Silverdale AAPC Chapter Meeting January 10, 2013

Medicare Updates for 2013 Medicare Part B Provider Outreach and Education (POE)

DISCLAIMER

This information release is the property of Noridian Administrative Services, LLC (NAS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NAS and CMS. The most current edition of the information contained in this release can be found on the NAS website at http://www.noridianmedicare.com

and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. January 2013 NAS, LLC Proprietary 2

Agenda

• Medicare Updates • Medicare Initiatives and Incentive Programs • Audit Programs • Contractor Updates January 2013 NAS, LLC Proprietary 3

2013 Deductible, Coinsurance and Premium Rates

2013 Medicare Part B Rates

Standard Premium Deductible Coinsurance $104.90 a month $147.00 a year 20% January 2013 NAS, LLC Proprietary 4

2013 Conversion Factor

• 2013 conversion factor is $34.0230

• 2012 conversion factor is $34.0376

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President Obama Signs the American Taxpayer Relief Act of 2012

• Section 601 - Medicare physician payment update • Section 602 - Extension of Medicare physician work geographic adjustment floor • Section 603 - Extension related to payments for Medicare outpatient therapy services • Section 604 - Extension of ambulance add-on payments • Section 605 - Extension of Medicare inpatient hospital payment adjustment for low-volume hospitals • Section 606 - Extension of the Medicare-Dependent Hospital (MDH) P rogram January 2013 NAS, LLC Proprietary 6

Section 602 - Extension of Medicare Physician Work Geographic Adjustment Floor

• The 2012 1.0 floor on the physician work geographic practice cost index is extended through December 31, 2013. As with the physician payment update, this extension will be reflected in the revised 2013 MPFS.

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Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services

• $1900 therapy and speech-language therapy combined • • $1900 for occupational • Extension of the KX modifier until 12/31/13 • 3700 threshold • Critical Access Hospital are included http://www.cms.gov/manuals/downloads/cl m104c05.pdf

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Claims-Based Data Collection for Outpatient Therapy Services (CR 8005)

• 42 new non-payable functional G-codes – G8978-G9174 – Status Code “Q” • 7 new modifiers • System to include – Data by therapy providers and practitioners furnishing therapy services – Collection of data by the contractors January 2013 NAS, LLC Proprietary 9

Severity Modifiers

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Reporting Functional G-Code Requirements

• Severity Modifier CH-CN • Therapy modifier-GP,GO or GN • Date of the billable service • Nominal charge – Penny- for institutional claims – Zero charge is acceptable for professional claims January 2013 NAS, LLC Proprietary 11

Application of New Coding Requirements

• Effective January 1, 2013 • Testing period 1/1/2013 through June 30, 2013 • Separate CR will be issued regarding the editing • Claims will be rejected and returned after July 1, 2013 January 2013 NAS, LLC Proprietary 12

Section 604 - Extension of Ambulance Add-On Payments

• Extends the three Job Creation Act provisions • 3% for originating rural ground. • 2% for originating urban ground • Continuation of the “super rural” bonus for originating transports in the lowest 25th percentile of all rural areas. • Rural Air is extended until 6/30/13 January 2013 NAS, LLC Proprietary 13

New Waive Tests

• Effective date: January 1, 2013 • 36 newly added waived tests • New CPT code 86803QS • • Assigned for hepatitis C antibody test https://www.noridianmedicare

.com/provider/updates/docs/ mm8054_new_waived_tests.

pdf 14

CPT CODE

86803GW 87809QW 81003QW 86294QW 82055QW G0434QW 83036QW 87880QW 87880QW G0433QW

New Non-Physician Specialty Code for Centralized Flu

• Effective date: January 1, 2013 • New non-physician practitioner specialty code for Centralized Flu –C1 • • Only applicable to CMS-855B enrollment application http://www.cms.gov/Outreach-and Education/Medicare-Learning-Network MLN/MLNMattersArticles/Downloads/MM7884.p

df .

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National Correct Coding Initiative Associated Modifier Changes

• Change Request #8111 • Key Points : • Additional modifiers shall be added to the list of NCCI-associated modifiers that will allow an edit with modifier indicator of ”1” to be bypassed when the modifier is utilized. January 2013 NAS, LLC Proprietary 16

National Correct Coding Initiative Associated Modifier Changes

2

• These modifiers are LM (left main coronary artery), RI (ramus intermedius), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery) January 2013 NAS, LLC Proprietary 17

New Multiple Procedure Payment Reductions (MPPR)

• Change Request #7848 • Key Points: • New Payment reduction for the technical component (TC) of diagnostic cardiovascular and ophthalmology procedures • Applies when multiple procedures are furnished to the same patient on the same date of service • Does not apply to the professional component( PC) January 2013 NAS, LLC Proprietary 18

MPPRs Application to TC Services for Cardiovascular and Ophthalmology

• • • CR 7848 – • The MPPRs apply to TC-only services, and to the TC of global services.

For cardiovascular services

, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.

For ophthalmology services

, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day. January 2013 NAS, LLC Proprietary 19

Examples of Payment Reductions

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CY 2013 Proposed CPT Changes

• Telehealth Expansion – Alcohol and/or other substance abuse assessments (G0396 – G0443) – Depression screening (G0444, G0445) – Behavioral counseling (G0446, G0447) • Individual Psychotherapy (90832, 90833, 90834, 90836, 90837, 90838) – Replaces 90804 – 90809 • Psychiatric Diagnostic Exam (90791/ 90792) – Replaces 90801 January 2013 NAS, LLC Proprietary 21

Update To Publication 100-04, Chapter 12, Non-Physician Practitioners (NPPs

)

• Effective 2/19/2013 • Must have their own “nonphysician practitioner” NPI number • NPP assistant-at-surgery services bill with "AS" modifier only • Physicians use 80, 81, 82, only • Modifiers eliminated: QB, QU, AH, AJ January 2013 NAS, LLC Proprietary 22

Provider Open Enrollment Extension

• CR 8055 • The deadline has been extended from 12/31/12 to 02/15/13 due to the MPFS has been updated.

• Open enrollment information can be located at: • h ttps://www.noridianmedicare.com/partb/enroll/p articipation/open_enrollment.html%3f , January 2013 NAS, LLC Proprietary 23

CHANGE REQUESTS OF INTEREST

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Balance Billing Prohibited

• SE1128 Prohibition on Balance Billing for Qualified Medicare Beneficiary (QMB) • • At state’s discretion, Medicaid may pay part of Part A, B or C Advantage premiums http://www.ssa.gov/OP_Home/ssact/title19 /1902.htm

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Crossover Claim Address

• SE1245 states ongoing problem of Medicare crossover claims failing HIPAA compliance with Coordination of Benefits Contractor (COBC) – Due to P.O. Box or Lock Box within PECOS • 2010AA N301 and N302 segments January 2013 NAS, LLC Proprietary 26

Crossover Claim Address

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• EDI Technical Report Type 3 (TR-3) Guides prohibit inclusion of P.O. Box or Lock Box Address – Within provider address • Any health care claims exchanged electronically between HIPAA “covered entities” – Includes providers, health plans and clearinghouses January 2013 NAS, LLC Proprietary 27

Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies

• Change Request # 7834 • Key Point(s): • In order to be granted a timely filing extension, the provider, supplier, or beneficiary must furnish an official letter from the Social Security Administration (SSA) that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service January 2013 NAS, LLC Proprietary 28

Medicare Entitlement and Timely Filing Exceptions on Retroactive Entitlement involving State Medicaid Agencies 2

• If an official SSA letter to the beneficiary is not submitted, Medicare contractors must check the Common Working File (CWF) database January 2013 NAS, LLC Proprietary 29

Termination of Common Working File (CWF) ELGB Provider Query

• CR8086 – Effective April 1, 2013 • CMS required by HIPAA to use proper format when exchanging information • PPTN users no longer able to access ELGB (eligibility) query • Users can access HIPAA Eligibility Transaction System (HETS), IVR or Endeavor January 2013 NAS, LLC Proprietary 30

Miscellaneous Change Requests

• CR 8007 - Beneficiary incarcerated DOS – Partially/fully overlap when beneficiary incarcerated – Medicare will generally not pay for items/services • Medicare creating new IUR process to identify previously paid claims January 2013 NAS, LLC Proprietary 31

New from CMS Medicare Learning Network (MLN)

• “ HIPPA Eligibility Transaction System (HETS) to Replace Common Working File (CWF) Medicare Beneficiary Health Insurance Eligibility Queries” MLN Matters® Article - Released • “Important Reminder for Providers and Suppliers Who Provide Services and Items Ordered or Referred by Other Providers and Suppliers” MLN Matters® Article Revised • Subscribe to the MLN Educational Products and MLN Matters Electronic Mailing Lists • Submit Feedback on MLN Educational Products January 2013 NAS, LLC Proprietary 32

New from CMS MLN

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• “Implementation of Provider Enrollment Provisions in CMS-6028 FC” MLN Matters® Article – Revised • “Further Details on the Revalidation of Provider Enrollment Information” MLN Matters® Special Edition Article – Revised • “Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange (EDI) Standards” Web-Based Training Course – Reminder January 2013 NAS, LLC Proprietary 33

New from CMS MLN

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• “ The National Provider Identifier (NPI): What You Need to Know” Booklet – Revised • “Mass Immunizers and Roster Billing” Fact Sheet – Revised • “Federally Qualified Health Center” Fact Sheet – Revised • “Phase 2 of Ordering/Referring Requirement “MLN Matters® Article - Revised January 2013 NAS, LLC Proprietary 34

New from CMS MLN

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• “Prescription Drug Monitoring Programs: A Resource to Help Address Prescription Drug Abuse and Diversion” MLN Matters® Article – Released • New MLN Provider Compliance Fast Fact January 2013 NAS, LLC Proprietary 35

RECOVERY AUDITOR, CERT AND OIG UPDATES

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Comprehensive Error Rate Testing (CERT)

• National Claim Paid Error Rate: 9.2 % 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 January 2013 NAS, LLC Proprietary 37

Recovery Audit Program Myths

• • Published 12/17/12 • Provide correct information about the Medicare Fee-for-Service Recovery Audit Program • Further questions can be directed to CMS at [email protected]

http://www.cms.gov/Research-Statistics Data-and-Systems/Monitoring Programs/recovery-audit program/index.html?redirect=/RAC/ January 2013 NAS, LLC Proprietary 38

Compliance - Signatures

• Signature Requirements Fact Sheet – 5 pages total – CERT error driven – http://www.cms.gov/Outreach-and Education/Medicare-Learning-Network MLN/MLNProducts/ProviderCompliance.html

– http://www.cms.gov/Outreach-and Education/Medicare-Learning-Network MLN/MLNEdWebGuide/Downloads/Guided_Path ways_Basic_Booklet.pdf

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CMS Provider Compliance Resources

• http://www.cms.gov/MLNProducts/45_ProviderCompliance.asp

– MLN Catalog of Products • • • • http://www.cms.gov/Outreach-and-Education/Medicare-Learning Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf

– MLN Product Ordering Page http://cms.meridianksi.com/kc/pfs/pfs_lnkfrm_fl.asp?lgnfrm=reqprod&fu nction=pfs – MLN Publications List http://www.cms.gov/Outreach-and-Education/Medicare-Learning Network-MLN/MLNProducts/MLN-Publications.html

– MLN Provider Compliance Products http://www.cms.gov/Outreach-and-Education/Medicare-Learning Network-MLN/MLNProducts/Downloads/ProvCmpl_Products.pdf

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Office of the Inspector Generals (OIG) 2013 Work Plan

• On-Site Visits for Enrollment and Reenrollment. • Claims Submitted by Error Prone Providers. • Payments for Immunosuppressive Drugs. • Anesthesia Services. • High-Cost Diagnostic Radiology Tests. January 2013 NAS, LLC Proprietary • High Cumulative Part B Payments.

• Independent Therapists • Anesthesia Services • Electrodiagnostic Testing • High-Cost Diagnostic Radiology Tests.

• Incident-To Services Performed by Non Physicians.

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CONTRACTOR UPDATES

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Left-hand Navigation Revised

• Part B Home Page • Allows providers to view most frequently accessed website – Categories/ subcategories • Selecting (+) symbol expands view – Displays most commonly viewed subcategories • Selecting another category or ( –) symbol – Will collapse view January 2013 NAS, LLC Proprietary 43

Sign Up to Get Medicare News Now!

• Receive the most recent NAS and CMS news and information – Regulation and policy updates – Payment and reimbursement updates – Workshop and educational event notices – NAS hours of availability and related notifications January 2013 NAS, LLC Proprietary 44

Foresee Survey – We Want to Hear From You.

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NAS Single Toll- Free Customer Service Line Effective March 1, 2013

• One number for all inquiries to offer the best service possible • Unify customer service and simplify provider contact • Watch NAS’s “What’s New/Latest Updates” webpage and e-mails for new phone number and additional information January 2013 NAS, LLC Proprietary 46

Single Toll Free Customer Service Line for JF MAC – 1-877-908-8431

• Purpose of consolidation – Better customer service • Departments affected – General Inquiries, Phone Reopenings, EDI, Enrollment, User Security • Hours of operation – 8 a.m. to 4 p.m. in respective time zone January 2013 NAS, LLC Proprietary 47

Reminder from Medical Review

• Medical record documentation for MRI, CT scans and X-rays should include: – Physicians’ orders to support diagnostic radiology services performed – Complete interpretation and reports • Report released by Office of Inspector General – https://oig.hhs.gov/oei/reports/oei-07-09 00450.pdf

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2013 HCPCS LCD Revisions

• • • • • • • Effective date: January 1, 2013

L24280

- Botulinum Toxin Types A and B

L32528

- Circulating Tumor Cell Marker Assays

L24308

- Genetic Testing

L24473

- Non-Covered Services

L24273

- Application of Bioengineered Skin Substitutes: Ulcers (of Lower Extremities)

L24359

- Sensory Evoked Potentials & Intraop Neurophysiology Monitoring January 2013 NAS, LLC Proprietary 49

MSP Reminder

• Against Medicare Secondary Payer (MSP) laws to accept payment from a beneficiary – Upon admission or when services rendered – When another insurer is primary to Medicare • If you are performing this practice, stop immediately • Per Special Edition (SE) 1227 January 2013 NAS, LLC Proprietary 50

Prompt Payment Act Interest Rate

• • Effective date: January 1, 2013 – CPT interest rate changed to 1.375% – Previously, was 1.750% – Current and previous rates available at: http://www.treasurydirect.gov/govt/rates/tci r/tcir_opdprmt2.htm

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Electronic Remittance Advice (ERA)

• Tired of paper piling up on your desk?

• • Sign up for benefits of ERAs – Earlier notification of payment status – ERA is same as Standard Paper Remit (SPR) – Free software to read, view and print • ERA Hot Line – 800-279-2833, 11 a.m. – 3 p.m. CT – Automatic posting* • *There are some software that have this capability http://www.edissweb.com/cgp/ January 2013 NAS, LLC Proprietary 52

Electronic Funds Transfer (EFT)

• All providers not currently receiving EFT payments must submit CMS-588 EFT form – With Provider Enrollment Revalidation application, or – When any change is being made to enrollment record • Enrollment Revalidation information – Special Edition Article SE1126 at http://www.cms.gov/MLNMattersArticles/downloa ds/SE1126.pdf

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Upcoming Part B POE Workshops

Date Time (CT) Workshop Title

01/08/13 01/15/13 11 a.m.

11 a.m.

Submission Errors January Quarterly Update Release 01/16/13 2 p.m.

CMS-1500 Claim Submission 01/24/13 2 p.m. Mental Health Register Now!

https://www.noridianmedicare.com/partb/train/workshops/index.html

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What Questions Do You Have?

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