Comprehensive Error Rate Testing (CERT)

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Transcript Comprehensive Error Rate Testing (CERT)

Maryland AAHAM March 15, 2013


• All Current Procedural Terminology (CPT) only copyright 2012 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (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 information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. • Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

• Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

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

• Novitas Solutions does not permit videotaping or audio recording of training events.

Agenda • Medicare Updates and Notifications • Contractor Updates • Comprehensive Error Rate Testing Program (CERT) • Self Service Options

Medicare Updates and Notifications

New FISS Consistency Edit to Validate Attending Physician National Provider Identifier (NPI) • Change Request 7902 – Effective: January 1, 2013 – Implementation: January 7, 2013 • Key Points: – Edit for institutional claims to ensure that the institutional provider has not used their billing NPI in the Attending Provider NPI Data Element • For more information: – MLN/MLNMattersArticles/Downloads/MM7902.pdf

(Part A)

April Outpatient Perspective Payment System (OPPS) Update • Change Request 8228 – Effective/Implementation Date: April 1, 2013 – New Services Payable • C9734 • C9735 – Drug and Biological Additions • C9130 • C9297 • C9298 • J7315 • Q4127 – Influenza Vaccine Flucelvax Covered • 90661 (Part A)

Place Of Service (POS) Coding Instructions

• • • • Change Request #7631 Effective: April 1, 2013, Implementation: April 1, 2013 Key Points: – Adds provisions regarding use of POS codes 22 and 24 – The POS code to be used will be assigned as the same setting in which the beneficiary received the face-to-face service – Two exceptions to this face-to-face provision/rule in which the physician always uses the POS code where the beneficiary is receiving care as a hospital inpatient or an outpatient of a hospital, regardless of where the beneficiary encounters the face-to-face service – In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner will be the setting in which the beneficiary received the TC of the service For more information: – MLN/MLNMattersArticles/downloads/MM7631.pdf

(Part B)

Implementation of Ordering/Referring Edits

• SE 1305 • Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims • • Phase 1 – Informational messaging: – Began October 5, 2009 • Phase 2 – Effective May 1, 2013, – CMS will turn on the edits to deny Part B, DME, and Part A HHA claims that fail the ordering/referring provider edit (Part B)

American Taxpayer Relief Act of 2012

• Issued: January 03, 2013 • Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services – Extends the exceptions process for outpatient therapy caps through December 31, 2013 – Extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department, and counts outpatient therapy services furnished in a Critical Access Hospital towards the cap and threshold ( Part A & B)

2013 Therapy Cap Values

• Change Request # 8129 – Effective: January 1, 2013 – Implementation January 7, 2013 • Key Points – $1,900 combined for Physical Therapy and Speech-Language Therapy – $1,900 for Occupational Therapy • For more information: – Guidance/Guidance/Transmittals/2012-Transmittals Items/R2600CP.html

(Part A & B)

2013 Manual Therapy Review

• Article issued 3/1/2013 –

• Therapy above $3,700 threshold subject to Complex Medical Review • Pre-approval process not applicable • Services above $3,700 threshold will suspend for pre-payment Medical Review • Follow instructions on ADR for submitting review documents.

New Claim-based Therapy Reporting Requirements

• Change Request (CR) #8005 – Effective: January 1, 2013 – Implementation: January 7, 2013 • Key Points – New claims-based data reporting – 42 New G-codes, to report patient function – 8 New Modifiers, to describe severity • For more information: – Guidance/Guidance/Transmittals/2012-Transmittals Items/R2603CP.html

(Part A & B)

Services and Providers Affected by CR 8005

• Applies to all services furnished under Medicare Part B outpatient therapy benefit, as well as physical therapy, occupational therapy and speech language therapy provided by Comprehensive outpatient rehabilitation facilities (CORF) • Providers Types: Hospitals, Critical Access Hospitals, Skilled Nursing Facilities, CORFs, Rehab agencies, Home Health (Part B), Therapists in private practice, physicians, and Non-Physician Practitioners (Part A & B)

Outpatient Therapy Functional Reporting Non-Compliance Alerts

• Change Request #8166 • Effective Date: April 1, 2013 • Key Points: – For therapy claims, with dates of service on and after January 1, 2013, processed on and after April 1, 2013 through June 30, 2013, providers will be alerted to include the applicable 42 new G-codes and seven modifiers on future therapy claims through a new Remittance Advice message – There will be no alert messaging for institutional claims between April 1, 2013, and July 1, 2013 – For professional and institutional claims, effective July 1, 2013 will enforce the functional reporting requirements by requiring claims that do not contain the required functional G-code and modifier information to be returned or rejected (Part A & B)

Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services • Change Request # 8206 • Effective date: April 1, 2013 • Key Points: – American Taxpayer Relief Act of 2012 increased the Multiple Procedure Payment Reduction (MPPR) on selected therapy services to 50 percent for both office and institutional settings – This is effective for claims with dates of service on or after April 1, 2013 (Part A & B)

ICD-10 Delayed

• ICD-10 compliance date delayed to October 1, 2014 • Keep Up to Date – Sign up for CMS ICD-10 Industry Email Updates 10_Industry_Email_Updates.html

– Follow @CMSGov on Twitter – Subscribe to Latest News Page Watch

ic_id=USCMS_609 (Part A & B)

Special Edition Article SE1249

• The HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (HETS) will replace CWF eligibility inquiries – Part B - By April 2013 access to CWF eligibility queries will be removed from Profession Provider Telecommunication Network (PPTN) – Part A - Soon thereafter, access to Health Insurance Query Access (HIQA) and CWF inquiry menu option 10 will be terminated – For more information: – Network-MLN/MLNMattersArticles/Downloads/SE1249.pdf

Mandatory Payment Reductions – “Sequestration ” • Article posed March 11, 2013

– 03112013.html

• Medicare Fee-for-Service claims with dates of service or date of discharge on or after April 1, 2013 • 2% reduction to Medicare payment

CMS Provider Compliance

 CMS Provider Compliance Webpage • Educational products on how to avoid billing errors and improper payments • Compliance Products  Quarterly Newsletter with CERT and RA findings  October 2012 RA Findings on Major Joint Replacement, Cardiac Procedures, Acute Inpatient Respiratory Conditions  Podcasts  September 2012 RA Findings on Medical Necessity of Renal and Urinary Tract Disorders  Fact Sheet  August 2012 Complying with Medicare Signature Requirements • Network-MLN/MLNProducts/ProviderCompliance.html

Program for Evaluating Payment Patterns Electronic Report (PEPPER)

• PEPPER provides hospital-specific data for Medicare severity diagnosis-related groups and discharges at high risk for payment errors • • For short-term and long-term acute care hospitals

Contractor Updates

Local Determinations (LCDs)

• The following J12 MAC LCDs were posted for notice. They will become effective April 4, 2013: – Circulating Tumor Cell (CTC) Assay (L32930) – Intravenous Immune Globulin (IVIG) (L32937) – Transcranial Magnetic Stimulation (TMS) for the Treatment of Depression (L32055) – Transoral Incisionless Fundoplication (L32932) • The following J12 MAC Local Coverage Determinations (LCDs) have been revised: – Ambulance (Ground) Services (L32252) – Removal of Benign or Premalignant Skin Lesions (L27527)

Required Information When Calling About Claims Files

• Provider Bulletin Issued: March 8, 2013 – pub/bulletins/2013/03082013.html

• Customers should be aware that reports for all claims submitted electronically are only available for retrieval and review for 45 days, including the Electronic Remittance Advise (ERA). If you require EDI assistance, you must call EDI within 45 days of submitting the electronic claims.

– Please obtain the following information before contacting EDI: • The


of the submitted claims to Medicare • The


of the submitted claims to Medicare • The outbound


of the claims submitted to Medicare • The


of the deposit and

check number

calling for ERA or

dollar amount


Claims Editing for Reason Code 30940

• Provider Bulletin Issued: Issued: March 05, 2013 – 03052013.html

• Reason code 30940 is received when attempting to adjust a claim with a medically denied line • If you are trying to add diagnosis codes, change CPT codes or move denied charges from non covered to covered, you must submit a redetermination

Fax to Image

• • • • • • • Were you aware records for an Additional Development Request (ADR) can be faxed directly to Novitas Solutions? The fax to image option allows for documentation to be submitted directly to Novitas Solutions. – – Available 24 hours a day, 7 days a week Fax ADR response to 1-877-439-5479 Faxes should not exceed 200 pages The original ADR request must be submitted as the cover sheet to the records Supporting documentation, or requested medical records, should follow the ADR letter Each ADR request must be faxed separately Additional Tips – –

Fax to Image

• • • • • • • Were you aware records for an Additional Development Request (ADR) can be faxed directly to Novitas Solutions? The fax to image option allows for documentation to be submitted directly to Novitas Solutions. – – Available 24 hours a day, 7 days a week Fax ADR response to 1-877-439-5479 Faxes should not exceed 200 pages The original ADR request must be submitted as the cover sheet to the records Supporting documentation, or requested medical records, should follow the ADR letter Each ADR request must be faxed separately Additional Tips – –

Part B Redetermination Request

• Correct clerical errors or omission by calling the Claims Correction line – J12 Providers 1-877-235-8073 – JH Providers 1-855-252-8782 • Part B Redetermination Requests may be faxed – Available 24 hours a day, 7 days a week – 1-888-541-3829 • Complete and print the online redetermination request form (use as fax cover sheet) – – form.pdf

• Appeals Status Inquiry Tool now available

New Part B Appeals Status Inquiry Tool • Use the Appeals Status Inquiry Tool to check the status of your submitted appeal • Search By:

– Case Control Number (CCN) – Provider Transaction Access Number (PTAN) – PTAN and Internal Control Number (ICN) – https://www.novitas

Provider Enrollment

• Provider Enrollment Status Inquiry Tool – – https://www.novitas

• Release of Information – Individual Physician or Practitioner – Authorized Delegated Official • Upcoming Revalidation Mailings and Certification/MedicareProviderSupEnroll/Revalidation s.html

Comprehensive Error Rate Testing (CERT)

Comprehensive Error Rate Testing (CERT)

• National Claim Paid Error Rate – 6.8 % Inpatient hospitals – 4.8 % Non-inpatient hospital facilities – 9.9 % Physician/Lab /Ambulance • Impacts all providers submitting Fee for Service claims • Limited random claim sample • Record requests must be received within 30 days from the initial CERT letter • Right to Appeal? Yes

J12 Part A Common Errors

• Insufficient documentation: – No valid physician’s order – Inpatient stay – Missing or illegible documentation and/or physician signature – Procedure/service performed – No valid certification for therapy services – Skilled Nursing Facility (SNF) 3 day qualifying stay • Medical necessity errors: – Need for an inpatient stay – Related services • Other errors: – Diagnosis Related Group (DRG) – Discharge disposition code – Resource Utilization Group (RUG) – Laboratory services and – Debridement code

J12 Part B Common Errors

• Insufficient documentation: – Procedure/service billed – Missing or illegible documentation and/or physician signature – No valid physician’s order – No physical therapy certified plan of care/treatment plan • Incorrect coding errors: – Evaluation and Management (E/M) codes – Critical care, discharge day management, physical therapy – Units of medication/infusion services – Laboratory services

Self Service Options

Jurisdiction 12 Customer Contact Information • Provider – 1-877-235-8073 – Hours of Operation, Eastern Time (ET) • Monday - Thursday: 8:00 am – 4:00 pm ET • Friday: 8:00 am – 2:00 pm ET – Call Flow •


• Interactive Voice Response (IVR) – Hours of Operation • Monday: 6:00 am – 8:00 pm ET • Tuesday - Friday: 4:00 am – 8:00 pm ET • Saturday: 6:00 am – 4:00 pm ET – Step-by-Step Guide •


Beneficiary Contact Information

• Patient / Medicare Beneficiary – 1-800-MEDICARE (1-800-633-4227) •

J12 Fiscal Intermediary Standard System Hours • District of Columbia (DC), Maryland (MD), New Jersey (NJ), Pennsylvania (PA) – Monday – Friday • 6 am – 9 pm, Eastern Time (ET) – Saturdays • 6 am – 4 pm ET • Delaware (DE) – Monday – Friday • 6 am – 6 pm ET – Saturdays • 6 am – 4 pm ET

Stay Informed

• Subscribe to our E-Mail Lists –

• Available mailing lists – Jurisdiction 12 Part A or B General Education – Jurisdiction 12 Part A or B Electronic Billers (EDI) • Weekly podcast covering important Medicare news and events – Automatically delivered – Easy to subscribe, just copy the link to your podcast software •

Calendar of Events

• Our Training and Events Center offers a wide variety of education • Join us for Workshops, Teleconferences, and Webinars • To view the most current calendar of events, visit: –

Centers for Medicare and Medicaid Services (CMS) • The CMS website offers valuable resources such as: – CMS Internet Only Manuals (IOMs) – Medicare Learning Network (MLN) Matters Articles – Open Door Forum • For additional resources visit: –

Thank You Janice Mumma, CPC, CPC-H

Supervisor Provider Outreach and Education 717-526-6528 [email protected]