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JM HHH Medicare advisory

What’s Inside...

Latest Medicare News for JM Home Health & Hospice

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March 2018Volume 2018, Issue 03

The JM HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction M HHH. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM HHH Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/Medicare.

CPT only copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved.

MLN Connects ..............................................................................................................3Weekly Articles ........................................................................................................3Special Edition Articles ..........................................................................................3Therapy Cap Claims Rolling Hold ...........................................................................3New Medicare Card: Web Updates ..........................................................................4New Medicare Card: When Will My Medicare Patients Receive Their Cards? ......4

Home Health and Hospice Information ......................................................................5Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial ...............................................................................................5Identifying Prior Hospice Days When Calculating Hospice Routine Home Care Payments After a Transfer .....................................................................7 Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System ........................8Reinstating the Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System from CR9911 ....................10Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update .............................................12We’d Love Your Feedback! ....................................................................................15Get Your Medicare News Electronically ................................................................16Medicare Learning Network® (MLN) ....................................................................16

Electronic Data Interchange (EDI) Information ......................................................17Healthcare Provider Taxonomy Codes (HPTCs) April 2018 Code Set Update .....17Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update ....................19

Fee Schedule Information ..........................................................................................20Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update ..................................................................................................20

Learning and Education Information .......................................................................23Get to Know KEPRO Your BFCC-QIO Webcast ..................................................23Home Health and Hospice Quarterly Updates Webcast .........................................23

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CPT codes, descriptors and other data only are copyright 2016 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data con-tained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

March 2018 Home Health and Hospice Educational Events

Get to Know KEPRO Your BFCC-QIO WebcastPalmetto GBA will host an informative ‘Get to Know KEPRO Your BFCC-QIO’ webcast on Wednesday, March 14, 2018 at 10 a.m. ET.

Home Health and Hospice Quarterly Updates WebcastPalmetto GBA will host the March 2018 Home Health and Hospice Quarterly Updates webcast on Thursday, March 15, 2018, at 10:00 a.m. ET. The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements. 2018 Jurisdiction M (JM) Home Health Medicare Workshop Series - Winning with Medicare Palmetto GBA is pleased to announce our 2018 Home Health Workshop Series, Winning with Medicare. These workshops are designed for home health providers and their staff to equip them with the tools they need to be suc-cessful with Medicare billing, coverage and documentation requirements.

2018 Jurisdiction M (JM) Hospice Medicare Workshop Series – Winning with MedicarePalmetto GBA is pleased to announce our 2018 Hospice Workshop Series, Winning with Medicare. These work-shops are designed for hospice providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

For more information and registration instructions to attend these education sessions, please go to Page 23 of this issue.

Learning and Education Information (continued)2018 Jurisdiction M (JM) Home Health Medicare Workshop Series - Winning with Medicare ..........................................................................................242018 Jurisdiction M (JM) Hospice Medicare Workshop Series – Winning with Medicare ..........................................................................................26Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA ................................................................................................28

Medical Policy Information .......................................................................................29HHH Local Coverage Determinations (LCDs) Updates ........................................29HHH Local Coverage Determinations (LCDs) Article Updates ............................29

Tools You Can Use .......................................................................................................31Billing Occurrence Code 27, Occurrence Span Code 77 and Late Recertifications Module .................................................................................31

Helpful Information ....................................................................................................33Contact Information for Palmetto GBA Home Health and Hospice ......................33


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MLN CONNECTS

MLN Connects will contain Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recent issues, please copy and paste the following links into your Web browser:

Weekly Articles

February 22, 2018 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-02-22-eNews.pdf




Special Edition Articles

Therapy Cap Claims Rolling Hold

CMS is immediately releasing for processing held therapy claims (https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html) with the KX modifier with dates of receipt beginning January 1-10; CMS will also implement a “rolling hold” to minimize impact if legislation to extend the outpatient therapy caps exceptions process is enacted.

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New Medicare Card: Web Updates

To help you prepare for the transition to the Medicare Beneficiary Identifier (MBI) on Medicare cards beginning April 1, 2018, review the new information about remittance advices.

Beginning in October 2018, through the transition period external link , when providers submit a claim using a patient’s valid and active Health Insurance Claim Number (HICN), CMS will return both the HICN and the MBI on every remittance advice. Here are examples of different remittance advices:

• Medicare Remit Easy Print (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Downloads/MREP-Example.pdf) (Medicare Part B providers and suppliers)

• PC Print for Institutions (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Downloads/PC-Print-Example.pdf)

• Standard Paper Remits: FISS (Medicare Part A/Institutions) (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Downloads/FISS-SPR-Example.pdf) , MCS (Medicare Part B/Professionals (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Downloads/MCS-SPR-Example.pdf), VMS (Durable Medicare Equipment) (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/Downloads/VMS-SPR-Example.pdf)

Find more new information on the New Medicare Card provider external link webpage (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html). New Medicare Card: When Will My Medicare Patients Receive Their Cards?

Starting April 2018, CMS will begin mailing new Medicare cards to all people with Medicare on a flow basis, based on geographic location and other factors. Learn more about the Mailing Strategy (https://www.cms.gov/Medicare/New-Medicare-Card/NMC-Mailing-Strategy.pdf). Also starting April 2018, your patients will be able to check the status of card mailings in their area on Medicare.gov.

For More Information:

• Mailing Strategy (https://www.cms.gov/Medicare/New-Medicare-Card/NMC-Mailing-Strategy.pdf)


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• Questions from Patients? Guidelines (https://www.cms.gov/Medicare/New-Medicare-Card/New-Medicare-Card-Messaging-Guidelines-July-2017.pdf)

• New Medicare Card overview (https://www.cms.gov/Medicare/New-Medicare-Card/index.html) and provider (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html) webpage

HOME HEALTH AND HOSPICE INFORMATION

Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial

MLN Matters Number: MM10372 Revised Related CR Release Date: January 5, 2018 Related CR Transmittal Number: R3948CP Related Change Request (CR) Number: CR10372 Effective Date: July 1, 2017 Implementation Date: July 2, 2018

Note: This article was revised on January 30, 2018, to correct the effective date, which is July 1, 2017. All other information remains the same.

Provider Types Affected This MLN Matters® Article is intended for Home Health Agencies submitting claims to Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed Change Request (CR) 10372 informs MACs about revisions to the edit that matches claims and assessments, creating a bypass when condition code DR is reported on the claim. CR 10372 also identifies a newly added edit to ensure the correct Type of Bill code is submitted with condition code 21 when the HHA is billing for denial. Make sure that your billing staffs are aware of these changes.

Background In April 2017, CMS implemented Change Request (CR) 9585, which denied claims for Home Health (HH) episodes when the corresponding Outcomes and Assessment Information Set (OASIS) was due but not found by Medicare systems. You can review related article, MM9585, at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9585.pdf. This enforced Medicare’s policy of requiring the OASIS data as a condition of payment. When an assessment is not found, the claim is “returned to provider”.

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In response to hurricane and wildfire events in 2017, the Secretary of the Department of Health & Human Services declared that public health emergencies existed in various States and authorized waivers and modifications under §1135 of the Social Security Act. Under one of these waivers, the OASIS transmission requirements at 42 CFR 484.20 are suspended for those Medicare approved HHAs serving qualified home health patients/evacuees in the affected areas. When submitting claims for episodes to which this waiver applies, HHAs use the DR condition code to indicate Medicare payment is conditioned on the presence of a “formal waiver,” in accordance with CR6451. You may review MM6451 at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM6451.pdf.

Currently, Medicare systems logic does not include a bypass for condition code DR. As a result, HH claims suspended to determine the appropriateness of condition code DR and then released for processing would be returned to provider in error unless the MAC takes additional manual actions. The Centers for Medicare & Medicaid Services (CMS) has added a bypass for condition code DR to this reason code, so a manual workaround will no longer be necessary.

Additionally, during research of other problems related to the claims-OASIS match, MACs reported HH claims with condition code 21 (billing for denial) that were sent to the matching process unnecessarily. This occurred because the HHA submitted condition code 21 claims using the wrong Type of Bill (TOB). To prevent this, CMS created a new edit in Medicare systems to ensure that condition code 21 may only be reported on HH claims with TOB 0320, consistent with longstanding instructions in the Medicare Claims Processing Manual.

Additional Information The official instruction, CR10372, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2018Downloads/R3948CP.pdf.

If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.

Document History

Date of Change Description January 30, 2018 The article was revised to correct the effective date, which is July

1, 2017. All other information is the same. January 5, 2018 Initial article released.


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Identifying Prior Hospice Days When Calculating Hospice Routine Home Care Payments After a Transfer

MLN Matters Number: MM10180 Related CR Release Date: January 26, 2018 Related CR Transmittal Number: R2014OTN Related Change Request (CR) Number: 10180 Effective Date: January 1, 2016 Implementation Date: July 2, 2018

Provider Type Affected This MLN Matters Article is intended for Hospices submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

What You Need To Know Change Request (CR) 10180 calls for changes to Medicare’s claims processing systems, especially the Common Working File (CWF) to correct the number of days used to determine the 60 days of high Routine Home Care (RHC) payments on hospice claims. It ensures that the count includes the days provided by another hospice when there is a transfer during a benefit period. Previously, Medicare instructed you to account for this by reporting the benefit period start date as the admission date on your claim in the case of transfers. While this workaround resulted in correct payments, it required you to submit misleading information. The requirements in CR 10180 instruct the CWF to identify prior days correctly in transfer situations, so that you no longer need to use this workaround as of the implementation date of CR10180 (July 2, 2018). Be sure your billing staffs are aware of this update.

Background Medicare pays a higher rate for hospice services at the RHC level of care for the first 60 days of service. These 60 days are counted on a beneficiary level across any hospice benefit periods that are not separated by a 60-day gap. Because the number of prior service days cannot be identified in all cases by the Fiscal Intermediary Shared System (FISS) from the face of the claim, the CWF must read data from services provided at other hospices and return additional days that apply to the payment calculation to FISS.

To date, Medicare has instructed the CWF to identify prior service days based on prior benefit periods. This overlooks the possibility that service days may have occurred at another provider prior to a transfer within the same benefit period. When a transfer occurs during a benefit period, the admitting (second) hospice submits a transfer notice (Type of Bill 08xC) which establishes the second hospice’s start date (START DATE 2) on the benefit period record in CWF. When the second hospice bills for services, the days between the original start date of the benefit period (START DATE 1) and the second hospice’s start date (START DATE 2) should be included in the prior service days used in RHC payment calculations.

CR10180 contains no new policy. It corrects the implementation of existing hospice payment policy.

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Additional Information The official instruction, CR 10180, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2014OTN.pdf.

If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.

Document History

Date of Change Description January 26, 2018 Initial article released.

Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System

MLN Matters Number: MM10397 Related CR Release Date: February 16, 2018 Related CR Transmittal Number: R2031OTN Related Change Request (CR) Number: 10397 Effective Date: July 1, 2018 Implementation Date: July 2, 2018

Provider Type Affected This MLN Matters Article is intended for physicians, suppliers, and providers submitting electronic medical documentation to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed Change Request (CR) 10397updates the business requirements to enable MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system. CR10397 is for esMD purposes only. Please make sure your billing staffs are aware of these updates.

Background CR10397 also contains attachments that include cover sheets that must be used for electronic, fax, or mail submissions of documentation. There are three cover sheets, one each for Part A and Part B providers, as well as one for durable medical equipment (DME) suppliers. In addition, there are two companion guides attached to CR10397, one for institutional claims and one for professional claims. A link to CR10397 is available in the Additional Information section of this article.

With CR10397, MACs will modify PWK, also known as unsolicited documentation procedures to include electronic submission(s) via esMD. Also, Medicare systems will accept PWK 02 values “EL” and “FT” for


9 03/2018

those MACs in a CMS-approved esMD system. This mechanism will suppress initial auto letter generation, if applicable, when PWK 02 is “EL” or “FT,” and is present at any level of the claim or line.

Providers will receive communication from MACs via companion documents for 5010 X12 837 to include:

• The value “EL” (electronic) in PWK 02 to represent an esMD submission for sending the documentation using X12 Standards (6020 X12 275)

• The value “FT” (file transfer) in PWK 02 to represent an esMD submission for sending the documentation in PDF format using XDR specifications.

MACs will allow 7 calendar “waiting days” (from the date of receipt) for additional information to be submitted when the PWK 02 value is “EL” or “FT.”

MACs will use RC Client to reject the PWK data submissions as administrative error(s) when the received cover sheet (via esMD) is incomplete or incorrectly filled out as applicable to current edits. Providers can expect to see new generic reason statements introduced to convey these errors as follows (Codes for these statements will be finalized and sent along with the RC implementation guide):

• The date(s) of service on the cover sheet received is missing or invalid.

• The NPI on the cover sheet received is missing or invalid.

• The state where services were provided is missing or invalid on the cover sheet received.

• The Medicare ID on the cover sheet received is missing or invalid.

• The billed amount on the cover sheet received is missing or invalid.

• The contact phone number on the cover sheet received is missing or invalid.

• The beneficiary name on the cover sheet received is missing or invalid.

• The claim number on the cover sheet received is missing or invalid.

• The Attachment Control Number (CAN) on the cover sheet is missing or invalid.

Once again, examples of the cover sheet are included as an attachment to CR10397.

Additional Information The official instruction, CR 10397, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2031OTN.pdf.

The X12 837 Companion Guides are available at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/CompanionGuides.html.

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Date of Change Description February 16, 2018 Initial article released.

Reinstating the Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System from CR9911

MLN Matters Number: MM10433 Related CR Release Date: February 2, 2018 Related CR Transmittal Number: R3965CP Related Change Request (CR) Number: 10433 Effective Date: July 1, 2018 Implementation Date: For claims processed on or after July 2, 2018

Provider Types Affected This MLN Matters® Article is intended for providers and suppliers who submit claims to Part A/B Medicare Administrative Contractors (MACs).

What You Need To Know Effective with Change Request (CR) 10433, the Centers for Medicare & Medicaid Services (CMS) will reintroduce Qualified Medicare Beneficiary (QMB) information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN). CR 9911 modified the Fee-For-Service (FFS) systems to indicate the QMB status and zero cost-sharing liability of beneficiaries on RAs and MSNs for claims processed on or after October 2, 2017. On December 8, 2018, CMS suspended CR 9911 to address unforeseen issues preventing the processing of QMB cost-sharing claims by States and other secondary payers outside of the Coordination of Benefits Agreement (COBA) process. CR 10433 remediates these issues by including revised “Alert” Remittance Advice Remark Codes (RARC) in RAs for QMB claims without adopting other RA changes that impeded claims processing by secondary payers. CR 10433 reinstates all changes to the MSNs under CR 9911. Please make sure your billing staff is aware of these changes.

Background Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances. (See Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act.) The QMB program is a State Medicaid benefit that assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copays. In 2015, 7.2 million individuals (more than one out of 10 beneficiaries) were enrolled in the QMB program.


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Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States may limit Medicare cost-sharing payments, under certain circumstances. Be aware, persons enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing.

System Changes to Assist Providers under CR 9911 To help providers more readily identify the QMB status of their patients, CR 9911 introduced a QMB indicator in the claims processing system for the first time. CR 9911 is part of the CMS ongoing effort to give providers tools to comply with the statutory prohibition on collecting Medicare A/B cost-sharing from QMBs.

Through CR 9911, CMS indicated the QMB status and zero cost-sharing liability of beneficiaries in the RA and MSN for claims processed on or after October 2, 2017. In particular, CR 9911 changed the MSN to include new messages for QMB beneficiaries and reflect $0 cost-sharing liability for the period they are enrolled in QMB. In addition, CMS modified the RA to include new Alert RARCs to notify providers to refrain from collecting Medicare cost-sharing because the patient is a QMB (N781 is associated with deductible amounts and N782 is associated with coinsurance).

Additionally, CR 9911 changed the display of patient responsibility on the RA by replacing Claim Adjustment Group Code “Patient Responsibility” (PR) with Group Code “Other Adjustment” (OA). CMS zeroed out the deductible and coinsurance amounts associated with Claim Adjustment Reason Code (CARC) 1 (deductible) and/or 2 (coinsurance) and used CARC 209 – (“Per regulatory or other agreement, the provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to the patient if collected. (Use only with Group code OA).”) However, the changes to the display of patient liability in the RAs for QMB claims caused unforeseen issues affecting the processing of QMB cost-sharing claims directly submitted by providers to states and other payers secondary to Medicare. Providers rely on RAs to bill State Medicaid Agencies and other secondary payers outside the Medicare COBA claims crossover process. States and other secondary payers generally require RAs that separately display the Medicare deductible and coinsurance amounts with the Claim Adjustment Group Code “PR” and associated CARC codes and could not process claims involving the RA changes from CR 9911. Barriers to the processing of secondary claims have additional implications for institutional providers that claim bad debt under the Medicare program since they must obtain a Medicaid Remittance Advice to seek reimbursement for unpaid deductibles and coinsurance as a Medicare bad debt for QMBs.

To address these issues, on December 8, 2017, CMS suspended the CR 9911 system changes causing the claims processing systems to suspend the RA and MSN changes for QMB claims under CR 9911. Reintroduction of QMB information in the MA and MSN under CR 10433

Effective with CR 10433, the claims processing systems will reintroduce QMB information in the RA without impeding claims processing by secondary payers.

The RA for QMB claims will retain the display of patient liability amounts needed by secondary payers to process QMB cost-sharing claims. CMS systems shall output Claim Adjustment Group Code “PR” along with CARC 1 and/or 2, as applicable, with monetary values expressed on outbound Medicare 835 Electronic

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Remittance Advices (ERAs) and on standard paper remittance advices (SPRs), as applicable. Medicare’s shared systems shall discontinue the practice of outputting Claim Adjustment Group Code OA with CARC 209 and reflecting the CARC 1 and 2 monetary amounts as zero.

The shared systems shall include the revised Alert RARCs N781 and N782 in association with CARCs 1 and/or 2 on the RA. These RARCs designate that the beneficiary is enrolled in the QMB program and may not be billed for Medicare cost sharing amounts. Additionally, for QMB claims, the Part A and B shared systems shall include the revised Alert RARC N781 in association with CARC 66 (blood deductible). The revised Alert RARCs are as follows:

• N781 - Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.

• N782 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

CR 10433 reestablishes all CR 9911 changes to the MSN by including QMB messages and reflecting $0 cost-sharing liability for the period beneficiaries are enrolled in QMB.

Additional Information The official instruction, MM10433, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3965CP.pdf.


Document History


Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update

MLN Matters Number: MM10454 Related CR Release Date: February 2, 2018 Related CR Transmittal Number: R3966CP Related Change Request (CR) Number: 10454 Effective Date: April 1, 2018 Implementation Date: April 2, 2018


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Provider Types Affected This MLN Matters Article is intended for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

What You Need To Know The HCPCS code set is updated on a quarterly basis. Change Request (CR) 10454 informs MACs of the April 2018 updates of specific biosimilar biological product HCPCS code, modifiers used with these biosimilar biologic products and an autologous cellular immunotherapy treatment. Be sure your staffs are aware of these updates.

Background CR 10454 describes updates associated with the following biosimilar biological product HCPCS codes and modifiers. The April 2018 HCPCS file includes three new HCPCS codes: Q5103, Q5104, and Q2041 Also, the April 2018 HCPCS file includes a revision to the descriptor for HCPCS code Q5101.

Effective for services as of April 1, 2018, The April 2018 HCPCS file includes these revised/new HCPCS codes:

• HCPCS Code: Q5101

o Short Description: Injection, zarxio

o Long Description: Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram


o Short Description: Injection, inflectra

o Long Description: Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg

o Type of Service (TOS) Code: 1,P

o Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator: E


o Short Description: Injection, renflexis

o Long Description: Injection, infliximab-abda, biosimilar, (renflexis), 10 mg

o TOS Code: 1, P

o MPFSDB Status Indicator: E

• HCPCS Code:Q2041

o Short Description: Axicabtagene ciloleucel car+

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o Long Description: Axicabtagene Ciloleucel, up to 200 million autologous Anti- CD19 CAR T Cells, Including leukapheresis and dose preparation procedures, per infusion

o TOS Code: 1

o MPFSDB Status Indicator: E

Effective for claims with dates of service on or after April 1, 2018, HCPCS code Q5102 (which describes both currently available versions of infliximab biosimilars) will be replaced with two codes, Q5103 and Q5104. Thus, Q5102 Injection, infliximab, biosimilar, 10 mg, will be discontinued, effective March 31, 2018.

Also, beginning on April 1, 2018, modifiers that describe the manufacturer of a biosimilar product (for example, ZA, ZB and ZC) will no longer be required on Medicare claims for HCPCS codes for biosimilars. However, please note that HCPCS code Q5102 and the requirement to use biosimilar modifiers remain in effect for dates of service prior to April 1, 2018.

Medicare Part B policy changes for biosimilar biological products were discussed in the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) final rule at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal- Regulation-Notices-Items/CMS-1676-F.html. Effective January 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code. The rule also stated that instructions for new codes for biosimilars that are currently grouped into a common payment code and the use of modifiers would be issued.

Additional Information The official instruction, CR 10454, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2018Downloads/R3966CP.pdf.

If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.



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We’d Love Your Feedback!

Palmetto GBA is committed to continuously improve your customer experience. We welcome your feedback on your experiences with the PalmettoGBA.com website and the eServices portal. As a visitor to the Palmetto GBA’s website, you may be presented with an opportunity to take the website satisfaction survey.

The next time the survey is offered to you, please agree to participate and provide us with your feedback. You have the opportunity to explain your comments, share your honest opinions, and tell us what you like and what you would like to see us improve. If you find a feature or tool specifically helpful, let us know including any suggestions for making them simpler to use.

We continuously analyze your feedback and develop enhancements plans to better assist you with your experience. We value your opinion and look forward to hearing from you.

16 03/2018


Get Your Medicare News Electronically

The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about:

• Medicare incentive programs • Fee Schedule changes• New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv:

Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

Medicare Learning Network® (MLN)

Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.html

• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”


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• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources:• MLN Publications List: contains the electronic versions of the downloadable publications. These

products are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing ListTo stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service:

1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or Unsubscribe’ link under the ‘Options’ tab on the right side of the page.

2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].

ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION

Healthcare Provider Taxonomy Codes (HPTCs) April 2018 Code Set Update

MLN Matters Number: MM10402 Related CR Release Date: February 16, 2018 Related CR Transmittal Number: R3977CP Related Change Request (CR) Number: 10402 Effective Date: July 1, 2018 Implementation Date: July 2, 2018

Provider Types Affected This MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

What You Need To Know Change Request (CR) 10402 directs MACs to obtain the most recent Healthcare Provider Taxonomy Codes (HPTCs) code set and use it to update their internal HPTC tables and/or reference files. Make sure your billing staffs are aware of these changes.

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Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that covered entities comply with the requirements in the electronic transaction format implementation guides adopted as national standards. The institutional and professional claim electronic standard implementation guides (X12 837-I and 837-P) each require use of valid codes contained in the HPTC set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.

You should note that:

1. Valid HPTCs are those codes approved by the National Uniform Claim Committee (NUCC) for current use.

2. Terminated codes are not approved for use after a specific date.

3. Newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears.

4. Specialty and/or provider type codes issued by any entity other than the NUCC are not valid.

5. Medicare would be guilty of non-compliance with HIPAA if MACs accepted claims that contain invalid HPTCs.

The HPTC set is maintained by the National Uniform Claim Committee (NUCC) for standardized classification of health care providers. The NUCC updates the code set twice a year with changes effective April 1 and October 1. The HPTC list is available for view or for download from the NUCC website at http://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40.

Although the NUCC generally posts their updates on the WPC webpage 3 months prior to the effective date, changes are not effective until April 1 or October 1, as indicated in each update. The changes to the code set include the addition of a new code and addition of definitions to existing codes. When reviewing the HCPT code set online, revisions made since the last release are identifiable by these color codes:

• New items are green

• Modified items are orange

• Inactive items are red.

Additional Information The official instruction, MM10402, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3977CP.pdf.


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Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

MLN Matters Number: MM10489 Related CR Release Date: February 16, 2018 Related CR Transmittal Number: R3980CP Related Change Request (CR) Number: 10489 Effective Date: July 1, 2018 Implementation Date: July 2, 2018

Provider Types Affected This MLN Matters® article is intended for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

What You Need To Know Change Request (CR) 10489 updates the Remittance Advice Remark Codes (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print. Be sure your staff are aware of these changes and obtain the updated MREP and PC Print software if they use that software.

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA, using valid standard codes. Medicare policy states that CARCs and RARCs, as appropriate, which provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment, are required in the remittance advice and coordination of benefits transactions.

The Centers for Medicare & Medicaid Services (CMS) instructs MACs to conduct updates based on the code update schedule that results in publication three times per year – around March 1, July 1, and November 1. This Recurring Update Notification applies to Chapter 22, Sections 40.5, 60.1, and 60.2 of the “Medicare Claims Processing Manual.”

The Shared System Maintainers (SSMs) have the responsibility to implement code deactivation, making sure that any deactivated code is not used in original business messages and allowing the deactivated code in derivative messages. SSMs must make sure that Medicare does not report any deactivated code on or after the effective date for deactivation as posted on the Washington Publishing Company (WPC) website. If any

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new or modified code has an effective date past the implementation date specified in CR 10489, MACs must implement on the date specified on the WPC website, available at: http://wpc-edi.com/Reference/.

A discrepancy between the dates may arise as the WPC website is only updated three times per year and may not match the CMS release schedule. For this recurring CR, the MACs and the SSMs must get the complete list for both CARC and RARC from the WPC website to obtain the comprehensive lists for both code sets and determine the changes that are included on the code list since the last code update, CR 10270 (see MLN Matters article MM10270).

Additional Information The official instruction, MM10489, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3980CP.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/

Document History

Date of Change Description February 16, 2018 Initial article released

FEE SCHEDULE INFORMATION INFORMATION

Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2018 Update

MLN Matters Number: MM10488 Related CR Release Date: February 16, 2018 Related CR Transmittal Number: R3976CP Related Change Request (CR) Number: 10488 Effective Date: January 1, 2018 Implementation Date: April 2, 2018

Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed Change Request (CR) 10488 amends payment files issued to MACs based upon the calendar year 2018 Medicare Physician Fee Schedule (MPFS) Final Rule. Make sure your billings staffs are aware of these changes.


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Background Payment files were issued to contractors based upon the 2018 MPFS Final Rule, published in the Federal Register on November 15, 2017, to be effective for services furnished between January 1, 2018, and December 31, 2018. Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services.

CR 10488 presents a summary of the changes for the April update to the 2018 MPFSDB. Unless otherwise stated, these changes are effective for dates of service on and after January 1, 2018.

CPT/HCPCS & Mod

Action

G0516 Change in short descriptor on 4-1-18 to “insert drug implant,>=4” 45399 Global Days = YYY G9976 Procedure Status = IG9977 Procedure Status = I 83992 Procedure Status = I

The following “Q” codes are effective for services performed on or after April 1, 2018 (see MLN Matters Article MM10454 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10454.pdf)for additional information):

CPT Code

Short Descriptor Action

Q2041 Axicabtagene ciloleucel car+

Procedure Status = E; there are no RVUs

Q5101 Injection, zarxio Change in short descriptor Q5102 Inj., infliximab biosimilar Procedure Status = I (invalid); code

discontinued 4-1-18 & after Q5103 Injection, inflectra Procedure Status = E; there are no RVUs Q5104 Injection, renflexis Procedure Status = E; there are no RVUs

The HCPCS “G” codes listed below have been added to the MPFSDB effective for dates of service on and after April 1, 2018. All of these new codes were communicated through other instructions. Please consult those instructions for the description and other information. In addition, the descriptions are available also at https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html.

CPT/HCPCS & Mod

Action

G9873 Procedure Status = X; there are no RVUs; all policy indicators = concept does not apply


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Providers should be aware MACs do not need to search their files to either retract payment for claims already paid or to retroactively pay claims. However, MACs will adjust claims that you bring to their attention.

Additional Information The official instruction, CR10488, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3976CP.pdf.




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LEARNING AND EDUCATION INFORMATION

Get to Know KEPRO Your BFCC-QIO Webcast

Palmetto GBA will host an informative ‘Get to Know KEPRO Your BFCC-QIO’ webcast on March 14, 2018 at 10 a.m. ET. This webcast is intended for Medicare Part A, Part B, Home Health and Hospice providers and Railroad Retirement Board (RRB) Specialty MAC beneficiaries and providers.

KEPRO is the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for over 30 states. You will learn more about the services that they offer to Medicare beneficiaries and their families concerning beneficiary complaints, discharge appeals and immediate advocacy.

Registration is via the Event Registration Portal. Please note that when registering if you do not have a NPI/PTAN, please enter “none” or “n/a”.

To register for this Webcast, please copy and paste in your browser the link below:

https://event.on24.com/wcc/r/1561142/89967C5899087751D76413DB570ABE78

Home Health and Hospice Quarterly Updates Webcast

Palmetto GBA will host the March 2018 Home Health and Hospice Quarterly Updates webcast on March 15, 2018, at 10:00 a.m. ET. The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements.

This webcast is designed to provide pertinent updates, changes, and reminders to assist the provider community in staying compliant with Medicare rules, regulations and will include:

Medicare Updates and Changes

• Palmetto GBA Updates

• Reminders

• Audio

The audio for this presentation will be broadcasting through your computer. For best results, it is recommended that you use headphones. You should not use your telephone to dial into the conference.

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HandoutsA copy of the presentation will be available through the event portal once the session begins.

*Please enter a valid PTAN and NPI, if you have one. If you do not have a PTAN or NPI, please enter ‘none’ or ‘n/a.’

Registration link: https://event.on24.com/wcc/r/1581691/4B02250F57C24BACD593DD6444BA2604

2018 Jurisdiction M (JM) Home Health Medicare Workshop Series - Winning with Medicare

Palmetto GBA is pleased to announce our 2018 Home Health Workshop Series, Winning with Medicare. These workshops are designed for home health providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

These workshops will provide insight for home health agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend our online learning courses for beginners at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices!

The following topics will be covered during the workshop:

Part I

1. Data Analysis

a. Utilization

b. Length of Stay

c. Disbursement

2. Top Denials

a. Jurisdiction

b. State

3. Case Scenarios

4. Nursing Documentation


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Part II:

5. What You Need to Know for 2018

6. Data Driven Topics

a. Reason Code 37253 – Why Did My Claim RTP?

b. Comparative Billing Report (CBR)

7. eServices Online Portal

8. Reminders

a. CERT Program

b. Provider Enrollment Revalidation

c. EDI

9. Provider Resources/Self Service Tools

a. CMS Resources

b. Top Links

c. Forms/Tools

d. Social Media

e. Education/Events

Registration InformationThe schedule of workshops is available on the Event Registration Portal under the Learning and Education section of the Palmetto GBA Home Health and Hospice webpage (www.PalmettoGBA.com/hhh).

The state associations are sponsoring the workshops. Please select the link for the date of the workshop you want to attend and that will take you directly to the Association’s registration page.

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2018 Jurisdiction M (JM) Hospice Medicare Workshop Series – Winning with Medicare

Palmetto GBA is pleased to announce our 2018 Hospice Workshop Series, Winning with Medicare. These workshops are designed for hospice providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

These workshops will provide insight for hospice agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend online learning courses for beginners offered at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning Section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices!

The following topics will be covered during the workshop:

Part I:

1. Data Analysis

a. Utilization

b. Medical Review Top Denials

2. Recertification

3. Amyotrophic Lateral Sclerosis (ALS)

Part II:

4. What You Need to Know for 2018

5. Data Driven Topics

a. Notice of Election (NOE) – Late Submission

b. Comparative Billing Report (CBR)

6. eServices Online Portal


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7. Reminders

a. CERT Program

b. Provider Enrollment Revalidation

c. EDI

8. Provider Resources/Self-Service Tools

a. CMS Resources

b. Top Links

c. Forms/Tools

d. Social Media

e. Education/Events

Registration InformationThe schedule of workshops is available on the Event Registration Portal under the Learning and Education section of the Palmetto GBA Home Health and Hospice webpage (www.PalmettoGBA.com/hhh).

The state associations are sponsoring the workshops. Please select the link for the date of the workshop you want to attend and that will take you directly to the Association’s registration page.

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Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA

Don’t Miss this Wonderful Opportunity!If you are in search of an opportunity to interact with and get answers to your Medicare billing, coverage and documentation questions from Palmetto GBA’s Provider Outreach and Education (POE) department, please see these educational offerings which have a question and answer session:

Quarterly Ask the Contractor Teleconferences (ACTs)

ACTs are intended to open the communication channels between providers and Palmetto GBA, which allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference.

Preceding the presentation, providers are given an opportunity to ask questions both on the topics discussed as well as any other question they may have. While we encourage providers to submit questions prior to the call, this is not required. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form). Once the form is completed, please fax it to (803) 935-0140, Attention: Ask-the-Contractor Teleconference

Quarterly Updates Webcasts

The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements.

Providers are able to type a question and have it responded to by the POE department throughout the webcast. At the end of the presentation the moderator will also read and respond to questions submitted by attendees in order to share the responses with the group at large.

Event Registration Portal

Visit our Event Registration Portal to find information on upcoming educational events and seminars.

This is a complete listing of both our face-to-face outreach opportunities as well as our teleconference and webcast listings. Providers are able to dialogue with POE and get answers to their questions at all of these educational events.

If you have a question that you need an answer to today or a claims specific question which requires the disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at 1-855-696-0705.


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MEDICAL POLICY INFORMATION

HHH Local Coverage Determinations (LCDs) Updates

Revised ICD-10 LCDsThe table below provides a summary of recent HHH ICD-10 LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/hhh/lcd. Select “Active LCD Policies under the Medical Policies” section. Make sure “Active LCDs” is selected under the “Select LCD Types(s)” section. Then select the “Submit” button.

TitleLCD ID NumberRevision Number

Changes/Additions/Deletions Effective Date

Home Health Speech-Language Pathology LCD Number: L34563Revision Number: 10

Under Coverage Indications, Limitations and/or Medical Necessity – Reevaluation the verbiage was italicized and the formatting was corrected. Under Sources of Information – Bibliography corrected a citation.

02/01/2018

HHH Local Coverage Determinations (LCDs) Article Updates

Revised ICD-10 LCD Article UpdatesThe table below provides a summary of a recent HHH MAC ICD-10 LCD article revision/updates. To view these revised LCD articles, go to www.PalmettoGBA.com/jma/hhh. In the Articles section select Coverage Articles. Under the Articles for Contractor Browser section, make sure the Active Articles category is selected and the click on the Submit button. The LCD articles are listed in alphabetical order.

TitleLCD Article ID NumberRevision Number

Changes/Additions/Deletions Effective Date

CPT Code 97755 - Assistive Technology AssessmentLCD Article Number: A53053Revision Number: 7

Under Associated Contract Numbers added contract number 1104 as this was inadvertently omitted.

02/08/2018

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This advisory should be shared with all health care practitioners and managerial members of the provider/supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www.PalmettoGBA.com/hhh.

Address Changes

Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the CMS website. To obtain the hard copy form plus information on how to complete and submit it, visit the Palmetto GBA website (www.PalmettoGBA.com/hhh).


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TOOLS THAT YOU CAN USE

Billing Occurrence Code 27, Occurrence Span Code 77 and Late Recertifications Module

This module focuses on billing Occurrence Code (OC) 27 and Occurrence Span Code (OSC) 77 and late recertifications.

Physician certifications or recertifications of terminal illness are the CORE of the Medicare Hospice Benefit. The certification of terminal illness for a hospice patient is required at the start of hospice care and for each subsequent benefit period.

To access this module, please copy and paste the following in your web browser:

https://www.palmgba.com/elearn/BillingOccurrence27/story.html

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NOTES


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HELPFUL INFORMATION

Contact Information for Palmetto GBA Home Health and Hospice

Department Contact Information Type of InquiryAppeals Palmetto GBA

HHH AppealsMail Code: AG-630P.O. Box 100238Columbia, SC 29202-3238Fax: (803) 699-2425

Fed Ex/UPS/Certified Mail AddressPalmetto GBAHHH AppealsMail Code: AG-630Building One2300 Springdale DriveCamden, SC 29020

• Request for Redeterminations

• Redetermination Form

Contact Center (Providers)

Palmetto GBA HHH PCC Mail Code: AG-840 P.O. Box 100238 Columbia, SC 29202-3238Provider Contact Center: 855-696-0705Our PCC representatives are ready to answer your questions about billing problems and other issues. Please see the following links for more guidance about the HHH Interactive Voice Response (IVR) and contacting the Contact Center:

IVR Flowchart (http://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_HHH_Flowchart.pdf/$File/IVR_HHH_Flowchart.pdf)

Call Flowchart (http://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_Flowchart.pdf/$File/IVR_Flowchart.pdf)

IVR Conversion Toolhttp://www.palmettogba.com/palmetto/ivrt.nsf/Main?OpenFormHHH PCC Hours: 8 a.m. to 5 p.m. ET

Email HHH to have your inquiry answered. Please do not include any Protected Health Information.

• General coverage and Medicare-related questions

• Crossover questions

• Questions regarding claim filing requirements

• Explanation of denial reasons

• IVR resources

• MSP resources

• Modifier guidelines

• Medical record documentation questions

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Cost Report Cost Report Filing

Mailing AddressPalmetto GBAAttn: Cost Report AcceptanceMail Code: AG-330P.O. Box 100144Columbia, SC 29202-3144

Fed Ex/UPS/Certified Mail AddressPalmetto GBAAttn: Cost Report AcceptanceMail Code: AG-3302300 Springdale DriveBuilding OneCamden, SC 29020-1728

Cost Report Overpayments Address (checks only)Palmetto GBAMedicare FinanceMail Code: AG-260P.O. Box 100277Columbia, SC 29202-3277

• Cost Reports • Checks

Credit Balance Reporting

Regular and Certified MailPalmetto GBAAttn: Credit Balance ReportingP.O. Box 100277Columbia, SC 29202-3277

Fed Ex/UPS/Overnight CourierPalmetto GBACredit Balance Reporting2300 Springdale DriveBuilding OneCamden, SC 29020

Reports may be faxed to:MCBR ReceiptsAttn: Credit Balance Reporting(803) 419-3277

If you have questions about your Credit Balance Report, please call the Provider Contact Center at: 855-696-0705.

All email inquiries may be sent to: [email protected]

• Questions or concerns regarding credit balance reports

Customer Service Center (Beneficiary)

1-800-Medicare (1-800-633-4227)TTY: 877-486-2048

Visit the Medicare website at www.medicare.gov.

• All questions related to the Medicare Program


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Electronic Data Interchange (EDI)

Email: [email protected]

Provider Contact Center: 855-696-0705

• EDI enrollment

• Administrative Simplification and Compliance Act (ASCA)

• Electronic Remittance Advice (ERA)

• PC-ACE Pro 32 (billing software)

• Direct Data Entry (billing software)

• Other EDI-related issues DDE Hours of Availability • Monday to Friday

6 am - 8 pm ET

• Saturday 6 am - 4 pm ET

• Sunday: Not Available Financial correspondence with/without checks

Palmetto GBAPO Box 100277Columbia, SC 29202

Freedom of Information Act (FOIA) Requests

Palmetto GBA – HHHFOIA CoordinatorMail Code: AG-840P.O. Box 100190Columbia, SC 29202-3190


• FOIA requests

Medical Affairs Palmetto GBAMedical AffairsMail Code: AG-275P.O. Box 100238Columbia, SC 29202-3238Fax: 803-462-2652


• Local coverage determinations (LCDs)

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Medical Review Palmetto GBAHHH Medical ReviewMail Code: AG-230P.O. Box 100238Columbia, SC 29202-3238

Please call the Provider Contact Center (PCC) at 855-696-0705 for Medical Review questions.

Fed Ex/UPS/Overnight CourierPalmetto GBA Mail Code: AG-2302300 Springdale Drive, Building OneCamden, SC 29020Fax: (803) 699-2436

• Responding to Additional Documentation Requests (ADRs)

• Responses to our requests for medical records

Medicare Secondary Payer (MSP)

For questions/concerns related to MSP records, contact the Benefits Coordination & Recovery Center (BCRC) at: 855-798-2627 (TTY/TDD at 855-797-2627 for the hearing and speech impaired). Customer Service Representatives are available to provide you with quality service Monday through Friday from 8 a.m. to 8 p.m. ET, except holidays.

Mailing addresses are available on the CMS website.

• MSP questions

• Questions regarding beneficiary’s primary or secondary records

Overpayments Palmetto GBAHHH OverpaymentsMail Code: AG-340P.O. Box 100277Columbia, SC 29202-3277

Provider Inquiries For inquiries regarding overpayments, please call the Provider Contact Center at 855-696-0705.

Fax Numbers

• To send any financial correspondence to the overpayment department by fax, please fax this information to (803) 419-3275

• To request an immediate offset, fax your request to (803) 462-2574

• Overpayments • Checks for cost reports and

credit balances


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Provider Audit Palmetto GBAProvider AuditMail Code: AG-320P.O. Box 100144Columbia, SC 29202-3144

Palmetto GBACost Report Appeals and ReopeningsMail Code: AG-380P.O. Box 100144Columbia, SC 29202-3144

Email:Filing of Cost Report [email protected]

Filing of Cost Report [email protected]

• Issues related to cost reports, desk reviews, audits and settlements

• Issues related to the filing of cost report appeals and reopenings

Provider Enrollment Palmetto GBAHHH Provider EnrollmentMail Code: AG-331P.O. Box 100144Columbia, SC 29202-3144

For inquiries regarding provider enrollment, please call the Provider Contact Center at 855-696-0705.

• Enrollment (credentialing) questions

• Request CMS-855 B, I or R forms

• Change address, add a location, add a new member to a provider group

• Independent Diagnostic testing facility (IDTF) enrollment

• Electronic Funds Transfer (EFT) CMS 588 form

• Medicare Participating Physician or Supplier Agreement (PAR) CMS 460 form

• How to obtain a National Provider Identifier (NPI)

• Participation corrections

• IRS 1099 tax form corrections

• Consent forms

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Provider Outreach and Education (POE)

Palmetto GBAHHH POEMail Code: AG-830P.O. Box 100238Columbia, SC 29202-3238

For education, please complete the Education Request Form. To access this document, go to the Forms Web Page at www.PalmettoGBA.com/hhh/forms.

• Educational training requests

• Request a speaker for association meetings in your state

Provider Reimbursement

Palmetto GBAProvider ReimbursementMail Code: AG-330P.O. Box 100144Columbia, SC 29202-3144

Provider inquiries, please call (803) 382-6104.

Fax updated certificates for diabetes education to the reimbursement department at (803) 935-0262.

• Submission of interim rate information

• Reimbursement issues

• Reimbursement specialist

• Submission of certificates

Zone Program Integrity Contractor (ZPIC)

Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee home health and hospice providersAdvanceMed, an NCI Company520 Royal Parkway, Suite 100Nashville, TN 37214Website: www.nciinc.com/about-us/advancemedPhone Number: (615) 871-2361

New Mexico, Oklahoma and Texas home health and hospice providersHealth Integrity, LLCWebsite: www.healthintegrity.orgPhone Number: (972) 383-0000

Florida home health and hospice providersSafeguard Services (SGS)Website: http://www.safeguard-servicesllc.com/Phone Number: (954) 624-3999

• Fraud

• Abuse

• Questionable billing practices


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NOTES

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NOTE: Should you have landed here as a result of a … · pdf. February 15, 2018 . ... Here are...

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Transcript of NOTE: Should you have landed here as a result of a … · pdf. February 15, 2018 . ... Here are...