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A/B MAC - Palmetto GBA

Part A Medicare Quarterly Updates

Provider Outreach & Education March 21, 2018

1

Disclaimer

This information is current as of March 6, 2018 Any changes or new information superseding this

webcast is provided in articles with publication dates after March 6, 2018, posted on our website at:

www.PalmettoGBA.com

CPT only copyright 2018 American Medical Association. All rights reserved.

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2018 American Dental

Association (ADA). All rights reserved.

2

http:www.PalmettoGBA.com

Objective

To provide pertinent updates, changes and reminders to assist our provider community in staying compliant with Medicare rules and regulations.

3

Agenda

Change Requests Updates & CMS Initiatives

Comprehensive Error Rate Testing (CERT)

Palmetto GBA Updates

4

Change Request Updates & CMS Initiatives

5

Quarterly Updates

Comprehensive CMS resources! Purpose of publications: Provide non-regulatory changes Define policy & manual instructions Information about new developments Clarification & understanding of CMS policies

& programs

6

Change Requests (CR)

Discontinue HCPCS Q5102, effective 3/31/2018

Three new HCPCS codes: Q5103, Q5104 & Q2041

Revision to HCPCS code Q5101

10454

7

Change Request (CR)

Article for the April 2018 I/OCE Specifications is at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10514.pdf

10515

8

https://www.cms.gov/Outreach-and

Title Effective lmpactTo

104302 Update CWF Edits for 7-1-2018 7-2-2018 Acute Kidney Injury (AKI) Claims

10433 Reinstating QMB 7-1-2018 7-2-2018 Indicator

10435 Editing Update for 1-1-2018 7-2-2018 Mammography Services

10481 Advanced Diagnostic 7-1-2018 7-2-2018 Imaging - QQ Modifier

Change Requests (CR)

9

CR 104302 Bypass edit U5715 for AKI claims for DOS

on or after 1/1/2017: Type of bill 72X submitted with condition code

84 & CPT G0491 & one of these ICD-10 codes: N17.0, N17.1, N17.2, N17.8, N17.9, N99.0 T79.5XXA, T79.5XXD,T79.5XXS

Palmetto GBA will adjust any AKI claims brought to our attention with edit U5715

104302

10

CR 10433

CR 10433 reestablishes Qualified Medicare Beneficiary (QMB) information to the remittance advice (RA) without impeding claims processing by secondary payers RA for QMB claims will retain the display of

patient liability amounts needed by secondary payers to process QMB cost-sharing claims

10433

11

CR 10435

Claims with dates of service (DOS) on or after January 1, 2018; Modifies edits to allow line item claims

containing HCPCS 77065, 77066, or 77067, regardless of what FDA certified provider to perform (film or digital) MACs will deny line-items on claims for

mammography services when the facility is not certified to perform mammograms

10435

12

Appropriate use criteria for CR 10481 -

CR 10481

Advanced Diagnostic Imaging Voluntary participation & reporting period HCPCS Modifier QQ

Effective for claims with DOS on or after 7-1-2018 MACs will accept QQ modifier on same claim

line as any CPT codes that fall within ranges identified in CR

10481 13

Outpatient Therapy Cap Repeal Congress repealed the Outpatient Therapy

Cap on February 9, 2018 Claims for services on & after 1/1/18 No longer subject to therapy cap Threshold for medical review is lowered Use KX modifier for services in excess of

prior therapy cap amount https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers/Downloads/Medicare-Expired-Legislative-Provisions-Extended.pdf

14

https://www.cms.gov/Center/Provider-Type/All-Fee-For

Medicare Covered Preventive/Screening Services

Preventive services educational tool https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ Downloads/MPS_QuickReferenceChart_1.pdf

Preventive services poster for your office https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PreventiveServicesPoster.pdf

15

https://www.cms.gov/Outreach-and-Education/Medicarehttps://www.cms.gov/Medicare/Prevention/PrevntionGenInfo

CMS 2018 MLN Matters Articles are located on the CMS Website

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018-Transmittals.html

3/21/2018 16

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2017-MLN-Matters-Articles.htmlhttps://www.cms.gov/Regulations-and

Weekly Official e-News News & Announcements Provider Compliance Claims, Pricers & Codes Upcoming Events MLN Publications & Multimedia

17

T h ,e M edicare L ear n iin 1g Network

F ,ee, e ducation.a l m a t e r i a lls f o r h ea It h c a r e p rofess io n a Is on C l'v1 S p irog 1r a rns . po I i c ie,s ,

a rnd in irt iativ es _

Get qui ck a o cess t o the i n fo 1Tll111a t:Jio n you rneedl _

Publications & Mu ltimed i

lrmwl Publications Nat -on a l Prrovi dle r Calls & E v ernts

M LIN M a tte r s A rtic le,s 'Web-Based Training

Multirne d-a

NeV1Tsletters & Socia Continuing Edu cation

M LN Corn n ect s Eam o o ntinuing ,edu caltion c r edit

m 1edicar-e j' Learinrng

netwloi'll . ::,,-T lh e M edic a r e L e a rrn i rn g N le two rk, ML N Gornnect s , and r\11 LN

(\/l a tters a r e reg1is t e red 1i:raderna r ks of t h e, u _s _ Dep,artm e nt of IHea llt h & H u man Services ( H HS)_

18

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Medicare Learning Network {MLN) Suite of Products & Resources for Compliance Officers

med . le n net ~ ci!l l l'of!Titl.iM H . C.-i,

Ptifllll~ C1n trutJ:

ICN 908525 August 2016

What's Inside the Suite?

Find online resources that provide guidance to educate and address the many compliance issues facing providers today.

How Will the Suite Help Me?

MLN products can enhance and strengthen your knowledge of general compliance gu idelines, the claims submission process, as well as supporting your understanding of initiatives and incentives. Save this suite to use as a reference!

Start Learning Now

Cli ck on any of the resources to view the product You can download infom1ation, listen to a podcast, explore an article through MLN Matters, or even sign up for a Web.Based Training (WBT) course-many of which offer continuing education credits.

The MLN is your hane for Cenfern for Medicare & Medicaid Services (CMS) education, information, and resources for the heath care professional cocrmmi!y.

Medicare Benefit Policy Manual

The Medicare Benefit Policy Manual describes general Medicare coverage instructions.

Medicare Claims Processing Manual

The Medicare Claims Processing Manual contains billing requirements, rules, and regUlatioos.

Medicare Coverage Database (MCD)

The MCD contains national and local Medicare coverage defeminations, analyses, proposed decisions, coding analyses, and other inlormalion. Use this how-to guide to access inlormalion abolt lhe MCD.

National Correct Coding Initiative (NCCI)

Learn how to navigate lhe CMS NCC I website with this helpful booklet The NCCI helps reduce coding and billing errors.

19

Medicare Learning Network (MLN) Suite of Products & Resources for Compliiance Officers

SELIECT A TOPIC FOR IMORE INFORMATION

General Compliance Resources

SELECT A RESOURCE IBY SPECIALTY

Ambulance

Cardiology

Chiropractic

General Surgery

Home Health

Hospice

Diagnostic Radiology and Imaging Services

Durable Medical Equipment (DME)

Hospital

Neurology

Oncology

Pulmonology

Therapy Services

Urology

Skilled Nursing Facility

Part AfPart B Fee-ForSetVice (FFS} Providers

Visit the MLN at http://go.cms.gov~MLNGenlnfo on the CMS website.

Check out CMS on: ... All ( OU a.. u.u llD

1. Go to the MLN learning Maoogemert and Prowd Ordering System (l M/POS)

2. Create an aero.rt oc log in to the LMPOS 3. Select "Training Catalog" 4. You may browse l7f cafegoly by selecting

one of the categories that appear. To browse all products, leaw the "Search for" field Illar*, and select "Sea-ch"

Popular Courses Continuing Education Credlts

Affordable Cae Act Provider Compliance Programs: Getting stirted

Certificate of Medical Necessity

Diagnosis Coding: Using the ICD-1~

Drug Diversion: Do You KnowVVhere the Drugs Are Going?

HIPAA EDI Slandards

Medicare Billing: 8371 and Fonn CMS-1450

Medicare Billing: 837P and Fonn CMS-1500

Medicare Fraud and Abuse: ~tion, Detection, and Reporting

Medicare Secondary Payer Provisions

Safeguarding Your Medical Identity

World of Medicare

Your Institution in the World of Medicare

Your Office in the Wond of Medicare

Standard Courses

Unifonn Billing (UB-04)

Medicare BiDing Certificate F'rO!Jlll1l fa- P!W! A Providers

Medicare Billing Certificate PrO!Jllffl fa- P!W! B Providers

20

CMS Events - Dialog with CMS

CMS Open Door Forums offer current information about Medicare initiatives & policies

National Provider Calls & Events Documentation Guidelines & Burden Reduction

Listening Session, 3/21/18 1:30 - 3 pm ET CMS subject matter experts cover changes to

the Medicare program

21

MED1 ICARE QUARTERL y PIROVID,EIR COMIPLIANCE NEWSLETTER

Guidance to Address Billing Errors VolU1me 8, Issue 2

PRINl-F,RIENDLY VERSION

Table of Contents

2 Introduction

3 Comprehensive Error Rate Testiing1 (CERT) !Findling: Advance Care Planning

6 !Reminder: Proper Use of Modifier 59

22

New Medicare Card

By April 2019 MACRA requires the removal of SSNs from all Medicare cards

23

HICN vs MBI Number

HICN Primary Beneficiary

account holder Social Security No. + BIC (Beneficiary Identification Code) 9-byte SSN + 1 or

2-byte BIC Key positions1-9

numeric

Medicare Beneficiary Identifier (MBI)

Non-intelligent unique identifier 11 bytes Key positions 2, 5, 8 & 9

alphabetic

24

Obtaining New MBIs

Beginning October 2018, through the transition period, when you submit a claim using yourpatients valid and active HICN, we will return both the HICN and the MBI on every remittance advice The MBI will be in the same place you currently get the

current HICN

Youll be able to look up your Medicare patients newMBI through Palmetto GBAs eServices portal starting in June 2018

Sign up for eServices NOW!

25

MBI Reminders Those who are new to Medicare in April

2018 & after will only receive a card with the MBI

You may want to consider: Automatically accepting the new MBI from the

remittance advice (835) transaction Identifying patients who qualify for Medicare

under the Railroad Retirement Board (RRB) Coordinate with your vendors & billing/

administrative staff

26

Verify patients addresses If address on file is different than address on electronic

Get Ready for the MBI

eligibility transaction responses, ask your patients tocontact SSA to update their Medicare records Sign up for the weekly MLN Connects newsletter Sign up for eServices for secure portal look-up tool Reference the new Medicare card webpage

https://www.cms.gov/Medicare/New-Medicare-Card/index.html Use resources when speaking to Medicare beneficiaries

https://www.cms.gov/Medicare/New-Medicare-Card/Partners-and-Employers/Partners-and-employers.html

27

27

https://www.cms.gov/Medicare/New-Medicare-Card/Partners-andhttps://www.cms.gov/Medicare/New-Medicare-Card/index.html

MBI Generation & Transition Period

28

Timeline April 2018 All systems/processes

able to accept MBI Begin MBI card distro

to 60M beneficiaries

June 2018 Launch Look-Up tool

October 2018

April 16, 2019 Statutory deadline to

issue MBI cards

January 2020 HICN no longer

exchanged Limited exceptions

MBI return on remit advice

29

Action To Be Ready

Keep informed via the Palmetto GBA website at: www.palmettogba.com

30

http:www.palmettogba.com

Comprehensive Error Rate Testing (CERT)

31

CERT Purpose and Process

Is Provider Billing

Correctly?

Is Contractor Processing/Paying

Correctly? Purpose

32

2-0-1 7 AJB1 MA~ C E----or R~t~ _ _ _ _ _ _ _ __ _ _ _ _ _ _ a _ e

Con "but 1an1 Scor,e,

Improper Payment Rate :

1

2

A/B MACs

0 .0 % - 3 .9 %

4 .0 % - 7 .9 %

8 .0 % -1 1.9%

12 .0 % - 15.9%

16 .0 % a n d

above

Service Type lmp:roper Payment Improper Payment

Rate Amount. ,(2)

10verau 9.51% 36.21 B

Part A Providers (excluding

Hospi all Inpatient Prospec ive 11 .31 % $18.24 B

Payment System (IPPS)) ...... , -

Part B Providers 10.16% $91.85 B

Durabl,e Medcal Equipment.

Prosthetics. Orthotics, and 44.60 0 $3.6S B

Supplies I

1

Hospi al IPPS ===f 3.91 % I $4.46 B 33

Identify Improper Payments

Submit Claim Adjustment to MAC When Error Identified

If No Error Identified - No Action is Taken

Respond to any audit specific questions you may have, such as their rationale for identifying potential improper payment

CERT Contractor Responsibilities

34

Palmetto GBA uses CERT reports to identify

CERT

areas of focus for education CERT Tips are based on actual data analysis & frequent

provider inquiries

CERT Improper Payment report = www.cms.gov/CERT

CMS Program Integrity Manual = www.cms.gov/manuals/downloads/pim83c12.pdf

CERT Video: Provider Minute: UtilizingYour MAC = https://www.youtube.com/watch?v=mdnfuzr7yyE&feature =youtu.be

35

http:youtu.behttps://www.youtube.com/watch?v=mdnfuzr7yyE&featurewww.cms.gov/manuals/downloads/pim83c12.pdfwww.cms.gov/CERT

CERT Appeal Receive a CERT denial? Appeal CERT decision! CERT Redetermination Request Form

Do not resubmit the claim Denial decision was based on review of medical

records; therefore, claims for these services may not be resubmitted, they may be appealed

36

CERT Task Force 'Ill Bookmark Email Iii Print

ED I

eServices Porta l

A Learning & Education a a m Medical Policies

The Medicare A/B Contractor CERT Task force Medica l Review , Part A/B Medicare

Administrative Contractors (MACs) to commur New to Med icare? of concern regarding improper paym 1ents to the, Medicare program. Publlications to educate Medcar1e providers on numerous topics affecting most Resources ;hares the goal of reducing the national improper payment rate :omprehensive Error Rate Testing (CERT) program. The, education is View All Topics nent ongoing e,fforts

of the Centers for Me,dicare & Medicaid se,rvices (CMS}, the Medicare, Learning Network (MLN). and the MACs individual error-reduction activibes wthin its jurisdictions.

Palmetto GBA has designated task force members on the A/B Contractor Task Force and w1e will be sharing CERT Task Force education mat1erial as it become,s availabl 1e.

Latest Articles 37

c:go PALMETTO GBA , JM Home Health and Hospice Hub Topics , Forms / Tools Education I Events ~ Search

A CCLERI.AN G~OUP COMPANY

palmettogba com I JM Home Health and Hospice / CERT / nm CMS~N~

CERT Task Force '" B0o1

CERT Task Force Education Task Force educates & contributes to CMS MLN

Provider Compliance Fast Facts

Review CERT Fast Facts at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast- Facts.html

39

https://www.cms.gov/Outreach-and

Complying with Medical Record Documentation

CERT Task Force Education

Requirements Fact Sheet Complying with Documentation Requirements for

Laboratory Services Caring for Medicare Patients is a Partnership

Inpatient Skilled Nursing Facility Denials IRFs: Improving Documentation Positively Impacts

CERT (WBT) https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/CERT-A-B-MAC-Outreach- Education-Task-Force-.html

40

https://www.cms.gov/Medicare/Medicare

MAC Updates

41

Email & Faxed Inquiries CMS requires all providers to utilize the Provider

Contact Center (PCC) as their point of contact with their Medicare Administrative Contractors Unsolicited fax or email inquiries sent directly to a

specific department will be routed to the written correspondence area within the PCC for proper logging, tracking, research & response An escalation process is used for complex issues

42

PCC Inquiries - February 2018

JJA Total: 7,054 JMA Total: 5,619

43

Pro,vider Inquiries

Top S Telephone lnquiries by Subca.teg1ory:

Nov,ember 201"'117 - January 201'1]8

CLAIM DENIALS Frequen cy/ Dollar Amount

Limitati on 67~145

CLAIM DENIALS Contractual Obi lgatl on Not

Met

C LAIM DEN IALS Codin g E rir o r s/Modifiiers

98.,077

CLAIM DEN IALS aal m Overlap

100,814

C LAIM S TATUS Payment

E x p anat ion/cal c ula tlon 99.,60 0

'Total CSR Telephone Inquiries: 2,'1 64.,023

National PCC Inquiries

44

Claims Overlap FAQs

Top Inquiry is related to overlap denials Claims Overlap FAQs published 2/23/2018.

Education

45

Palmetto GBA Education Tools

46

eServices Secure Portal

Palmetto GBAs goal is to give our providers secure and fast access to Medicare information seamlessly via our website through the eServices application

eServices is a free Internet-based, provider self-service secure application

47

47

eServices Functions

Eligibility Claims Status eClaim Submissions First Level of Appeal Requests Clerical Error Claim Reopening Requests Remittances Online Financial Information Financial Forms Secure Forms Secure Messaging eDelivery

48

48

Participate in eServices Must have signed Electronic Data Interchange

(EDI) Enrollment Agreement on file Electronic submitters already have an EDI

agreement on file

Only one provider administrator per EDI Enrollment Agreement related to a PTAN/NPI combination performs the registration process Provider administrator grants permissions to additional

users related to that PTAN/PTAN combination

49

49

Claims Submission Errors Help

Claim submission error data includes: Claims in Returned To Provider (RTP) Claims that have Rejected

Claim Submission Error Help Self-Service Tool Quarterly Top 10 Denials

50

Claims Payment Issues Log (CPIL)

51

Provider Outreach & Education

52

ebinars 'Vi eos ln~erac~ ive Tools&.

ebsite Educat ion materia ls

------ . ' ~

.Speaker Re uests or .. shops an :

Partnersh ip E ents

Specia lty Conferences and As .. the Contractor Teleconferences (ACT

Please use POE Education Request Form 53

Upcoming Education Opportunities

April 25, 2018 - Skilled Nursing Facility (SNF) Consolidated Billing Webcast

May 15, 2018 - Quarterly Ask the Contractor Teleconference (ACT) Hyperbaric Oxygen (HBO) Therapy

54

Provider Contact Center JM 855-696-0705 JJ 877-567-7271

55

~ 0 PALMETTO GBA A CELERIAN GROUP COMPANY

Please take the Survey!

56

Part A MedicareQuarterly UpdatesDisclaimerObjectiveAgendaChange Request Updates & CMS InitiativesQuarterly UpdatesChange Requests (CR)Change Request (CR)Change Requests (CR)CR 104302CR 10433CR 10435CR 10481Outpatient Therapy Cap RepealMedicare Covered Preventive/Screening ServicesSlide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20CMS Events - Dialog with CMSSlide Number 22New Medicare CardHICN vs MBI NumberObtaining New MBIsMBI RemindersGet Ready for the MBIMBI Generation & Transition PeriodTimelineAction To Be ReadyComprehensive Error Rate Testing (CERT)CERT Purpose and ProcessSlide Number 33CERT Contractor ResponsibilitiesCERTCERT AppealSlide Number 37Medicare A/B MAC CERT Task ForceCERT Task Force EducationCERT Task Force EducationMAC UpdatesEmail & Faxed InquiriesPCC Inquiries - February 2018National PCC InquiriesClaims Overlap FAQsPalmetto GBA Education ToolseServices Secure PortaleServices FunctionsParticipate in eServicesClaims Submission Errors HelpClaims Payment Issues Log (CPIL)Slide Number 52Slide Number 53Upcoming Education OpportunitiesSlide Number 55Slide Number 56