sd mgma third party payer day · 4/1/2018 · 9/20 3 p.m. / 1 p.m. basic e/m avoiding common...
TRANSCRIPT
SD MGMA
Third Party Payer Day
Presented by:
Part B Provider Outreach and Education
September 2017
Disclaimer
2
This information release is the property of Noridian Healthcare Solutions, LLC.
It may be freely distributed in its entirety but may not be modified, sold for profit
or used in commercial documents.
The information is provided “as is” without any expressed or implied warranty.
While all information in this document is believed to be correct at the time of
writing, this document is for educational purposes only and does not purport to
provide legal advice.
All models, methodologies and guidelines are undergoing continuous
improvement and modification by Noridian and CMS. The most current edition
of the information contained in this release can be found on the Noridian
website at https://med.noridianmedicare.com and the CMS website at
https://www.cms.gov.
The identification of an organization or product in this information does not
imply any form of endorsement.
CPT codes, descriptors, and other data only are copyright 2017 American
Medical Association. All rights reserved. Applicable FARS/DFARS apply.
September 2017
Agenda
• CMS Updates
– Current Changes
• Noridian Updates
– Current Changes & Additions
– Reviewing Contractor Updates
• Items of Interest
September 2017 3
CMS Updates
New Medicare Card Project
• Social Security Numbers removed from all Medicare cards by April 2019
• Replaced with new Medicare Beneficiary Identifier (MBI)– Example 1EG4-TE5-MK73
– MBI Format Specifications• https://www.cms.gov/Medicare/New-Medicare-
Card/Understanding-the-MBI-with-Format.pdf
• Transition period April 1, 2018 through December 31, 2019– Beneficiaries may use the new card upon receipt
September 2017 5
Elimination of Paper Remits
• Change Request (CR) 10151
• Effective 1/01/2018
– For all providers/suppliers who receive ERAs for 45
days or more
• Effective 2/14/2018
– For all providers/suppliers EDI enrolled who are
receiving ERAs and SPRs
• Some exceptions, i.e.:
– Natural disaster or CMS discretion
September 2017 6
Noridian Updates
Targeted Probe & Educate (TPE)
•CMS authorized Noridian to conduct TPE Pilot review process
•Targeted by Medical Review (JF only)• Driven by data analysis
• Educational opportunity for error reduction
• Note:– CR 10073 Targeted Probe & Educate Pilot
• CMS is expanding to three contractors, Jurisdictions B, D, and E
8September 2017
TPE Webpage
September 2017 9
Provider Self-Audit with Validation
and Extrapolation Pilot (PSAVE)
• CMS authorized pilot program
• Noridian education provided while allowing providers to
self-audit documentation with many benefits
• Immunity granted from MAC and RAC reviews on pilot
claims involved upon successful completion
• Visit website for information and PSAVE recording:
– https://med.noridianmedicare.com/web/jfb/cert-
reviews/psave
• Questions? Contact us:
– (800) 284-4351 or email [email protected]
September 2017 10
Prolonged Services Findings
• CPT 99354 – 99357
• Prolonged services are intended to be used for
unusual circumstances requiring additional time
beyond typical/average time of visit code billed
• Prolonged services is an example of time-based
service that requires time be documented in
medical record
September 2017 11
Medicare Secondary
Payer (MSP) Calculator
• Used to determine line by line payment calculations
• Will not accurately calculate:– Non-participating
providers/suppliers
– Sequestration
– 100% allowed payments (i.e. lab codes)
– Psychiatric reduction
– Tertiary payments
September 2017 12
New Additional Static Pages
• Noridian Website
– https://med.noridianmedicare.com/
• Care Plan Oversight (CPO)
• Chronic Care Management (CCM)
– Locate under Browse By Specialty/ E/M
• Chemotherapy Administration
– Locate under Browse By Topic/ Drugs & Biologicals
• Outpatient Therapy
– Locate under Browse By Specialty
September 2017 13
Contractor Updates
CERT, RAC, SMRC & OIG
Responding to “The Letter”
• Request for documentation:
– CERT, Medical Review, RAC ,SMRC
• Demand letters have a response date
• Verify your physical address is correct in PECOS
• Gather the information quickly and neatly
• Make sure the signatures are present and
legible.
• Ensure the information is sent to the correct
person
September 2017 15
Updating Address for CERT Letters
• CERT sends correspondence to Pay-To address
in PECOS
• Update address in PECOS
– https://pecos.cms.hhs.gov/pecos/login.do#headingLv
1
September 2017 16
CERT Webpage
September 2017 17
CERT November 2016 Report - JF
September 2017 18
CERT November 2016 Report - JF
September 2017 19
November 2016: JFB Root Causes Errors Weighted
Error $
South Dakota Totals 9 $3,686,107.62
Chiro-There is no chiropractic treatment plan documented to support a plan of care and documentation
does not adequately describe the service billed
1 $2,174,393.67
Missing valid physician order and/or documentation to support intent
1 $748,434.06
Does not meet medical decision making and physical exam key element for billed E/M service level
1 $525,349.30
Valid ICD-9/ICD-10 code(s) was submitted, however record is insufficient to support services billed
5 $224,595.07
Umbilical Hernia repair with mesh billed, record indicates no mesh used
1 $13,335.52
Recovery Auditor Contractor (RAC)
September 2017 20
• HMS Federal Solutions (HMS)
– https://racinfo.hms.com/home.aspx
– Contact information• Part B Providers
• Telephone: (877) 350-7993
• Fax: (702) 240-5510
RAC Newest Complex Review
• Annual Wellness Visits (AWV) for G0439
(subsequent visits)
• Errors found:
– Failure to submit documentation
– Service did not meet key elements
September 2017 21
RAC Webpage
September 2017 22
Supplemental Medical Review Specialty
Contractor (SMRC)
September 2017 23
SMRC Sample
Letter
September 2017 24
Office of Inspector General (OIG)
• 2017 work plan
• Current Reporting:– https://oig.hhs.gov/reports-and publications/workplan/index.asp
September 2017 25
Medical Documentation
Requirements
September 2017 26
Surgical Pathology Medical
Documentation Letter
September 2017 27
Documentation Letter• https://med.noridianmedicare.
com/documents/10546/12345
760/Surgical+Pathology+Medi
cal+Documentation+Letter
Signature Requirements For Medical
Review Purposes
For medical review purposes, Medicare requires
that services provided/ordered be authenticated by
the author. The method used shall be a hand
written or an electronic signature. Stamp
signatures are not acceptable.
September 2017 28
Note: Refer to exceptions for stamped signatures
Valid Signature
• Valid signature criteria which must be met:
– Services provided/ordered must be authenticated by
ordering practitioner
– Signatures are:
• Handwritten
• Electronic
• Stamped – If requirements to utilize stamped signature are
met
– Signatures are legible
September 2017 29
Acceptable
Valid if anywhere on document it states “Signed” or Final”
September 2017 30
Request for Signature
• Provider has 20 days from date of receipt of
phone call from Noridian to submit attestation
– Failure to submit records with valid signatures upon
request, or valid and timely attestations, will result in
your claims being denied
– Result of signature requirements not met
• Causes overpayment and recoupment of payment
September 2017 31
Signature Errors
• Missing physician signature on order
• Incomplete progress notes
• Unauthenticated medical records
• No documentation of intent to order services and
procedures
• No signed and dated attestation statement for
operative report (if physician signature was
missing or illegible)
September 2017 32
Utilize Documentation Checklists
September 2017 33
Items of Interest
Redeterminations and Reopenings via
NMP Letters
• Medicare Redetermination Notices (MRNs) will
no longer be mailed
• Providers /suppliers who submit
Redetermination or Reopening requests through
NMP will receive MRNs via NMP
• Ability to view/print determination letters
35September 2017
Advanced Beneficiary Notice of
Noncoverage (ABN) Form
• Effective June 21, 2017
– Exp. 3/2020
• Alternative format
available in Spanish and
larger font size
• Form available on CMS
website:
– https://www.cms.gov/medic
are/medicare-general-
information/bni/abn.html
September 2017 36
CMS-1500 Claim Form Updated Version
• Effective August 30, 2017
• CMS-1500 claim version 02/12 only acceptable version
– Photocopies are NOT acceptable
– Purchase forms from U.S. Government Printing Office website• https://bookstore.gpo.gov/catalog/health-
insurance-claim-forms
–Call (202)512-1800– IOM 100-04 Chapter 26, Section 10
September 2017 37
CMS-1500 Claim Form Updated Version 2
September 2017 38
Top
Bottom
Noridian Medicare Portal (NMP)
September 2017 39
Noridian Upcoming Part B WebinarsDate Time (CT / PT) Title
9/13 3 p.m. / 1 p.m. Duplicate Claims
9/14 1 p.m. / 11 a.m. Critical Care
9/19 1 p.m. / 11 a.m. Modifier 59 Clarification and Changes
9/20 3 p.m. / 1 p.m. Basic E/M Avoiding Common Errors
9/26 1 p.m. / 11 a.m. Chronic Care Management (CCM)
9/26 2 p.m. / 12 p.m. CPT 20610 Coding Guidance
9/26 3 p.m. / 1 p.m. New Provider-Biller Part I
9/27 3 p.m. / 1 p.m. New Provider-Biller Part II
9/28 3:30 p.m. / 1:30 p.m.
Initial Preventive Physical Examination and Annual Wellness Visit
REGISTER NOW!
Education & Outreach / Schedule of Events
September 2017 40
Medicare “After Hours” Webinars
• 6 p.m. PT / 8 p.m. CT • Webinars also during day - earlier same week• All webinars earn 1.0 CEU• Register at Noridian: Education and Outreach- Schedule of Events
Date Topic
9/28 Chronic Care Management (CCM)
10/26 Roster Billing for Influenza and Pneumonia Immunizations
11/16 Transitional Care Management Services
12/7 Understanding National and Local Coverage Determinations
September 2017 41
In Summary
• Use Noridian/CMS website tools
– Attend workshops like this presentation
– Read Medicare emails and articles
– Refer to links to Noridian and CMS website for
signature requirements
September 2017 42
Questions?
Thank you!