New Patient Visits by Same Physician or Physician Group: Overpayments

March 25, 2015, 1:25 am

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Medicare's Common Working File (CWF) system detects erroneous billings when there are two new patient CPT codes being billed within a three-year period of time by the same physician or physician group.

The Recovery Auditors are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with 'New Patient' Evaluation and Management (E/M) services to have improper payments, because the new patient services have been billed two or more times within a three-year period by the same physician or physician group.

If Medicare discovers that a new patient code has been paid more than one time in a three-year period to the same physician, then Medicare Contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.

Codes that are checked:

•    CPT codes: 99201-99205, 99324-99328, 99341-99345, 99381-99387, 92002, and 92004
•    The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012, and 92014).

New Patient Definition:

The 'Medicare Claims Processing Manual,' Chapter 12, Section 30.6.7 provides that 'Medicare interpret the phrase 'new patient' to mean a patient who has not received any professional services (i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years). For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit).'

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Medicare Billing: 837P and Form CMS-1500

April 20, 2015, 2:10 am

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What are the 837P and Form CMS-1500?
837P: The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. Review the chart below “ANSI ASC X12N 837P” for more information about this claim format.

Form CMS-1500:The Form CMS-1500 is the standard paper claim form that health care professionals and suppliers use to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.
In order to align the CMS-1500 with some of the changes in the electronic format, the previous 08/05 version was revised to the 02/12 version. Visit the National Uniform Claim Committee (NUCC) website
for information on the revision process. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (02/12) and the form is referred to throughout this fact sheet as the CMS-1500.

In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers. Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both.

ANSI ASC X12N 837P
The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional)
Version 5010A1 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
P = Professional version of the 837 electronic format Version
5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers.

          Implementation and Companion Guides for Electronic Transactions
Health care professionals or suppliers billing electronic claims must comply with the ASC X12N implementation guide. The “837P Health Care Claim: Professional” implementation guide is available for purchase and provides instructions on the content and format requirements for each of the standards’ requirements. ASC X12N implementation guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards’ requirements. These documents are written for use by all health benefit payers, not specifically for Medicare.

Implementation Guides, including Version 5010 Consolidated Guides, can also be purchased from the
Washington Publishing Company on the Internet. CMS publishes a companion guide to supplement the implementation guide and provide further instruction specific to Medicare. The “5010A1 Part B 837 Companion Guide” is located on the CMS website and provides specific 837P claim loop and segment references. MACs also publish their own companion documents, which provide additional information specific to that contractor’s business. To locate a MAC’s companion guide, visit that contractor’s website.
Please note that the implementation guides and companion guides are technical documents and health care professionals or suppliers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims
Health care professionals and suppliers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.

In addition to correct claims completion, Medicare payment requires that an item or service:
• Meets a benefit category;
• Is not specifically excluded from coverage; and
• Is reasonable and necessary.
In general  fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. It is a crime to defraud the Federal government and its programs. Punishment may involve imprisonment, significant fines, or both under a number of laws including the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the Criminal Health Care Fraud Statute.


When Does Medicare Accept a Paper Form CMS-1500?
Initial claims for payment under Medicare must be submitted electronically unless a health care professional or supplier qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.


ASCA Exceptions: Before submitting a hard copy claim on the Form CMS-1500, health care professionals and suppliers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, health care professionals and suppliers that have fewer than 10 Full-Time
Equivalent (FTE) employees and bill a MAC are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If a health care professional or supplier meets an exception, there is no need to submit a waiver request.

Waiver Requests: There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of a health care professional’s or supplier’s staff prevents use of a computer for electronic submission of claims. Health care professionals and suppliers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their MAC.

New Timeframe for Response to Additional Documentation Requests

April 29, 2015, 1:29 am

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Provider Types Affected

This MLN Matters Article is intended for physician, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.

Background

In certain circumstance, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments or the billing history found in claims processing system (if applicable) or Medicare's Common Working File (CWF).

In those instances, the CMS review contractor will solicit documentation from the provider or supplier by issuing as ADR. The requirements for additional documentation are as follows:

The Social Security Act, Section 1833 (e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.

According to the "Medicare Program Integrity Manual" Chapter 3, Section 3.2.3.2, (Verifying Potential Errors and Tracking Corrective Actions), when requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.

Note: This article was revised on November 18, 2014, to make corrections in the article, especially to clarify ADR requirements related to pre-payment review.

J3590/C9399 Vimizim™ (elosulfase alfa) and Diagnostic Tests- CMS Requirements

May 11, 2015, 1:30 am

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J3590/C9399 Vimizim™ (elosulfase alfa)

Vimizim™ (elosulfase alfa) injection, for intravenous use is a hydrolytic lysosomal glycosaminoglycan (GAG) specific enzyme indicated for patients with Mucopolysaccharidosis type IVA (MPS IVA: Morquio A syndrome). Vimizim™ was approved by the Food and Drug Administration (FDA) on February 14, 2014.
Vimizim™ is supplied as a concentrated solution for infusion in a 5mg/5ml (1mg / mL) single-use vial requiring dilution. As approved by the FDA the recommended dose is 2mg per kg administered intravenously over a minimum range of 3.5 to 4.5 hours, based on infusion volume, once every week. Pre-treatment with antihistamines with or without antipyretics is recommended 30-60 minutes prior to the start of the infusion.

In the absence of a national coverage determination (NCD) or local coverage determination (LCD), Medicare can consider coverage of a drug that is usually not self-administered per the FDA indication when administered incident to a physician service or in the hospital setting. The patient’s medical record must also support the diagnosis of Mucopolysaccharidosis, type IVA (MPS IVA; Morquio A syndrome using the appropriate ICD-9-CM code(s) of 277.5 (Mucopolysaccharidosis) and FDA guidance for use as well as the administration.

Diagnostic Tests- CMS Requirements
The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of diagnostic tests due to missing physician/non-physician practitioner order or intent within the medical record.  This has led to the recoupment of overpayments by Novitas Solutions, Inc totaling over $355.64. More importantly, when CMS and CERT extrapolate these errors to the universe, they will account for approximately $22.1 million in claims payment errors for the November 2012 report.
Medicare defines a Diagnostic Test as including:
"All diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary."

And further defines Clinical Laboratory Services as:

"The biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition."
CMS also gives direction that Clinical Laboratory Services "must be ordered and used promptly by the physician who is treating the beneficiary."

CMS defines an order as:
" A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y)."
An order can be written in the beneficiary's record or can be a telephone order from the physician's office to the testing facility.  If a telephone order, both the treating physician and the testing facility must have documented in the beneficiary's record the telephone call and the extent of the diagnostic tests being ordered.

Although CMS does not require the order to be signed by the physician, the physician must have clearly documented in the beneficiary's record the intent to order the diagnostic test.

Documentation requested by the CERT contractor or Novitas Solutions, Inc to support the order for the diagnostic test (or the physician's intent to order), will be sent to the testing facility, as it is the facility that is billing for the test.   Often the testing facility is unable to provide the physician's order or intent because this information is in the beneficiary's record in the physician's office.   The testing facility has to request this information from the physician in order to be paid for the service.  Without the order for the test, or the intent to order, both the CERT contractor and Novitas Solutions, Inc will deny payment for the diagnostic test or service.

To avoid such denials, testing facilities and physician's offices need to work together.  Testing facilities should attempt at the time the beneficiary is presenting to the facility, to have a diagnostic test performed, to obtain a physician's order.  This can be accomplished by directing the beneficiary to bring a prescription that includes the condition or diagnosis code for which the diagnostic test is ordered as well as the order for the diagnostic test. If the beneficiary presents without a valid order, the testing facility could call the physician's office to obtain a telephone order for the diagnostic test.

Medicare Billing: 837I and Form CMS-1450

May 22, 2015, 2:09 am

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What are the 837I and Form CMS-1450?

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. In addition to billing Medicare, the 837I and Form CMS 1450 may be suitable for billing various government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).


 ANSI ASC X12N 837I

The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional)
Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
I = Institutional version of the 837 electronic format
Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.

Implementation and Companion Guides for Electronic Transactions

ASC X12N implementation guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards’ requirements. The documents are written for use by all health benefit payers, not specifically for Medicare. Implementation guides, including Version 5010 consolidated guides, can be purchased at the ASC X12 store or from the Washington Publishing Company on the Internet.

CMS publishes a companion guide to supplement the implementation guide to provide further instruction specific to Medicare. The “5010A2 - Part A 837 Companion Guide” is located on the CMS website and provides  specific 837I electronic claim loop and segment references. MACs also publish their own companion documents, which provide additional information specific to that contractor’s business. To locate a MAC’s Companion Guide, visit that contractor’s website. Implementation guides and companion guides are technical documents, and providers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims

Providers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.
In addition to correct claims completion, Medicare coverage and payment is contingent upon a determination that an item or service:
• Meets a benefit category;
• Is not specifically excluded from coverage; and
• Is reasonable and necessary.

In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. It is a crime to defraud the Federal government and its programs. Punishment may include imprisonment, significant fines, or both under a number of laws including the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the Criminal Health Care Fraud Statute.

When Does Medicare Accept a Hard Copy Claim Form?
Initial claims for payment under Medicare must be submitted electronically unless an institutional provider qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Before submitting a hard copy claim, providers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, institutional providers that have fewer than 25 Full-Time Equivalent (FTE) employees and bill a MAC are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If an institutional provider meets an exception, there is no need to submit a waiver request.

There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of an institutional provider’s staff prevents use of a computer for electronic submission of claims. Institutional providers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their MAC.

New Timeframe for Response to Additional Documentation Requests AND Payment for G0101 and Q0091 in RHC

June 10, 2015, 8:38 pm

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Payment for G0101 and Q0091 in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that Bill Under the All-Inclusive Rate (AIR) System.

Provider Types Affected

This MLN Matters Article is intended for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who are authorized to bill under the All Inclusive Rate (AIR) system and submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 8927 adds Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) to the list of preventive services paid based on the All-Inclusive Rate (AIR) for RHCs and FQHCs. Make sure your billing staffs are aware of this changes.

Background

The Centers for Medicare and Medicaid Services (CMS) has determined that HCPCS codes G0101 and Q0091 are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.

CR8927 instructs MACs to allow HCPCS codes G0101 and Q0091 to be billed as a stand-alone encounter/visit. These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Tyoes of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to G0101 or Q0091. If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.

G0101 or Q0091 are payable annually for women at high risk for developing cervical or vaginal cancer, and women of childbearing age who have had an abnormal Pap test within the past 3 years. It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, G0101 and Q0091 are qualifying visit when billed with FQHC payment HCPCS codes G0466 or G0467.

Your MAC will not search for claims that have been denied with HCPCS code G0101 or Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.


New Timeframe for Response to Additional Documentation Requests

Provider Types Affected

This MLN Matters Article is intended for physician, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.

Background

In certain circumstance, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments or the billing history found in claims processing system (if applicable) or Medicare's Common Working File (CWF).

In those instances, the CMS review contractor will solicit documentation from the provider or supplier by issuing as ADR. The requirements for additional documentation are as follows:

The Social Security Act, Section 1833 (e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.

According to the "Medicare Program Integrity Manual" Chapter 3, Section 3.2.3.2, (Verifying Potential Errors and Tracking Corrective Actions), when requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.

Note: This article was revised on November 18, 2014, to make corrections in the article, especially to clarify ADR requirements related to pre-payment review.

Tention Health Professionals: Information Regarding the 2015 Medicare Physician Fee Schedule

June 18, 2015, 2:05 am

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On April 1, 2015, the Medicare Physician Fee Schedule (MPFS) was updated using the Sustainable Growth Rate (SGR) methodology as required by current law. The SGR methodology required a 21% decrease in all MPFS payments beginning April 1, 2015. The Centers for Medicare & Medicaid Services (CMS) took steps to limit the impact on Medicare providers and beneficiaries by holding claims paid under the MPFS with dates of service on and after April 1, 2015. Additionally, Medicare is also holding all therapy claims that would no longer qualify for the therapy cap exceptions (those therapy claims with the ‘KX’ modifier), due to the expiration of the therapy cap exceptions process on April 1, 2015.  In the absence of additional legislation to avert the negative update, CMS must update payment systems to comply with the law, and implement the negative update.

Beginning on April 15th, 2015, CMS will release held MPFS claims, paying at the reduced rate, based on the negative update, on a first-in, first-out basis, while continuing to hold new claims as they are received.  CMS will release one day's worth of held claims, processing and paying at the rate that reflects the negative update. At the same time, CMS will hold the receipts for that day, thus, continuing to hold 10 days' worth of claims in total. This is to provide continuing cash flow to providers, albeit at the rate that reflects the negative update. This “rolling hold” will help minimize the number of claims requiring reprocessing should Congress pass legislation changing the negative update.

Providers should remember that claims for services furnished on or before March 31, 2015 are not affected by the payment cut and will be processed and paid under normal time frames.  We are working to limit any impact to Medicare providers and beneficiaries as much as possible. The MACs will automatically reprocess the claims paid at the reduced rate if Congressional action is taken to avert the negative update.  No action is necessary from providers who have already submitted claims for the impacted dates of service.

Informational Alert
Issued 4/15/2015 at 7:22 AM
Common Working File (CWF) Hosts will be Conducting History Purges
On Saturday, May 2, 2015, the CWF Northeast, Southwest, Southeast, Great Lakes, and Mid-Atlantic Hosts will be conducting a history archive.
On Saturday, May 9, 2015, the CWF South, Pacific, Great Western, and Keystone Hosts will be conducting a history archive.

Due to the anticipated duration of this activity and to ensure the completion of the weekly processing and scheduled data center maintenance, Saturday, May 2, 2015, will be a CWF Dark Day at the Northeast, Southwest, Southeast, Great Lakes, and Mid-Atlantic Hosts only. Saturday, May 9, 2015, will be a CWF Dark Day at the South, Pacific, Great Western, and Keystone Hosts only. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until 12:00 p.m. (Eastern Standard Time) each Saturday.

All files received from satellites for Friday’s cycle (May 1, 2015 and May 8, 2015) will be completed prior to bringing CWF production down.
If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history archive has been completed.

The oldest claim history maintained after the purge process will be as follows:

• Oldest Inpatient Thru Date To Keep On File: 01/01/1966
• Oldest Outpatient Thru Date To Keep On File: 02/01/2013 (27 Months)
• Oldest Part B Thru Date To Keep On File: 05/01/2013 (24 Months)
• Oldest Hospice Thru Date To Keep On File: 01/01/1966
• Oldest Home Health Thru Date To Keep On File: 01/01/1998

• Oldest DMERC Thru Date To Keep On File: 05/01/2013 (24 Months)

Items and Services Furnished Outside the United States (U.S.) - Medicare

June 19, 2015, 8:44 pm

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Most items and services furnished or delivered outside the U.S. are not covered, including when the beneficiary was within the U.S. when the contract to purchase the item was made or the item was purchased from an American firm. Payment will not be made for a medical service (or a portion thereof) that was subcontracted to another provider or supplier located outside the U.S.Medicare pays for provider professional services that are furnished in the U.S., except for certain limited services as described below under
Exceptions. The Centers for Medicare & Medicaid Services (CMS) recognizes the following as being
within the U.S.:
• The 50 States;
• The District of Columbia;
• The Commonwealth of Puerto Rico;
• The Virgin Islands;
• Guam;
• The Commonwealth of the Northern Mariana Islands;
• American Samoa; and
• Territorial waters adjoining the land areas of the U.S. (for services furnished onboard a ship).
A hospital is considered outside the U.S. if it is not physically located in one of the jurisdictions listed
above, even if it is owned  or operated by the U.S. Government.

Exceptions
The following services are covered:
• Emergency inpatient hospital services furnished at a foreign hospital provided the foreign hospital is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency. One of the following conditions must exist:
◦ The beneficiary was physically present in the U.S. at the time of the emergency that necessitated inpatient services; or
◦ The emergency arose in Canada while the beneficiary was traveling, by the most direct route and without unreasonable delay between Alaska and another State;
• Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the U.S. provided the hospital is closer to, or substantially more accessible from, the beneficiary’s U.S. residence than the nearest participating U.S. hospital that is adequately equipped to deal with and available to treat the illness or injury;
• Physician and ambulance services furnished in connection with a covered foreign hospitalization. Payment will not be made for any other Part B outpatient, medical, and other health services that are furnished outside the U.S.;
• Services furnished onboard a ship in a U.S. port or furnished within 6 hours of when the ship arrived at or departed from a U.S. port. Services that do not meet this requirement are considered furnished outside U.S. territorial waters, even if the ship is of U.S. registry;
• Physician and ambulance services furnished in Canada and covered by the Railroad Retirement Board to a Railroad Retirement beneficiary in connection with covered hospital services; and
• Services for a beneficiary who has elected the religious nonmedical health care benefit; however, the receipt of medical services may revoke the religious nonmedical health care benefit.

B) Items and Services Required as a Result of War
Items and services that are required as a result of war or an act of war and that occur after
the effective date of the beneficiary’s current entitlement are not covered.

C) Personal Comfort Items and Services
Personal comfort items will not be covered because these items do not meaningfully contribute to the treatment of a beneficiary’s illness or injury or the functioning of a malformed body member.
Some examples of personal comfort items are:
• Radios;
• Televisions; and
• Beauty and barber services, except as described below under Exceptions.

When a beneficiary requests a personal comfort item, you should inform him or her that there is a
specified charge for the item. The specified charge may not exceed the customary charge, and
future charges may not be more than the amount specified. You cannot require the beneficiary
to request non-covered items or services as a condition of admission or continued stay.

Exceptions
Certain basic personal services that residents in Skilled Nursing Facilities (SNF) and general
psychiatric hospitals need and cannot perform for themselves are covered. Some examples include:
• Shaves;
• Haircuts;
• Shampoos; and
• Simple hair sets.
These services may be considered ordinary patient care and covered costs are reimbursable under Part A when they are:
• Furnished by a long-stay institution;
• Included in the flat rate charge; and
• Routinely furnished without charge to the beneficiary.

D) Routine Physical Checkups; Certain Eye Examinations, Eyeglasses and Lenses; Hearing Aids and Examinations; and Certain Immunizations
The following routine items and services are not covered:
• Routine or annual physical checkups, except as described in the Exceptions Section under
1) Services and Supplies That Are Not Medically Reasonable and Necessary below
• Physical examinations that are performed without a specific sign, symptom, or beneficiary complaint necessitating the service or that are required by third parties (for example, insurance companies, business establishments, or Government agencies);
• Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses;
• Eye refractions furnished by all practitioners for any purpose;
• Eyeglasses and contact lenses;
• Examinations for hearing aids;
• Hearing aids; and
• Immunizations, except as described in the Exceptions Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary given below.

Exceptions
The following items and services are covered:
• Physician services performed in conjunction with an eye disease (for example, glaucoma and cataracts);
• Services performed incident to physician services in conjunction with an eye disease;
• One pair of eyeglasses or contact lenses after each cataract surgery with insertion of
an intraocular lense;
• Vaccinations directly related to the treatment of an injury or direct exposure to a disease or condition (for example, antirabies treatment and immune globulin);
• Vaccinations that are specifically covered by statute (for example, seasonal influenza virus, pneumococcal, and Hepatitis B);
• A reasonable supply of antigens (not more than a 12-week supply that has been prepared for a particular beneficiary) a doctor of medicine (MD) or a doctor of osteopathy (DO) has prepared after
examining the beneficiary and determining a plan of treatment and dosage regimen. A different physician may administer the antigens; and
• Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve and are indicated only when hearing aids are medically inappropriate or cannot be utilized due to:
◦ Congenital malformations;
◦ Chronic disease;
◦ Severe sensorineural hearing loss; or
◦ Surgery.
These devices, which are payable as prosthetic devices, include:
• Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or the auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays; and
• Osseointegrated implants that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.

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How to Complete CMS-838 Credit Balance Reports

June 25, 2015, 2:22 am

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As your Medicare Administrative Contractor, Novitas Solutions, Inc. is responsible to ensure compliance with the Credit Balance reporting process. The information provided below offers a brief explanation of how the CMS-838 Credit Balance Reports should appear before mailing or faxing to Medicare.

The CMS-838 Credit Balance Report
The CMS-838 Credit Balance Report is comprised of the Certification Page and the Detail Page which is completed when there are credit balances to report. The Certification Page is required with every submission; no matter which of the following blocks are checked on the Certification Page:

Qualify as a Low Utilization Provider
The Credit Balance Report Detail Page is attached
There are no Medicare credit balances to report for this quarter (No Detail Page(s) attached).
Any Credit Balance 838-Certifications that are not accurate and complete will be deemed invalid. Effective for the 03/31/15 reporting quarter, the immediate return of invalid or incomplete CMS-838 Certification Pages will result for the following reasons. Please note that invalid Certification Pages will invalidate your entire submission:

The incorrect version of the CMS-838 Certification Page/Detail Page is received. Please use the correct version of the CMS-838 Credit Balance Report. You can type directly into this version which is strongly encouraged to ensure your report is legible. Once completed in full, the report should be printed for signatures.
Proper 6-digit Provider Transaction Access Number (PTAN) is missing, invalid, or a National Provider Identifier (NPI) is listed. The name of the facility should be indicated.
Multiple PTANS are present. Only one PTAN per Certification Page is acceptable
Incomplete or inaccurate Quarter Ending date. Quarters should be reported as 03/31/XX, 06/30/XX, 09/30/XX or 12/31/XX. Four digit years will also be acceptable.
Signature and date of Administrator is missing
Correct “Check One” block is blank or does not match the contents.
*Although Novitas will not return as invalid reports missing the Contact Person/Phone number, completing this section is necessary if contact to the provider with regard to the report is necessary.
When returning an invalid or incomplete report for the reasons listed above, you will receive a cover sheet detailing the reason for return. Your report should be corrected and mailed or faxed within the acceptable timeframe in order to avoid receiving a Delinquency Warning Letter or having 100% of your Medicare Payments withheld.
Please note that CMS-838 Detail pages are not necessary when there are no Medicare Credit Balances to report for the quarter (the third check block on the 838-Certification page). In addition, documents such as vendor reports verifying no credits, shared system reports, or other validation documents are not necessary when there are no Medicare credit balances to report.
When Medicare Credit Balances Are Identified
When reporting Medicare Credit Balances, a complete CMS-838 Detail Page is required with the submission. Although an 838-Certification Page may pass the initial validation process, the 838-Detail Page may contain inaccurate or incomplete information when reporting Medicare credit balances. Currently, telephone contact results when CMS-838 Detail Pages are incomplete or inaccurate and reports are not accepted as valid until what is requested is corrected and received timely. However, effective for the 06/30/15 reporting quarter, incomplete and/or inaccurate CMS-838 Detail Pages will be immediately returned.

Accurate and complete CMS 838-Detail Pages should include the following:
Column 1- Last name and first name of beneficiary
Column 2- Health Insurance Claim Number (HICN) of beneficiary
Column 3- Internal Control Number (ICN): Please note that this is not always the ICN of the original claim. This should be the ICN of the claim identifying the overpayment.
Column 4- Type of Bill (TOB): This is a required field and is 3-digits
Column 5- Admission Date: From date or start date service began
Column 6- Discharge Date: Through date or date service ended
Column 7- Paid Date: Date claim paid
Column 8- Cost Report: “O” is entered for a cost report period is open or “C” if closed
Column 9- Amount of Medicare Credit Balance: Total Credit Balance owed to Medicare. This is not the billed amount.
Column 10- Amount Credit Balance Repaid: This is the amount repaid with the submission of this report
Column 11- Method of Payment: The choices are “C” when remitting a check to repay the amount owed to Medicare (the check and UB04s must accompany the report), “X” when an adjustment has already been submitted through the shared system, or “A” when Novitas is expected to adjust the claim (UB04 is required)
Column 12- Amount of Medicare Credit Balance Outstanding: Column 10 minus Column 9)
Column 13- Reason for Medicare Credit Balance: The choices are “1” when a Duplicate is identified, “2” when MSP is identified, and “3” for Other.
Column 14- Value Code is required when reporting “2-MSP” in Column 13. Acceptable Value Codes are: 12-Working Aged, 13-End Stage Renal Disease (ESRD), 14-Auto/No Fault, 15-Worker’s Compensation, 16-Other Government Program, 41-Black Lung, 42-Department of Veterans Affairs (VA), 43-Disability, 44-Conditional Payment, and 47-Liability
Column 15- Name and complete billing address and is required when reporting “2-MSP” in Column 13. This column is also used to explain “3-Other” being reported in Column 13.
The following is an example of an acceptable CMS-838 Detail Page when “Duplicate” is the Reason for Medicare Credit Balance (Block 13)

The following is an example of an acceptable CMS-838 Detail Page when “MSP” is the Reason for Medicare Credit Balance (Block 13)

The following is an example of an acceptable CMS-838 Detail Page when “Other” is the Reason for Medicare Credit Balance (Block 13)

Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services

July 7, 2015, 2:06 am

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The Centers for Medicare & Medicaid Services (CMS) finalized clarifications and revisions to policies regarding physician certification and recertification of patient eligibility for Medicare home health services in the CY 2015 HH PPS final rule which was published on November 6, 2014. In the final rule, CMS also finalized revisions to the timeframe required for therapy functional reassessments.

Face-to-Face Encounter Requirements
The Affordable Care Act requires that the certifying physician or allowed NPP must have a
face-to-face encounter with the beneficiary before they certify the beneficiary’s eligibility for the home health benefit. CMS is implementing the following three changes to the face-to-face encounter requirements for episodes beginning on or after January 1, 2015. These changes will reduce administrative burden and provide HHAs with additional flexibilities in developing individual agency procedures for obtaining documentation supporting patient eligibility for Medicare home health care.

• CMS is eliminating the narrative requirement. The certifying physician is still required to certify (attest) that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility. For medical review purposes, Medicare requires documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of patient eligibility.
•If a HHA claim is denied, the corresponding physician claim for certifying/re-certifying patient eligibility for Medicare-covered home health services is considered non-covered as well because there is no longer a corresponding claim for Medicare-covered home health services.
•CMS is clarifying that a face-to-face encounter is required for certifications, rather than initial episodes; and that a certification (versus a re-certification) is generally considered to be any time a new start of care assessment is completed to initiate care.

Therapy Reassessments
CMS has eliminated the 13th and 19th visit therapy reassessment requirements. Forepisodes beginning on or after January 1, 2015; at least every 30 calendar days a qualified therapist

(instead of an assistant) must provide the needed therapy service and functionally reassess the patient. This policy change will lessen HHAs’ burden of counting visits. This change will reduce the risk of non-covered visits so that therapists can focus more on providing quality care for their patients, while still promoting therapist involvement and quality treatment for all beneficiaries regardless of the level of therapy provided.

Definition of Emergency Care Services and Appeals of Opt Out Determinations

July 19, 2015, 2:07 am

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This Article is intended for physicians and practitioners who opt-out of Medicare, and beneficiaries that receive services from opt out physicians and practitioners.

Note: The private contracting regulation at 42 CFR 405.450 describes certain opt-out determinations made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to appeal those determinations. The cross references to the processes used to appeal the determinations described in Section 405.450 were updated in the November 13, 2014 Federal Register (Volume 79, Number 219). The definition of Emergency care services at 42 CFR 405.400 was also corrected in that November 13, 2014
Federal Register.

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and because of the danger to life or health, which require use of the most accessible hospital available that is equipped to furnish those services. Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an ear infection with significant pain, the Centers for Medicare & Medicaid Services (CMS) would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.

What You Need to Know- Be aware that a physician or practitioner who is dissatisfied with a Medicare determination under Section 405.450(a) may utilize the enrollment appeals process currently available for providers and suppliers in Part 498. Be aware that a determination described in Section 405.450(b) (that payment cannot be made to a beneficiary for services furnished by a physician or practitioner who has opted out) is an initial determination for the purposes of Section 405.924 and may be challenged through the existing claims appeals procedures in Part 405 subpart I. Be aware that emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

Rehabilitation Therapy Billing Guidelines , calculation of units

July 19, 2015, 6:21 am

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Practitioner billing for Part B rehab therapy services on a 1500 claim form or electronic equivalent:
Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that best describe the therapy services rendered

Functional Therapy Reporting ‘G’ codes *

HCPCS/CPT therapy modifiers
GN, services delivered under a SLP plan of care
GO, services delivered under an OT plan of care
GP, services delivered under a PT plan of care
Severity/Complexity Modifiers
CH, 0% impaired, limited or restricted
CI, 1% but less than 20% impaired or restricted
CJ, 20% but less than 40% impaired or restricted
CK, 40% but less than 60% impaired or restricted
CL, 60% but less than 80% impaired or restricted
CM, 80% but less than 100% impaired or restricted
CN, 100% impaired or restricted

Units - Number of times the service/procedure reported according to the HCPCS/CPT code definition
Untimed, bill as 1 unit
Timed, definition includes time; e.g., 15 minutes
Bill as 1 or more units depending on time spent in direct one-on-one contact with the patient
Units are constrained by the total treatment time
Do not bill for less than 8 minutes
Time must be documented in the medical record as either:
total number of timed minutes or;
beginning and ending time
Pre- and post-delivery services are not to be counted towards treatment time
Counting Minutes for Timed Codes

Billable UnitsNumber of Minutes
1≥ 8 minutes through 22 minutes
2≥ 23 minutes through 37 minutes
3≥ 38 minutes through 52 minutes
4≥ 53 minutes through 67 minutes
6≥ 68 minutes through 82 minutes
7≥ 83 minutes through 97 minutes
8≥ 98 minutes through 112 minutes
9≥ 113 minutes through 127 minutes

Billing Units example
Documentation shows:
7 minutes of neuromuscular reeducation (97112)
7 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
21 Total timed minutes
Billable codes/units (21 minutes = 1 billable unit)
Select one of the codes to bill
Although only one code is billed, documentation should include all services rendered.

Important News - Attention Health Professionals: Information Regarding the Medicare Access and CHIP Reauthorization Act of 2015

July 27, 2015, 2:09 am

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On April 14 , 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015; the President is expected to sign it shortly. This law eliminates the negative update of 21% scheduled to take effect as of April 1, 2015, for the Medicare Physician Fee Schedule. In addition, provisions allowing for exceptions to the therapy cap, add-on payments for ambulance services, payments for low volume hospitals, and payments for Medicare dependent hospitals that expired on April 1 have been extended. CMS will immediately begin work to implement these provisions.

In an effort to minimize financial effects on providers, CMS previously instituted a 10-business day processing hold for all impacted claims with dates of service April 1, 2015, and later. While the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate. No action is necessary from providers who have already submitted claims for the impacted dates of service.

CMS Announces Opportunity to Apply for Navigator Grants in Federally-facilitated and State Partnership Marketplaces Navigator awards extend to three years to provide stability and assistance to consumers as they enroll in coverage

The Centers for Medicare & Medicaid Services (CMS) announced today the availability of funding to support Navigators in Federally-facilitated Marketplaces (FFM), including State Partnership Marketplaces. The Affordable Care Act is working for millions of Americans who are able to access quality health coverage at a price they can afford, in part because of the efforts of in-person assisters in local communities across the nation.  People shopping for and enrolling in coverage through the Health Insurance Marketplaces can get local help in a number of ways, including through Navigators. Navigators provide objective information about health coverage to consumers to help them make the best possible choice. They are knowledgeable about qualified health plans in the Marketplaces, and public programs including Medicaid and the Children’s Health Insurance Program. Grantees will be selected for a three year project period, and a total of up to $67 million is available for the first year of the award.

“Navigators play a vital role in helping Americans enroll in coverage through the Marketplaces and assessing if they qualify for any insurance affordability programs. Navigators have been an important resource for the millions of Americans who enrolled in coverage over the past two years. This funding announcement ensures this important work will continue over the next three years in states with a FFM, including during Marketplace open enrollment periods,” said CMS Acting Administrator Andy Slavitt. The funding opportunity announcement is open to eligible individuals, as well as private and public entities, applying to serve as Navigators in states with a FFM. It is open to new and returning HHS Navigator grant applicants, and applications are due by June 15, 2015.

The 2015 Funding Opportunity Announcement expands the project period from 12 months to 36 months. The multi-year grant award will be funded in 12-month increments and continued funding will be contingent on the grantee continuing to meet all Navigator program requirements and on funding availability. This change is designed to provide greater consistency for Navigator grantee organizations and their staff from year to year, reducing yearly start up time and providing for a more efficient use of grant funds. Navigator grant applicants should describe how they intend to assist consumers who are uninsured or underinsured and consumers who are likely to be eligible for or enrolled in coverage through a Marketplace. Applicants should also describe how they plan to assist persons seeking to re-enroll in coverage through a Marketplace and provide post-enrollment assistance.

New field qualifiers on 17

August 12, 2015, 7:53 am

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CMS 1500 Claim Form Instructions: Revised for Form Version 02/12

Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with
claims received on and after April 1, 2014:
• Medicare will begin accepting claims on the revised form, 02/12, on January 6,2014;
• Medicare will continue to accept claims on the old form, 08/05, through March 31,2014;
• On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500claim form, 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS1500 claim form, 08/05.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to  ifferentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain  roviders are being identified as having performed an ordering, referring, or supervising role in the furnishing f the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and
expands the number of possible diagnosis codes on a claim to 12.

The qualifiers that are appropriate for identifying an ordering, referring, or supervising role
are as follows:
• DN - Referring Provider
• DK - Ordering Provider
• DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that the paper format for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore supports the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception.

Proposed fiscal year 2016 payment and policy changes for Medicare Skilled Nursing Facilities

August 21, 2015, 2:10 am

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Overview
On April 15, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1622-P] outlining proposed Fiscal Year (FY) 2016 Medicare payment rates for skilled nursing facilities (SNFs). The FY 2016 proposals and other issues discussed in the proposed rule are summarized below.

The proposed rule proposes policies that continue a commitment to shift Medicare payments from volume to value. The Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. The proposed rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.

Changes to Payment Rates under the SNF Prospective Payment System (PPS)
Based on proposed changes contained within this rule, CMS projects that aggregate payments to SNFs will increase by $500 million, or 1.4 percent, from payments in FY 2015. This estimated increase is attributable to a 2.6 percent market basket increase, reduced by a 0.6 percentage point forecast error adjustment and further reduced by 0.6 percentage point, in accordance with the multifactor productivity adjustment required by law.

SNF Quality Reporting Program
The Improving Medicare Post-Acute Care Transformation Act of 2014 (P.L. 113-185) (IMPACT Act), enacted on October 6, 2014, requires the implementation of a quality reporting program for SNFs.

In addition, the Act requires establishing a SNF quality reporting program. Beginning with FY 2018, the Act requires SNFs that fail to submit required quality data to CMS under the SNF Quality Reporting Program will have their annual updates reduced by two percentage points.

•For the FY 2018 SNF QRP and subsequent years, CMS is proposing to adopt three measures addressing three quality domains identified in the IMPACT Act: (1) skin integrity and changes in skin integrity; (2) incidence of major falls; and (3) functional status, cognitive function, and changes in function and cognitive function. The proposed measures satisfy the IMPACT Act requirement of standardized data reporting across four post-acute care settings, including home health agencies, inpatient rehabilitation facilities, skilled nursing facilities and long term care hospitals.  The proposed measures are identified below in the Summary Table of Domains and Proposed Measures for the SNF QRP.  CMS intends to propose additional quality measures and resource use measures in future rulemaking.


Summary Table of Domains and Proposed Measures for the SNF Quality Reporting Program

Domain	Proposed Measures
Skin Integrity and Changes in Skin Integrity	Outcome Measure: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) (NQF #0678; Measure Steward: CMS)
Incidence of Major Falls	Outcome Measure: Application of Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674; Measure Steward: CMS)
Functional Status, Cognitive Function, and Changes in Function and Cognitive Function	Process Measure: Application of Percent of Patients or Residents With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF#2631) (Under NQF review Measure Steward: CMS)

SNF VBP Program

Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA) added new subsections (g) and (h) to section 1888 to the Social Security Act (Act) New Subsection 1888(h) authorizes establishing a Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program beginning with FY 2019 under which value-based incentive payments are made to SNFs in a fiscal year based on performance.

Measures
The rule proposes to adopt the Skilled Nursing Facility 30-Day All-Cause Readmission Measure, (SNFRM) (NQF #2510), as the all-cause, all-condition readmission measure that will be used in of the SNF VBP Program. The Skilled Nursing Facility 30-Day All-Cause Readmission Measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for SNF Medicare beneficiaries within 30 days of their prior proximal short-stay acute hospital discharge.

The Act also requires CMS to replace this measure with an all-condition, risk-adjusted potentially preventable hospital readmission rate. CMS intends to address this topic in future rulemaking.


Future Policy Considerations

In the proposed rule, CMS is seeking public comments on numerous issues related to the SNF VBP Program’s policies.  CMS intends to propose additional details of the SNF VBP in the FY 2017 SNF PPS proposed and final rules, and is currently seeking comments on:
•Performance standards
•Measuring improvement
•Appropriate baseline and performance periods
•Performance scoring methodology
•Public reporting of performance information

•Feedback reports

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Announcement About Medicare Participation for Calendar Year 2015

August 30, 2015, 8:35 pm

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We wish to emphasize the importance and advantages of being a Medicare participating (PAR) provider, and we are pleased that the favorable trend of participation continued into 2014 with a participation rate of  96.6 percent. As you plan for 2015 and become familiar with the coming changes, we are hopeful that you will continue to be a PAR provider or, if you are non-participating (Non-PAR), will consider becoming a PAR provider.

With the help of health care professionals across the country, the Medicare program is improving
faster than ever. The growth in spending per beneficiary is at an all-time low, which means that the
part B beneficiary premium will not increase in 2015. At the same time, the quality of care received
by Medicare beneficiaries continues to improve as indicated by lower hospital readmission rates,
significant reductions in health care acquired conditions, and other measures. And, with your help,
we can build upon these successes in the coming year by promoting the use of new preventive
services and other strategies geared toward disease prevention, early detection, and lifestyle modifications that support a healthier life.

WHY BECOME A PARTICIPATING MEDICARE PROVIDER

All physicians, practitioners and suppliers must make their calendar year (CY) 2015 Medicare participation decision by December 31, 2014. Providers who want to maintain their current PAR status, or Non-PAR status do not need to take any action during the upcoming annual participation enrollment period. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2015. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. As indicated, during CY 2014, 96.6 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and you bill for services paid under the Medicare physician fee schedule (MPFS), your Medicare fee schedule amounts are 5 percent higher than if you do not participate.

WHAT TO DO
If you choose to be a PAR physician in CY 2015:

•Do nothing if you are currently participating, or

•If you are not currently a Medicare participant, complete the available blank agreement and mail it
(or a copy) to each Medicare Administrative Contractor (MAC) to which you submit Part B claims.
(On the form show the name(s) and identification number(s) under which you bill.)

If you decide not to participate in CY 2015:

•Do nothing if you are currently not participating, or

•If you are currently a participant, write to each MAC to which you submit claims, advising of the
termination of your participation in the participating physician program effective January 1, 2015.
This written notice must be postmarked prior to January 1, 2015.

ICD-10 Conversion/Coding Infrastructure Revisions/ICD-9 Updates to National Coverage Determinations (NCDs)--2nd Maintenance CR

September 10, 2015, 2:14 am

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This article is the second maintenance update of  ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CRs, specifically CR7818, CR8109, CR8197, andCR 8691. Links to related MLN Matters® Articles MM7818, MM8109, MM8197, and MM8691 are available in the additional information section of this article. Some are the result of revisions required to other NCD-
related CRs released separately that also included ICD-10.

Edits to ICD-10 coding specific to NCDs will be included in subsequent, quarterly updates. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. Make sure that your billing staffs are aware of these spreadsheets attached to CR9087 for the following 13 NCDs:

NCD	NCD Title
20.29	Hyperbaric Oxygen Therapy
20.9.1	Ventricular Assist Devices
50.3	Cochlear Implantation
80.2	Photodynamic Therapy
80.2.1	Ocular Photodynamic Therapy (OPT)
80.3	Photosensitive Drugs
80.3.1	Verteporfin
110.1	Intravenous Iron Therapy
150.3	Bone (Mineral) Density Studies
160.18	Vagus Nerve Stimulation
180.1	Medical Nutrition Therapy
210.2	Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
250.3	Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases

HCPCS/CPT codes, reason/remark codes, frequency edits, POS/TOB/provider specialties, and so forth. The requirements described in CR9087 reflect the operational changes that are necessary to implement the conversion of the Medicare shared system diagnosis codes specific to the attached Medicare NCD Table.

Please note that there are 10 spreadsheets attached to CR9087. These spreadsheets relate to 13 NCDs, and provide pertinent policy/coding information necessary to implement ICD-10. Further, you should be aware that NCD policies may contain specific covered, non-covered and/or discretionary diagnosis coding. These spreadsheets are designated as such and are based on current NCD policies and their corresponding edits. Nationally covered and non-covered diagnosis code editing is finite and cannot be revised without subsequent discussions with CMS. Discretionary code lists are to be regarded as CMS’ compilation of discretionary codes based on current analysis/interpretation. Local MACs may or may not expand discretionary lists based on their individual local authority within their respective jurisdictions. Nothing contained in CR 9087 should be construed as new policy. Some coding details are as follows:

1.The ICD-10 diagnosis/procedure codes associated with the NCDs attached to CR9087 are not to be implemented until October 1, 2015, or until ICD-10 is implemented.

2.Your MAC will use default Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) messages, where appropriate:

•Remittance Advice Remark Code (RARC) N386 (This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered), along with Claim Adjustment Reason Code (CARC) 50 (These are noncovered services because this is not deemed a "medical necessity" by the payer), CARC 96 (Non-covered charge(s). At least one Remark Code must be provided [may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT]), and/or CARC 119 (Benefit maximum for this time period or occurrence has been reached).
3.When denying claims associated with the attached NCDs, except where otherwise indicated, your MACs will use:
•Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32(Advance Beneficiary Notice), or with occurrence code 32 and a GA modifier (The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient), indicating a signed ABN is on file).
• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier (The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient), indicating no signed ABN is on file).

NOTE: For modifier GZ, use CARC 50 and MSN 8.81 (If the provider/supplier should have known that Medicare would not pay for the denied items or services and did not tell you in writing before providing them that Medicare probably would deny payment, you may be entitled to a refund of any amounts you paid. However, if the provider/supplier requests a review of this claim within 30 days, a refund is not required until we complete our review. If you paid for this service and do not hear anything about a refund within the next 30 days, contact your provider/supplier).

Not able to submit ICD 10 What is alternative method? what is alternative method - part 1

September 14, 2015, 10:39 pm

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This MLN Matters® Special Edition article offers physicians, providers, and suppliers information that will assist them in avoiding claims processing disruptions after implementation of International Classification of Diseases, Tenth Edition (ICD-10) on October 1, 2015. It provides information for providers who have difficulties submitting ICD-10 claims due to being unable to complete necessary systems changes or having issues with billing software, vendor(s), or clearinghouse(s).


For FROM dates of service (on professional and supplier claims) or dates of DISCHARGE/ THROUGH dates (on institutional claims) on or after October 1, 2015, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use ICD-10 code sets adopted under HIPAA.


ICD-10 Claims Submission Alternatives

If you have difficulties submitting ICD-10 claims due to being unable to complete the necessary systems changes or having issues with your billing software, vendor(s), or clearinghouse(s), the following claims submission alternatives are available:

• Free billing software;
• Provider internet portals;
• Direct Data Entry (DDE); and
• Paper claims.

Each claims submission alternative is discussed in more detail below


FREE BILLING SOFTWARE
Providers Who Submit Claims to MACs

You may download the free billing software that the Centers for Medicare & Medicaid Services (CMS) A/B MACs offer on their web pages. The software has been updated to support ICD-10 codes and requires either a Network Service Vendor (NSV) or dial-up or both to transmit claims. The software download is free, but there may be fees associated with submitting claims through an NSV or dial-up. The MAC web pages also provide information about NSVs.


This billing software only works for submitting Fee-For-Service (FFS) claims to Medicare.

It is intended to provide submitters with an ICD-10 compliant claims submission format; it does not provide coding assistance.

Information about the free billing software is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission Alternatives Web Pages on the CMS website. Please note that submitting electronic claims to Medicare using the free billing
software does not change the requirement for ICD-10 compliant claims to be submitted for FROM dates of service (on professional claims) or dates of DISCHARGE/THROUGH dates (on institutional claims) on or after October 1, 2015.
Any claims containing ICD-9 codes for FROM dates of service (on professional claims) or dates of DISCHARGE/THROUGH dates (on institutional claims) on or after October 1, 2015, will be rejected by Medicare.

Providers Who Submit Claims to DME MACs

DME suppliers may download the free billing software that CMS offers via the Common Electronic Data Interchange (CEDI) website. The software has been updated to support ICD-10 codes and requires NSV connectivity to transmit Medicare DME claims to CEDI. The software download is free, but there may be fees associated with submitting claims through an NSV. The list of approved NSVs and an NSV Frequently Asked Questions document is available at http://www.ngscedi.com/nsv on the CEDI website. You must also have a CEDI Trading Partner/Submitter ID to use the free billing software to submit claims
to CEDI.


• If you currently do not have a CEDI Trading Partner ID (begins with A08, B08, C08, or D08) to submit claims directly to CEDI (for example, you submit claims through a clearinghouse or billing service), you will need to complete the necessary CEDI enrollment forms to obtain a CEDI Trading Partner ID.


• If you currently have a CEDI Trading Partner ID, you will use that to submit claims with the free billing software.

You can find CEDI enrollment forms at http://www.ngscedi.com/forms/formsindex.htm on the CEDI website. You should submit the forms to CEDI as soon as possible, but no later than September 15, 2015, to allow CEDI time to process your request and for any testing you might want to do prior to the October 1, 2015, ICD-10 implementation. You will also need to allow for any additional time to sign up and establish connectivity to CEDI through the NSV that you choose.

This billing software only works for submitting FFS claims to Medicare. It is intended to provide submitters with an ICD-10 compliant claims submission format; it does not provide coding assistance.

Information about the free billing software is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission Alternatives Web Pages on the CMS website.

LCD Guidelines for cpt 76492, 36470 and 22856, 76999

September 17, 2015, 9:24 pm

≫ Next: CMS 1500 box 24a, 24b and 24c Detailed view

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The local coverage determination (LCD) for noncovered services was revised to remove several CPT® codes from noncoverage. CPT® code 76999 (ultrasound guided sclerotherapy) was removed from the “CPT®/HCPCS Codes - Unlisted Procedure Codes - Procedures” section of the LCD since this service (billed as CPT® codes 36470/36471 and 76942) is addressed in another LCD (treatment of varicose veins of the lower extremity). In addition, the “CPT®/HCPCS Codes – Listed Procedure Codes - Procedures” section of the LCD was revised to remove CPT® codes 22856, 22861, and 22864based on a reconsideration request. Removing a service from noncoverage should not be interpreted as a positive coverage statement and coverage by Medicare. Claims for such services, assuming all other requirements of the program are met, would always need to meet the medically reasonable and necessary threshold for coverage in a prepayment or post payment audit of the official medical record.
Effective date


The LCD revision for CPT® code 76999 is effective for claims processed on or after September 9, 2015, for dates of service on or after August 9, 2015. The LCD revision for CPT® codes 22856, 22861, and 22864 is effective for services rendered on or after September 9, 2015. First Coast Service Options Inc. LCDs are available through the CMS Medicare coverage database at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx external link.


Coding guidelines for an LCD (when present) may be found by selecting “Attachments” in the “Section Navigation” drop-down menu at the top of the LCD page.

CMS 1500 box 24a, 24b and 24c Detailed view

September 22, 2015, 9:01 am

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24a  Dates of Service-unshaded NDC number-shaded (required when billing CPT/HCPCS codes for a drug)

Unshaded area: Enter date of service in the block, MMDDYY.

Shaded area: Drug codes require NDC. See www.wvdhhr/bms.org for the Drug Code List for procedure codes that require NDC codes. Enter the NDC qualifier of N4, followed by an 11-digit NDC number. Do not enter a space between the qualifier and NDC. Do not enter hyphens or spaces within the NDC number. The NDC number submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.

24b Place of Service
Enter the appropriate 2-digit code for place of service. Valid values are: 01 & 02 = Unassigned 03 = School 04 = Homeless Shelter 05 = Native American Health Service, Free Standing Clinic 06 = Native American Health Service, Provider Based Facility 07 = Tribal 638 Free Standing Facility 08 = Tribal 638 Provider Based Facility 09 & 10 = Unassigned 11 = Office 12 = Patient’s Home 13 = Assisted Living Facility 14 = Group Home 15 = Mobile Unit 16 – 19 = Unassigned 20 = Urgent Care Facility 21 = Inpatient Hospital 22 = Outpatient Hospital 23 = Emergency Room - Hospital 24 = Ambulatory Surgical Center 25 = Birthing Center 26 = Military Treatment Facility 27 – 30 = Unassigned 31 = Skilled Nursing Facility 32 = Nursing Facility 33 = Custodial Care Facility 34 = Hospice 35 – 40 = Unassigned 41 = Ambulance, Land 42 = Ambulance, Air or Water 43 – 48 = Unassigned 49 = Independent Clinic 50 = Federally Qualified Health Center 51 = Inpatient Psychiatric Facility 52 = Psychiatric 53 = Community Mental Health Center 54 = Intermediate Care Facility 55 = Residential Substance Abuse Treatment Facility 56 = Psychiatric Residential Treatment Center 57 = Non-Residential Substance Abuse Treatment Facility 58 & 59 = Unassigned 60 = Mass Immunization Center 61 = Comprehensive 62 = Comprehensive Outpatient Rehabilitation Facility 63 & 64 = Unassigned 65 = End-Stage Renal Disease Treatment Facility 66 – 70 = Unassigned 71 = State Public Health Clinic 72 = Rural Health Clinic 73 – 80 = Unassigned 81 = Independent Laboratory 99 = Other Unlisted Facility


24c Defaults to 1 for CMS services