Updated at least weekly

Current Claims Issues

Provider Types Affected

Situation Impact to Providers Status

J11 Part A A system release incorrectly affected the Release of Information (RI) field for the payer ID. Claims are auto populating a value of 'N' instead of 'Y' for the RI field for the payer ID.

This is causing claims to deny incorrectly with reason code 31313. 

12/22/2011The scheduled system fix is ongoing. For providers with claims that are still being affected, you are able to correct the RI field of the claim.

J11 Part A Medicare Secondary Payer (MSP) claims are returning to the provider (RTP) incorrectly with reason code 33981.

MSP claims with  contractual obligation value code 44 are being affected. The contractual obligation amount and the OTAF amount are not balancing out. 

12/22/2011Additional claims have been identified as being affected by this issue. The issue is still being researched by the FISS maintainer.

Current Claims Issues

Provider Types Affected

Situation Impact to Providers Status

J11 Rural Health Clinics (RHCs)

The Centers for Medicare & Medicaid Services (CMS) has instructed Palmetto GBA to hold all rural health clinic claims (type of bill 71x) containing preventative services noted in Change Request 7208.  

Claims impacted by this issue will be held in a suspense location until a correction is implemented.  

  12/22/2011A fix is scheduled for January 2012.

J11 Part A The July 2011 system release incorrectly affected Medically Unlikely Edits (MUEs) for several HCPCS/CPT codes.

Claims submitted with HCPCS/CPT codes affected by this issue are denying incorrectly with reason code 51MUE or 52MUE.

12/22/2011CMS will begin to adjust claims mid-January 2012.

Current Claims Issues

Provider Types

Affected

Situation Impact to Providers Status

J11 Skilled Nursing Facilities (SNFs) and Swing Bed (SB)

J11 Skilled Nursing Facilities (SNFs) and Swing Bed (SB)Change Request (CR) 7019, effective January 1, 2011, instructs providers to report the ARD date with occurrence code 50. However, the Health Insurance Prospective Payment System (HIPPS) code AAA00 does not need an accompanying occurrence code 50. 

SNF and swing bed claims billed with the default HIPPS code AAA00 (no-pay bills) are editing incorrectly with reason code 31742 and cannot continue to process.

12/22/2011The implemented fix did not address all issues. Therefore, a new fix is in research status. This revised fix is being scheduled.

Provider Types

Affected

Situation Impact to Providers Status

 J11 Part A Effective for claims with dates of service on or after May 9, 2011, Medicare will begin paying for CPT code 90654, influenza virus vaccine, split virus, preservative-free, for intradermal use.

CMS has instructed Medicare contractors to hold all institutional claims containing CPT code 90654 with dates of service on or after May 9, 2011 until their systems are able to accept them for processing no later than April 2, 2012.

Providers have the option to hold their claims containing CPT code 90654 until Monday, April 2, 2012. 

12/22/2011CMS will issue a Change Request when system update occurs no later than April 2, 2012, and claims may be released. Providers may refrain from submitting claims containing CPT code 90654 until April 2, 2012.

   

Current Claims Issues

Provider Types

Affected

Situation Impact to Providers Status

 J11 Part A Under the Inpatient Prospective Payment System (PPS), hospitals receive a special add-on payment for the costs of furnishing blood clotting factors to Medicare beneficiaries with hemophilia, admitted as inpatients of PPS hospitals.  The clotting factor add-on payment is automatically calculated by FISS. 

FISS is not applying the blood clotting factor add-on payment when billed on inpatient PPS claims.  These claims are only receiving the DRG payment.

12/22/2011The issue is currently being researched by the FISS maintainer.  

   

Current Claims Issues

FISS System Issue-Physical Therapy Denials

• We are having issues with ICD 9 and CPT codes related to physical therapy and therefore some PT claims are denying incorrectly.   

• The problem is that FISS has not been updated with the new codes. This is a FISS system issue and FISS is currently working on a resolution. 

• We are having to manually work these claims in the mean-time. 

Probe Medical Review of Inpatient Medical Severity Diagnostic Related Group (MS-

DRG)

• The J11 A/B MAC Medical Review department will perform a service-specific prepay probe review on inpatient hospital claims in Virginia and West Virginia.

• Data analysis identified inpatient hospital services and the circulatory Medical MS-DRGs as number one in these states.

• Further analysis indicated the Medical MS-DRGs listed below as the top three for Virginia and West Virginia.

• Claims review will be performed on approximately 100 claims per state for each of the Medical MS-DRGs selected.

• The DRGs identified are:– DRG 291 (Heart Failure & Shock w/MCC) – DRG 247 (Percutaneous cardiovascular proc w/drug-eluding stent w/o MCC) – DRG 292 (Heart Failure & Shock w/CC)

• Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

Palmetto GBAJ11 Part A Medical ReviewMail Code: AG-230P.O. Box 100238Columbia, SC  29202-3238

Or fax to (803) 699-2432

Probe Medical Review of Inpatient Medical Severity Diagnostic Related Group (MS-

DRG)• Hospitals should ensure the accuracy of their billing and send the following documentation

when responding to the ADRs:– Hospital history and physical – Physician’s orders for the admission to inpatient and all services billed – Plan of care – Diagnostic test results/reports, including imaging reports – Itemized list of all charges – Clinical/therapy notes – Hospital admission assessment – Consultation reports – Physician progress notes – Hospital discharge summary

• Please submit all documentation to support the medical necessity of services/DRG code billed • If you question the legibility of your signature, you may submit a signature log or an

attestation statement in your ADR response. Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable. Patient identification, date of service and provider of the service should be clearly identified on the submitted documentation.

• Completed review results will be posted to the Palmetto GBA Web Site. Individual providers with significant denials will be contacted for one-on-one education.

Questions regarding this review may be directed to the Medical Review department at (803) 763-7491. 

Responding to a Skilled Nursing Facility (SNF) Additional

Documentation Request (ADR)The following list is a recommendation for what to include when responding to a SkilledNursing Facility (SNF) Additional Document Request (ADR):• The hospital transfer/discharge summary• Physician’s certification that the beneficiary has a need for daily skilled care in the SNF• Physician’s recertification(s) that the beneficiary has a need for continuing daily skilled

care in the SNF• Physician’s orders for the look back period(s) and the dates of service under review• Nurses' notes for the look back period(s) and the dates of service under review.

Documentation should support the look back periods related to the assessment reference dates of the submitted MDS(s). It may include documentation 30 through 45 days prior to the dates of service under review.

• Therapy documentation (including the look back period) - Documentation to support therapy services must include the following:a) Physician’s orders for therapy servicesb) Initial therapy evaluation and any subsequent evaluationsc) Plans of treatmentd) Signed therapy daily treatment notes and progress notese) Documentation of the actual minutes of therapy rendered for each therapy session. Therapy minutes may be recorded on a grid or in the therapy documentation. f) Documentation of the number of group participants per therapist

Responding to a Skilled Nursing Facility (SNF) Additional

Documentation Request (ADR)

• Physician’s orders for therapy services and therapy plans of treatment must be signed and dated by the physician. Medical necessity of services must be apparent in the therapists’ documentation.

• Any additional documentation necessary to support the medical necessity of services (e.g., social worker notes, pertinent lab and X-ray reports, consultations, aide notes, etc.).

• When responding to an ADR for a condition code 20 claim, a copy of the signed and dated notice of non-coverage issued to the beneficiary/representative must be submitted for review

• Please send a manifest with medical records submitted and send the medical records in secure packaging to ensure the security of medical records

• If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.

• Attach a copy of the ADR request to each individual claim• Use one staple or elastic band per record to attach the documentation and ADR

together. Do not use paper clips as they can become dislodged.• Do not punch holes in medical records, as this may obscure valuable information• Return the medical records to the appropriate address listed below or on the ADR

Responding to a Skilled Nursing Facility (SNF) Additional

Documentation Request (ADR)

For Postal Delivery Please Use:J11 Part A Medical ReviewMail Code: AG-230P.O. Box 100238Columbia, SC 29202-3238

For FedEx/UPS/Certified Mail:J11 Part A Medical ReviewMail Code: AG-2302300 Springdale Drive, Building OneCamden, SC, 29020-1728

• Do not include any correspondence other than ADR responses to the Medical Review department in your envelope

• If billing corrections are needed, submit a hardcopy UB-uniform billing (latest version from CMS), with a XX7 bill type along with your medical records

• We are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.

The Palmetto GBA Medical Review Department developed a Responding to a SkilledNursing Facility (SNF) ADR checklist. Please complete this checklist and include itwhen responding to an ADR. This checklist is available on the Palmetto GBA Website: Responding_to_a_SNF_ADR_checklist_rev08162011.pdf (PDF, 27 KB)

The J11 Part A Outlier Billing Webinar handout is available

• www.PalmettoGBA.com/J11A

• Select Learning and Education

• Select Workshop Handouts

• Select the PDF file to download or print: J11A_Outlier_Billing_Webinar_102011.pdf (PDF, 157 KB)

FAQs: Additional Medical Review Projects and CERT

• To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto GBA was recently funded by CMS to undertake additional medical review projects that involve medical review of and education for certain E/M coded claims, advanced imaging claims, major procedure claims, inpatient hospital claims and home health claims that contributed to the majority of the J11 MAC CERT payment errors.

• Providers selected for education and/or medical review are selected based on the frequency of their billings for the services/codes mentioned above. Palmetto GBA’s educational and review efforts will primarily focused on reducing payment errors from insufficient documentation and improper coding. Providers will receive written results of the project’s findings if being selected for medical review.

• FAQs were developed to help clarify what the additional medical reviews involved and how providers can help in the process.

– www.PalmettoGBA.com/J11A– Select CERT– Select General– Select FAQs: Additional Medical Review Projects and CERT

• For more information, please refer to the article 'The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests.

What to do if you have a claim that needs to have timely filing overridden to process

and pay back an overpayment• If the claim is still online:

– Adjust the claim– Put in remarks you need timeliness overridden to repay a Medicare

overpayment • If it is offline:

– Call the PCC to request it be placed back online – Once the claim is back online, make the adjustment– Put in remarks you need timeliness overridden to repay a Medicare

overpayment • This will assure the claim is correct in case it is reviewd in the

future and it assures you know the correct amount to pay back to Medicare.

• The only time you report it on the credit balance report is if the claim did not get adjusted to repay that quarter.

• Note: Timeliness will NOT be overridden to pay an underpayment to the provider.

Determining to Appeal

Providers can appeal a claim or claim line that receives a full orpartial medical denial. If a claim or line item is medically denied(status location = D B9997) and the provider has medicalevidence that the service should be covered by Medicare, anappeal may be submitted by using the First Request:• Redetermination Request Form• To access this form, go to www.PalmettoGBA.com/J11A• Select Forms from the Top Links box on the left navigation

Determining to Adjust

Claims that are processed, paid, or rejected (status location code = P B9997 or R B9997) and are 'posted' to Medicarehistory in the Common Working File (CWF) can be adjusted. If a historical record of a claim exists in CWF, anadjustment transaction must be processed to update the historical record. These adjustments may be made throughDirect Data Entry (DDE) or through a vendor’s software. It is important to note if the claim was partially denied, (i.e.,the claim contains a medically denied line), the adjustment cannot be done through DDE. Please refer to theinstructions below for submitting a Clerical Error Reopening Request Form.

When to Submit an Online AdjustmentProviders can submit an online adjustment using bill type XX7 to correct: • Number of inpatient days • Claims coding • Adding additional charges • Blood deductible • Servicing hospital • Inpatient cash deductible of more than $1 • Diagnosis Related Group (DRG) code * • Discharge status in a Prospective Payment System (PPS) hospital • Outlier payment amount *If an adjustment the hospital initiates results in a change to a higher weighted DRG, the Medicare contractor edits theadjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.If it is, the Medicare Contractor processes the claim for payment. If the remittance date is more than 60 days prior tothe receipt date of the adjustment request and results in a change to a lower weighted DRG, the Medicare Contractorprocesses the claim for payment and forwards it to CWF.

The proper way to submit an adjustment claim (bill type XX7) that had previously

denied lines• The proper way to submit an adjustment claim (bill type XX7) that had

previously denied lines is to delete all non-covered lines and re-enter the lines with the corrections. This will prevent the claim from processing as non-covered a second time.

• Providers should remember to use the following instructions when correcting revenue code lines in Direct Data Entry (DDE):

To delete an entire revenue code line: – TAB to the line and type zeros over the top of the revenue code to be deleted or type 'D' in the

first position – Press HOME to go to the Page Number field. Press ENTER. The line will be deleted. – Next, add up the individual line items and correct the total charge amount on Revenue Code line

(0001)

To add a Revenue Code line: – TAB to the line below the total line (0001 revenue code) – Type the new revenue code information – Press HOME to go to the Page Number field. Press ENTER. The system will resort the

revenue codes into numerical order. – Correct the total charge amount of revenue code line (0001)

The proper way to submit an adjustment claim (bill type XX7) that had previously

denied linesTo change total and non-covered charge amounts:

– TAB to get to the beginning of the total charge field on a line item – Press END to delete the old dollar amount. It is very important not to use the spacebar to

delete field information. Always use END when clearing a field. – Type the new dollar amount without a decimal point (e.g., for $23.50 type '2350') – Press ENTER. The system will align the numbers and insert the decimal point. – Correct the totals line if necessary – Press F9 to update/enter the claim into DDE for reprocessing and payment

consideration. If the claim still has errors, reason codes will appear at the bottom of the screen. Continue the correction process until the system takes you back to the claim correction summary. When the corrected claim has been successfully updated, the claim will disappear from the screen. The following message will appear at the bottom of the screen: ‘PROCESS COMPLETED – ENTER NEXT DATA.’

• Reference: Direct Data Entry (DDE) Manual (PDF, 4.75 MB)

Reminder About Adjustments On Claims With Medically Denied Lines:

• If a line item on a claim is medically denied (status location = D B9997) and the provider has medical evidence that he or she thinks should allow the denied service to be covered by Medicare, an appeal must be filed using the Redetermination Request Form.

• If there is a medically denied line item on the claim, but the provider needs to adjust the claim to make a change to something OTHER THAN the denied line item, the provider may key the adjustment in the system with the appropriate condition code(s) that describes the change(s) on the claim. Once adjusted, the claim will go to an S “suspense” status and location to be reviewed by the claims department before processing.

• If there is a medically denied line item on the claim, and the Fiscal Intermediary Shared System (FISS) does not allow the provider to make an online adjustment: – In this instance, the provider should submit a hard copy adjustment using the:– Clerical Error Reopening Request Form – www.PalmettoGBA.com/J11A – Select Forms from the Top Links box on the left navigation

When to Submit a Clerical Error Reopening Form

The Centers for Medicare & Medicaid Services (CMS) defines clerical errors (including minor errors oromissions) as human or mechanical errors on the part of the party or the contractor, such as: • Mathematical or computational mistakes • Transposed procedure or diagnostic codes• Inaccurate data entry • Misapplication of a fee schedule Computer errors Denial of claims as duplicates which the party believes were

incorrectly identified as a duplicate • Incorrect data items, such as provider number, use of a modifier or date of service • If there is a medically denied line item on the claim, the Fiscal Intermediary Shared System (FISS) may not allow

the provider to make an online adjustment. – In this instance, the provider should submit a hard copy adjustment using the:– Clerical Error Reopening Request Form – www.PalmettoGBA.com/J11A – Select Forms from the Top Links box on the left navigation

Note: Clerical errors or minor errors are limited to errors in form and content, and that omissionsdo not include failure to bill for certain items or services. A contractor shall not grant a reopeningto add items or services that were not previously billed, with the exception of a few limited itemsthat cannot be filed on a claim alone (e.g., G0369, G0370, G0371 and G0374). Third party payererrors do not constitute clerical errors.

The following chart provides information

on claim change reason condition codes:   Code Description Code Description

D0 Changes to Service Date D6 Cancel only to repay a duplicate IOG payment

D1 Changes to Charges D7** Change to Make Medicare Secondary Payer

D2 Changes in Revenue Codes/HCPCS/HIPPS

D8 Chang eto Make Medicare Primary Payer

D3 Second or Subsequent Interim PPS Bill

D4 Changes in Grouper Codes

D5 Cancel to correct HICN or Provider Number

D9*** Any Other Change

E0 Change in Patient Status **Use D9 when adjusting primary payer to bill for conditional payment.

***This code is used if adding a modifier to change liability and there is no change to the covered charge amount.

Understanding When to Use the D9 Claim Change Reason (Condition) Code

• Use the D9 claim change reason code on an adjustment claim to reflect any other changes to be made to a claim that was already processed.

• It is used to report an adjustment to a claim when an original claim was rejected for Medicare Secondary Payer (MSP) but Medicare is primary.

• Additionally, it can be used when the original claim was processed as an MSP or conditional claim and a change needs to be made to the claim such as a change in the MSP value code amount.

• If an adjusted claim is in a Return to Provider (RTP) status (T B9997), it is important to verify that the D9 code is being used correctly.

• If the D9 is the best code to use, the claim will need to include remarks indicating the reason for the adjustment. If remarks are not submitted on the claim, then the Medicare contractor will return the claim back to the provider using reason code 37541.

Note: The Medicare contractor must suspend for investigation all adjustment requests with claim change reason codes D4, D8 and D9. Providers that consistently use D9 will be investigated. If a pattern of abuse is evident, they may be reported to the Office of Inspector General (OIG).

Questions?

• Call the J11 Part A PCC at:– (866) 830-3455

• Refer to the Palmetto GBA Web site J11 Part A Home page:– www.PalmettoGBA.com/J11A

• Refer to the CMS Internet-Only Manuals– www.cms.gov/manuals