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Medicare Part B Spring Update

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Medicare Part B Spring Update

CGS Administrators, LLC | Spring 2014

Disclaimer

This presentation was current at the time it was published or uploaded onto the CGS Web site. Medicare policy changes frequently so 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. The Centers for Medicare & Medicaid Services (CMS) 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 publication 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.

Spring 2014

Objectives

 Discuss new and ongoing Medicare initiatives  Provide information regarding medical record review contractors  Provide CGS operational reminders  Introduce resources and self-service technology options

• • • • • • •

2014 Medicare Physician Fee Schedule Open Payments ICD-10 Preparation Provider Enrollment Revalidation Revised CMS-1500 Claim Form Ordering/Referring Edits EDI Connectivity Changes

Hot Topics

2014 Medicare Physician Fee Schedule

The

Pathway for SGR Reform Act of 2013

 Signed December 26, 2013, to prevent substantial reduction to Medicare Physician Fee Schedule (MPFS) for CY 2014 • • Provides for 0.5% update to MPFS effective January 1 – March 31, 2014 Congressional action required to prevent negative update from taking effect April 1, 2014, and after

Protecting Access to Medicare Act of 2014

 Signed into law April 1, 2014 • • Maintains the MFPS at same reimbursement rate – Also affects therapy caps and the therapy cap exception process » $1, 920 for PT and SLP combined; $1, 920 for OT Affects dates of service April 1 – December 31, 2014 – Also affects dates of service January 1 – March 31, 2015 © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Sequestration

 The Budget Control Act of 2011 required mandatory across the-board federal spending cuts • Also known as

Sequestration

 The American Taxpayer Relief Act of 2012 • Delayed Sequestration for two months  Effective for dates of service (or dates of discharge) on or after April 1, 2013, all Medicare Fee-for-Service (FFS) claims will incur a two percent reduction in Medicare payment  Reduction was initially set to be applied through March 2014 

Just Announced! Sequestration reduction will be in effect through March 2015

Summer 2013

Sequestration: Q&As



Does the 2% payment reduction apply to the Medicare FFS fee schedules?

• No, only to the final payment of the claim 

How is the 2% reduction identified on the remittance advice?

• CARC 253: Sequestration – reduction in federal payment 

How is a payment calculated?

Approved Amount Deductible Provider Payment Co-insurance

Regular Payment

$100 $50 $50 x 80% = $40 $50 x 20% = $10

Sequestration Payment

$100 $50 $50 x 80% = $40 $40 x 2% = .80¢

$39.20

Spring 2014

Open Payments

Open Payments

creates greater transparency around the financial relationships of manufacturers, physicians and teaching hospitals   • Three template files for applicable manufacturers and GPOs to use Began reporting financial relationship data on August 1, 2013 – – – Data reported for August through December 2013 Had to be reported by March 31, 2014 Data released to public by September 30, 2014 • – CY 2014 data will be submitted via a template on the CMS web site » Physicians and teaching hospitals will have access to the data prior to posting • Two free apps for iOS (Apple™) and Android™ mobile phones One for physicians to use to ensure accuracy on information reported One for applicable manufacturers and GPOs  Two Continuing Medical Education (CME) activities are available http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment Transparency-Program/index.html

Spring 2014

ICD-10 Implementation

ICD-10 Implementation: Date of Service October 1, 2014

 CGS is following the timeline below in the ICD-10 implementation for LCDs per Change Request (CR) 8348 • • Current/new LCDs are being translated from ICD-9 to ICD-10 LCDs will be published on the

Medicare Coverage Database

no later than April 10, 2014 • Testing of new edits for ICD-10 began early-March 2014 ‒ Watch our ListServ for other testing opportunities! • All LCD articles will be updated by September 4, 2014  CMS ICD-10 implementation for NCDs • Translation from ICD-9 to ICD-10 will be an ongoing process for the October 2014 transition • Updates for translated NCDs will be published on the CMS and CGS websites as they are completed © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

ICD-10 Partial Code Freeze Date

October 1, 2011

Update

The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made October 1, 2012 October 1, 2013 Limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by federal regulations October 1, 2014 Limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by federal regulations There will be no updates to ICD-9-CM, as it will no longer be used for reporting October 1, 2015 Regular updates to ICD-10 will begin © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

ICD-10 Resources

CMS web site: www.cms.hhs.gov/ICD10/  Select

Provider Resources

for tools, fact sheets, FAQs, implementation guides, timelines and checklists   Also find Medscape modules offering CMEs and CE credits  • Sign up for email updates Select “CMS ICD-10 Industry Email Updates” • Resources tailored to small providers http://www.roadto10.org/  Find additional information in

ICD-10 Resources

Provider Enrollment Revalidation

 Requirement established by the Affordable Care Act • Applies to all providers that were enrolled prior to March 25, 2011 • Does not impact applications received on or after March 25, 2011  Initiative will last until approximately March 23, 2015  Revalidation request will be mailed in yellow CGS envelope  Sent to correspondence, special payments or practice address  Check CMS listing to see if you were sent a notice © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Revalidation Update

Phase III of Provider Enrollment Revalidation Process  Approximately 70% of Part B providers will receive Revalidation requests  Respond with completed application within 60 days • May use Internet-based PECOS or paper CMS 855 applications  Submit a complete and accurate enrollment application to avoid delays  Refer to CGS Revalidation Webpage • • • • Getting Started Sample Revalidation request letter Revalidation Checklist Frequently Asked Questions (FAQs) NEW Electronic Funds Transfer (EFT) Authorization Agreement: CMS 588  Old (05/10) and revised (09/13) form accepted through October 2014 • http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf

Spring 2014

Top Revalidation Development Issues

  Missing driver’s license/current passport CP575 or other preprinted IRS document must be included  • CMS 855I Section 1A ALL of the applicant's active PTANs and NPIs are identified in Section 1A  • Correspondence Telephone Number CGS will call phone number listed in Section 2 to verify that the applicant can be directly reached at this telephone number  • CMS 855I Section 4B Names and NPIs/PTANs for each active group affiliation are required  • Voided Check/Bank Letter for Electronic Funds Transfer (EFT) The CMS 588 (EFT) application must include confirmation of account information – Voided check: Name on account, electronic routing transit number, account number and type – Bank letterhead: the bank officer's name and signature  • CMS 855B and CMS 855I Section 4 Practice Location Section 4 needed for each practice location where services are rendered © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Revalidation Resources

Provider Enrollment Revalidation  http://cms.gov/Medicare/Provider-Enrollment-and Certification/MedicareProviderSupEnroll/Revalidations.html

• • Sample revalidation letters CMS listing of providers sent request to revalidate – Listing posted each month CGS website: Revalidation web page • • • • Link to Internet-based PECOS Checklists for paper (CMS-855) enrollment applications Top Revalidation Development Reasons Articles – Fees paid by institutional providers – Tips on sending everything the first time © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Revised CMS-1500 Claim Form

CMS announced updates to the CMS-1500 claim form

 Indicators for differentiating between ICD-9 and ICD-10 codes  Expand number of possible diagnosis codes to 12  Qualifiers to note ordering, referring or supervising provider in Item 17  Implementation Timeline • January 6, 2014: Medicare began receiving the revised (Version 02/12) claim form • January 6 though March 31, 2014: Medicare accepted old (Version 08/05) and revised (Version 02/12) CMS 1500 claim forms • April 1, 2014: Medicare accepts only the revised (Version 02/12) CMS 1500 Claim form – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNMattersArticles/Downloads/MM8509.pdf

Spring 2014

Ordering/Referring Provider Edits

Claims for dates of service on or after January 1, 2014   If the ordering/referring provider is not on claim, the claim will be rejected • If the ordering/referring provider is on the claim, edits verify provider is in PECOS and eligible to order and refer If not in PECOS or in PECOS but not of an allowed specialty, claim will be rejected Doctor of:  Medicine or Osteopathy  Dental Medicine  Dental Surgery   Podiatric Medicine Optometry       Physician Assistant Certified Clinical Nurse Specialist Nurse Practitioner Clinical Psychologist Certified Nurse Midwife Clinical Social Worker   • Part B clinical lab and technical component/global imaging services Services failing these edits will be DENIED instead of rejected • – If the required matching NPI is missing from the claim, service will be rejected Verify the ordering/referring provider’s enrollment in PECOS http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp

Spring 2014

EDI Connectivity

Effective July 1, 2014, CGS will no longer offer dial-up connectivity  Affects J15 providers who submit claims to CGS using a dial-up connection  Affected providers may consider the following options • • ABILITY (formerly IVANS) provides secure, high-speed internet connectivity to submit claims and access the Medicare Eligibility Database – Call 1.888.895.2649

– Email [email protected]

ECC Technologies’ RAPID Network provides secure, reliable and cost effective way to connect to Medicare using existing internet connection – Call 1.855.643.2252

– Email [email protected]

Spring 2014

MAC Consolidation

The Medicare Modernization Act of 2003  Required Medicare fiscal intermediaries (Part A) and carriers (Part B) to consolidate and form 15

Medicare Administrative Contractors (MACs)

 • In 2010, CMS announced further consolidation from 15 MACs to 10 Currently, there are 12 A/B MACs – – J8 and J15 were planned to form ‘JI’ in 2015-2016 J5 and J6 were to form ‘JG’ in 2016-2017  CMS decided to postpone the two remaining consolidations for five years  Additional time needed to evaluate process to ensure smooth transitions © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

•

Improper Payments



Comprehensive Error Rate Testing (CERT)



Recovery Auditors (RAs)

Compliance Corner

The Improper Payments Information Act Improper Payments Elimination and Recovery Act

Both laws require the heads of federal agencies to annually review the programs it administers to assess risk of improper payments

Improper Payments by Agency (FY 2013)

The Improper Payments Information Act Improper Payments Elimination and Recovery Act

The annual review of federal programs must:  Identify those susceptible to significant improper payments  Estimate the amount of improper payments  Submit information to Congress  Develop an action plan to reduce improper payments • Several medical record review programs were created including: – Comprehensive Error Rate Testing (CERT) – Recovery Auditors (RAs) and Recovery Auditor Pre-payment Review – Comparative Billing Reports (CBRs) – Prior Authorization of Power Mobility Devices – A/B Rebilling – Payment Error Rate Measurement (PERM) » Measures error rates for Medicaid and the Children’s Health Insurance Program (CHIP) © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

FY 2012 Improper Payment Rates by State

FY 2012 Improper Payments by State

*Dollars in Millions 25

FY 2012 Improper Payments by State

CERT Program

The

Comprehensive Error Rate Testing

Program was established by the Centers for Medicare & Medicaid Services (CMS)  Improve the processing and medical decision making involved with the payment of Medicare claims  Assess how successful Program is at reimbursing providers correctly • Critical to protecting the Medicare Trust Fund  Looks for

Improper Payments

• Any claim that was paid when it should have been denied • Any claim paid at the incorrect amount – Results in overpayments and underpayments  Outcomes used to identify educational needs © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

28 Error Category

No Documentation Insufficient Documentation • • • • • •

Error / Reminder

Send a COMPLETE medical record within 75 days Include a copy of bar-coded page Signature missing or illegible - Signature Attestation Statement Valid physician order ICD-9 code alone does not support medical necessity Documentation does not adequately describe service billed Medical Necessity • • Reason for diagnostic test missing from inpatient record Medical record does not support need for air ambulance Incorrect Coding Other • • • • • Key elements for E/M level billed are not met (downcoded) Documented time for counseling/coordination of care supports higher or lower level E/M service CPT code 93000 to 93005 Service does not meet definition of a new patient Check for obvious errors − Dates of service billed are supported in medical record − Place of service codes are correct CPT only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use.

Spring 2014

CERT Resources

The CERT Program  www.cms.gov/cert Government-level improper payments across various programs  http://www.paymentaccuracy.gov/ Signatures in Medical Records  • MLN Matters article SE1237 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNMattersArticles/Downloads/SE1237.pdf

 • MLN Matters article MM6698 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNMattersArticles/Downloads/MM6698.pdf

 • Signature Attestation Statement http://www.cgsmedicare.com/ohb/claims/cert/Signatures_06%2011%20(2).pdf

E/M Documentation Guidelines  1995 (general) or 1997 (specialty-focused) • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNEdWebGuide/EMDOC.html

Spring 2014

Recovery Audit

The

Recovery Audit

program was created to detect and correct past improper payments  Process applies to FFS Medicare • • • • RA “look back” period limited to three years Limits to number of medical record requests Automated, semi-automated and complex reviews Reviews performed on post-pay basis  Uses resources such as LCDs, NCDs and CMS manuals  Reviews performed by qualified staff to ensure accuracy • • • • Physician Contractor Medical Director (CMD) Therapists Nurses Certified coders  CMS requires issues to be approved and posted on RA website © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Recovery Audit Issues

Current CMS-approved listing of services submit to RAC review https://racb.cgi.com/Issues.aspx

Type in PROFESSIONAL or PHYSICIAN

CPT only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use.

Recovery Audit Issues

The Details link will display a page giving you a description of the issue and links to related policies.

Recovery Auditor Quarterly Stats

 Region B Top Error: Cardiovascular Procedures • Medical necessity for cardiovascular procedures performed in inpatient hospital are not supported in medical record Spring 2014 © 2014 Copyright, CGS Administrators, LLC.

Prepare for Recovery Audit

 Review OIG and CERT websites to learn “potential risks”  Respond to requests for medical records within 45 days  RAC overpayment requests will come from CGS • Remark code N432: Adjustment based on Recovery Audit  Options when overpayment found • • • Pay by check or allow recoupment (withholding) from future payments Request an extended payment plan File an appeal if you disagree with the decision – If done within 30 days, overpayment process delayed  Appoint a specific person for RA to contact • CGI Federal Call Center: 1.877.316.RACB (7222) © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Recovery Audit Program Changes

 CMS in procurement process for RA contracts • 4 MAC and 2 DME RAs  Pre-payment review demo activities are on hold • Last ADR request sent February 28, 2014  RAs will continue to perform automated reviews through June 1, 2014  Program changes to ADR limits, timeframes, etc. will be implemented with new contracts © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

RA Resources

The Recovery Audit Program  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring Programs/recovery-audit-program/ Region B Recovery Auditor https://racb.cgi.com/  • Additional documentation request (ADR) limits http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit Program/Provider-Resource.html

Office of Inspector General (OIG)  www.oig.hhs.gov/oas/cms.asp

CERT  www.cms.gov/CERT Questions regarding RA program? [email protected]

Spring 2014

Electronic Submission of Medical Documentation (esMD)

CMS established esMD for submitting medical documentation electronically



Medicare receives 4.8m claims per day



Claim review contractors issue over 1m requests for medical documentation annually



Most documentation is received in paper form

Spring 2014

Electronic Submission of Medical Documentation (esMD)



Most providers will use Health Information Handlers (HIHs) that provide an esMD gateway

esMD – Responding to ADRs

Providers using esMD reported a faster turnaround in payment



Reduced costs

• No print costs or need to feed a fax machine or burn CD-ROMs • No shipping and handling expenses • Consolidated services – Some claim clearinghouses and Electronic Health Record vendors offer this service 

Approximately 23 HIHs certified by CMS: www.cms.gov/esmd



ADR letters from CGS, CERT and RA provides options to respond

Spring 2014

• • • • •

Physician Quality Reporting System (PQRS) Electronic Prescribing (eRx) Physician Compare Electronic Health Records (EHR) Other Incentive Programs



HPSA Surgical Incentive Payment (HSIP)



Primary Care Incentive Payment (PCIP)

Quality Programs and Incentives

Physician Quality Reporting System

The

PQRS

is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals  Report the level of quality provided during patient encounters • Applies to Medicare Fee-for-Service patient – Includes Railroad and Medicare Secondary Payer  PQRS is a federally-mandated program  No sign-up or registration required • 2014 PQRS Implementation Guide • View quality measures and measures groups – Report 9 measures across 3 National Quality Strategy domains – Measures groups may only be reported through Registries © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

PQRS Eligible Professionals (EPs) Physicians

       Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Doctor of Chiropractic

Practitioners

          Physician Assistant Nurse Practitioner* Clinical Nurse Specialist* CRNA* / AA Certified Nurse Midwife* Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologist

*Includes Advanced Practice Registered Nurse (APRN)

Therapists

   Physical Therapist Occupational Therapist Speech-Language Pathologist Spring 2014

2014 Measure Reporting Changes

Emphasis on 2014 incentive AND avoiding 2016 payment adjustment  New satisfactory reporting requirements via claims, registry and EHR • 9 measures for incentive and to avoid payment adjustment  Registries can report less than 9 measures for EPs to potentially receive incentive and less than 3 measures to avoid payment adjustment • A new Measure-Applicability Validation (MAV) process implemented to ensure reporting accuracy  All measures group reportable via REGISTRY ONLY  Added EHR reporting for group practices  Certified Survey Vendor option for groups with 25> EPs in GPRO  New Qualified Clinical Data Registry reporting option http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/PQRS/Spotlight.html

2014 PQRS Participation

2014 educational resources to avoid 2016 payment adjustment  Welcome to PQRS • YouTube video providers an overview of PQRS  PQRS Overview Fact Sheet • Provides an overview of program, payments and reporting  PQRS Timeline 2014-2016 • Includes important PQRS dates from 2014 – 2016, as well as corresponding resources for each PQRS milestone  Additional reporting and analysis/reporting resources  http://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.

Spring 2014

PQRS Reporting Scenario

The patient was seen in the office. The provider is treating the patient for diabetes and coronary artery disease (CAD).

 CPT code 99213  ICD-9 250.00

 ICD-9 414.00

To view PQRS measures, go to www.cms.gov/pqrs

•

Select “How to Get Started”

•

Click on the “2014 Physician Quality Reporting System Measure List Implementation Guide”

PQRS Reporting Scenario

Quality Data Code (QDC) related to diabetes (ICD-9 250.00)

PQRS Reporting Scenario

Quality Data Code (QDC) related to diabetes (ICD-9 250.00)

PQRS Incentives and Adjustments

 The PQRS incentive is based on the EP's estimated total allowed charges for covered MPFS provided during the reporting period • 2013: 0.5% Incentive – Successful reporters will receive Incentive Fall 2014 • 2014: 0.5% Incentive  Payment reductions begin in CY 2015 for eligible professionals who do not satisfactorily report data on quality measures • 2015: –1.5% Payment Adjustment (based on reporting in 2013) – EP had to report ONE measure in 2013 to avoid CY 2015 payment adjustment • 2016: –2.0% Payment Adjustment (based on reporting in 2014) • 2017: –2.0% Payment Adjustment (based on reporting in 2015) © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Value-Based Payment Modifier

PQRS is the basis for Value-Based Modifier

  Provides comparative performance information to physicians Goal is to improve the quality and efficiency of medical care  CMS is moving toward physician reimbursement that rewards

value

rather than volume • Applies to Fee-for-Service (FFS) Medicare only • Groups (under a single Tax ID) with 100+ EPs – Subject to value modifier in CY 2015, based on PQRS performance in CY 2013 » Had to self-nominate and submit one of three group reporting methods to avoid 1% adjustment • All other EPs affected by CY 2017 © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

PQRS Resources

The Physician Quality Reporting System  • • • • • http://www.cms.gov/PQRS/ - Links for information on: How to Get Started CMS Sponsored Calls Measures Codes – 2014 PQRS Individual Claims Registry Measure Specification Supporting Documents (under

Related Links)

» List of QDCs and definitions Registry and EHR Reporting Payment Adjustment Information American Medical Association (AMA) PQRS web page • http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice improvement/clinical-quality/physician-quality-reporting-system-2013.page

Value-based Payment Modifier • http://www.cms.gov/Medicare/Medicare-Fee-for-Service Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

Spring 2014

PQRS Assistance

 Contact the QualityNet Help Desk for PQRS assistance • How to begin participating • Accessing feedback reports • Explanation of feedback reports – 1.866.288.8912, 7:00 a.m. - 7:00 p.m. CT, M-F – Email: [email protected]

Spring 2014

Electronic Prescribing

The

Electronic Prescribing was

an incentive program for those who transmitted prescriptions electronically  Reduced chance of medication dispensing errors due to illegible handwriting • Saves time by fewer contacts between the physician and pharmacy  CY 2013 was the last year for eRx incentive • HCPCS code G8553 is no longer valid and is not to be reported  Program now tied into Electronic Health Record (EHR) program • Still a requirement for EPs in order to achieve “meaningful use”  Successful e-prescribers will receive the eRx incentive for CY 2013 reporting period in Fall 2014 © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

Physician Compare

Healthcare professional directory on

Medicare.gov

Goal: Help consumers make informed choices about health care they receive through Medicare Search for physicians / practitioners

 Names, addresses, phone numbers, specialties, clinical training, and genders  Language(s) spoken other than English  Affiliation with hospitals  Accepting new Medicare patients  Accept the Medicare-approved amount, billing no more than the Medicare deductible and coinsurance  Information about participation in PQRS and/or eRx (in CY 2014) © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

The Electronic Health Record Incentive

Electronic Health Record  • Promotes Electronic Health Record (EHR) through incentive program for the “meaningful use” of certified electronic health records technology CMS has established the objectives for “meaningful use” that EPs, eligible hospitals and critical access hospitals must meet Requirements for Medicare  Eligible Professional (EPs)* • Doctor of Medicine or Osteopathy • • • • Doctor of Dental Surgery or Dental Medicine Doctor of Podiatric Medicine Doctor of Optometry Chiropractor – *Hospital-based EPs do not qualify for Medicare incentive © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

2014 EHR Milestones

January 1, 2014, marks many important milestones

  2013 attestation had to be done by March 31, 2014 Beginning of Stage 2 for EPs who have already completed at least two years of Stage 1  • A 3-month reporting period in 2014, regardless of the stage of meaningful use To allow time to upgrade to 2014 certified EHR technology  • Last year Medicare EPs can begin participation and earn an incentive EPs who first demonstrate meaningful use in 2014 must do so for a 90-day reporting period to avoid 2015 payment adjustment – – – Must occur in first 9 months of CY 2014 Must attest no later than October 1, 2014 Must continue to demonstrate meaningful use every year © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

EHR Incentive

CALENDAR YEAR

2011 2012 2013 2014 2015 2016

MAX TOTALS First Year in which EP receives an EHR Incentive CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and after

$18,000 $12,000 $18,000 $8,000 $4,000 $2,000

$44,000

$12,000 $8,000 $4,000 $2,000

$44,000

$15,000 $12,000 $8,000 $4,000

$39,000

$12,000 $8,000 $4,000

$24,000

$0 $0

• An additional 10% available for Medicare EP services in HPSA areas 

EPs may participate in Medicare OR Medicaid program

Spring 2014

EHR Payment Adjustment

 Medicare EPs who are not meaningful users will be subject to payment adjustment beginning January 1, 2015 EP is not subject to eRx payment adjustment in 2014 EP is subject to eRx payment adjustment in 2014

% Adjustment Assuming <75% of EPs are Meaningful Users CY 2015 CY 2016 CY 2017 CY 2018 CY 2019 CY 2020+

99% 98% 97% 96% 95% 95% 98% 98% 97% 96% 95% 95%

EP is not subject to eRx payment adjustment in 2014 EP is subject to eRx payment adjustment in 2014

% Adjustment Assuming >75% of EPs are Meaningful Users CY 2015 CY 2016 CY 2017 CY 2018 CY 2019 CY 2020+

EHR Hardship Exemption

EPs may apply for a 1-year exemption to avoid the payment adjustment  Hardship exemption request MUST be received by midnight ET July 1, 2014  Hardship granted only under certain circumstances upon CMS approval

Infrastructure 2014 EHR Vendor Issues Unforeseen Circumstances Patient Interaction EP must be in an area with insufficient internet access and face barriers to obtaining internet connectivity (e.g., lack of broadband) EP’s EHR vendor unable to obtain 2014 certification or EP unable to implement meaningful use due to 2014 EHR certification delays During CY 2013 or 2014 the EP faced extreme circumstances preventing EP from becoming a meaningful user (e.g., natural disaster) Lack of face-to-face or telemedicine encounters or lack of need to follow up when it is not part of normal scope of practice Lack of Control No control of availability of certified EHR technology for location(s) that constitutes more than 50% of patient encounters Spring 2014 © 2014 Copyright, CGS Administrators, LLC.

EHR Hardship Exemption

Some automatic exemptions will be granted and the 2015 payment adjustment will not be applied  EPs who successfully met meaningful use is 2013  EPs who meet meaningful use in 2014 and attest by October 1, 2014  EPs classified in PECOS with one of the following specialties • • • • • Diagnostic Radiology Nuclear Medicine Interventional Radiology Anesthesiology Pathology  EPs newly-enrolled in the Medicare program • Based on PECOS data  Hospital-based EPs in CY 2012 or 2013 © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

EHR Incentive Resources

The Electronic Health Record Incentive Program  • • • • http://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/index.html

Getting Started and Educational Resources Registration & Attestation Meaningful Use and Clinical Quality Measures Certified EHR Technology  • Information on Hardship Exemptions and Hardship Exemption Application http://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/PaymentAdj_Hardship.html

 • • • • EHR Information Center Check EP registration status and status on incentive payment in EHR program Order duplicate remittance or 1099 Assist with registration and attestation inquiries Password resets – 1.888.734.6433

Spring 2014

Primary Care Incentive Payment Program (PCIP)

The Affordable Care Act authorizes 10% quarterly incentive payments to qualified primary care practitioners for rendering primary care services

Eligible Specialties

 Family Medicine  Internal Medicare  Geriatric Medicine  Pediatric Medicine  Nurse Practitioners  Clinical Nurse Specialists  Physician Assistants

Eligible Services

 CPT codes 99201-99215  CPT codes 99304-99340  CPT codes 99341-99350 CPT only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use.

Primary Care Incentive Payment Program (PCIP)

Primary care practitioners must meet PCIP criteria  Primary care services must account for at least 60% of the practitioner’s payments under Part B • CY 2014 incentive based on claims data from 2 years prior – I year for newly-enrolled practitioners  Incentive payments are paid quarterly • Through December 31, 2015  PCIP Tool • Primary care practitioners can find out if they are eligible for the PCIP payment –

Kentucky:

http://cgsmedicare.com/kyb/claims/pcip/search.html

–

Ohio:

http://cgsmedicare.com/ohb/claims/pcip/search.html

» Enter the individual provider’s NPI number and click SUBMIT • http://www.cms.gov/MLNMattersArticles/Downloads/SE1109.pdf

Spring 2014

Health Professional Shortage Area Surgical Incentive Payment Program (HSIP)

 Authorizes 10% quarterly incentive payments to General Surgery specialty for rendering surgical procedures • Procedures with 90- and 10-day global period • Furnished in areas designated as a Health Professional Shortage Area (HPSA) – HCPCS modifier AQ must be used for areas not identified as automatic HPSA • HSIP incentive paid in addition to HPSA incentive • For services rendered through December 31, 2015 © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

• • • •

Appeals Overpayment/Recovery Claims Department Medical Staff / Medical Review

CGS Operational Updates

CGS Operational Updates - Appeals

Reopenings vs. Redeterminations  A

Reopening

is a correction of a minor error or omission to a previously processed claim • Reopening requests must be made within

one year

of the date of notice for the initial claim determination • Reopenings are separate and independent from the Appeals Process  After a claim determination is made, you may request a

Redetermination

• Refer to your Remittance Advice to determine whether Appeal rights exist –

MA01:

If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within

120 days

of the date you received this notice, unless you have a good reason for being late.

 Refer to

Reopening vs. Redetermination Job Aid

• http://www.cgsmedicare.com/ohb/claims/pdf/Reopen_vs_Redet_JobAid.pdf

CGS Operational Updates - Appeals

Requesting a Redetermination (1

level Appeal)

CGS now accepts Redeterminations through myCGS, our secure web portal  Find details under the section of this packet

Resources

If using the paper Redetermination Request Form   Complete the form in its entirety • Pay close attention to the “overpayment” section Missing this section may result in offset © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

CGS Operational Updates - Appeals

Medicare Redetermination Notices (MRNs)

 • CGS no longer sends a separate MRN when a Redetermination is

fully favorable

The Standard Paper Remittance (SPR) or the Electronic Remittance Advice (ERA), and the Medicare Summary Notice (MSN) for beneficiaries are CGS’s official notification when the outcome of the Redetermination request is

fully favorable

 If your Redetermination is

unfavorable

, CGS will continue to send an MRN which explains the rationale that was used in upholding the original claim determination  In instances where a Redetermination is considered

partially favorable

, CGS will generate an SPR or ERA, as well as an MRN  For more details: http://cgsmedicare.com/parta/pubs/news/2013/1213/cope24009.html

Spring 2014

CGS Operational Updates – OP/R

Overpayment and Recovery

 Requests for repayment of Medicare funds are time-sensitive • • Respond to demand letters immediately and include a copy with refund ALERT:

eOffset

process via myCGS – Watch for details!

‒

eOffsets a

llow providers to request “immediate offset” electronically  • • Voluntary Refunds Use the Overpayment Refund Form Complete the form in its entirety ‒ ‒ ‒ Use reason codes to identify reason for refund Identify MSP situations Include copies of remittance advices (RAs) © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

CGS Operational Updates - Claims

Responding to Additional Documentation Request (ADR) Letters

 When additional information is needed to process a claim an ADR letter is sent to the provider • Sent to correspondence address on file  Provide the documents/information requested and any related details  Check records for signatures before you send! Use the

Signature Attestation Statement

if the physician’s signature is illegible or missing.

 Include a copy of the ADR letter with your documentation  Return information within 30 days of request to the address indicated in the request  CMS requires these claims to be processed within 45 days  Do not resubmit the claim until you receive a determination • Will result in a duplicate denial © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

CGS Operational Updates - Claims

Incarcerated Beneficiaries

 CMS initiated recoveries from providers and suppliers based on data indicating patients were incarcerated or “in custody”  Previously paid claims with dates that partially or fully overlapped the incarceration period reported were identified  • Automatic collection of overpayments were made  • • • CMS has restored original data to identify payments incorrectly collected Letters sent to providers identifying claims being automatically adjusted Providers may request appeal if discrepancy in amount being refunded Some providers requested appeal prior to CMS adjustment – Appeals are still being processed • CMS website with FAQs, sample letter and spreadsheet http://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/2013 Claim-Denials-Due-to-Beneficiary-Incarceration-Status.html

Spring 2014

CGS Operational Updates – MR

Medical Review – Local Coverage Determination (LCD) Updates  Check for LCD changes if you provide any of these services

Outpatient Psychiatry and Psychology services (L31887) Human Papillomavirus (HPV) Testing (L31871) Hyperbaric Oxygen Therapy (HBO) (L31872) Laser Ablation of the Prostate (L31876) Immunohistochemistry (L31873) Speech-Language Pathology (L31899) Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34409) Flow Cytometry (L31870) Endoscopy by Capsule (L31838) Erythropoiesis Stimulating Agents (ESA) (L31867) Spring 2014 © 2014 Copyright, CGS Administrators, LLC.

CGS Operational Updates – MR

CGS Medical Review (MR) initiatives are designed to ensure Medicare claims are paid correctly  MR may request documentation to support billed services  Articles and checklists created to help providers with documentation  Find information on the CGS website under

Coverage & Pricing

Articles Checklists PCA Results

    Therapy Cap Process ASC – Claims for Unlisted Codes and Codes Subject to Medical Review Rule-Out Diagnosis Codes Radiology – Physician / Practitioners Order Required       E/M Services Advanced Imaging Blepharoplasty Chiropractic Services Radiation Therapy Physical Therapy       OH – CPT modifier 25 KY – New Patient Office Visits KY – Initial Hospital Care KY – Established Office Visits OH – New and Established Home Visits OH – Chiropractic Services CPT only copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use.

• • • •

Contacting CGS Electronic Remittance Advice (ERA) CGS Website myCGS Web Portal

Where To Go For Help

Resources

Contact CGS at

866.276.9558

and listen for sub-menu



: Speak with a

Part B Customer Service Representative



: Contact the

Electronic Data Interchange (EDI) Help Desk



: Speak with a

Provider Enrollment

representative 

: Request a

Telephone Reopening



: Speak with a representative regarding

Overpayment/Recovery

For Interactive Voice Response (IVR):

866.290.4036

Spring 2014

Resources

Electronic Remittance Advices (ERAs)

 26.5% of Part B providers are still receiving paper remits  Advantages to receiving the ERA • Access to your remittances the day the claim finalizes • Reduce costs associated with – Storage and maintenance – Staff time to review and file  Medicare Remit Easy Print (MREP) Software supplements the ERA • View and print ERAs in the paper remit format • It’s free and fully supported by our EDI team!

• Download directly from the CGS website  EDI Helpdesk: 1.866.276.9558

Spring 2014

Resources

CGS website -

Watch for EXCITING changes soon! http://www.cgsmedicare.com/Medicare.html

Resources

CGS ListServ:

https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

Resources

CGS Education



J15 Education Pages

• KY: http://www.cgsmedicare.com/kyb/education/education.html

• OH: http://www.cgsmedicare.com/ohb/education/education.html

Spring 2014

Resources

CGS offers

myCGS

, a web portal used to perform online functions securely over the Internet! Special functions will include

 Claim status  Patient eligibility inquiries  Provider financial inquiries, including the amount approved-to-pay and the last three checks paid  View/print copies of remittance advices 

NEW: Submit Redetermination requests!

From KY homepage

http://www.cgsmedicare.com/KYB

From OH homepage

Spring 2014

Resources

You can participate in myCGS if you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with CGS.

 Electronic submitters already have an agreement on file with us.

• You do NOT have to be an electronic submitter to register.

 The EDI Enrollment Agreement is located in the EDI Enrollment Packet • http://www.cgsmedicare.com/pdf/EDI_Enroll_Packet.pdf

 The turnaround time for a new EDI application to process is approximately 20 days.

Spring 2014

Resources



The myCGS Video Library

• The Benefits of myCGS • Introducing myCGS Three-Part Video Tutorials 

myCGS Web Portal Registration Checklist

• Step-by-step instructions to help you register 

myCGS Frequently Asked Questions (FAQs)



User Manual



EDI Helpdesk: 1.866.276.9558

Spring 2014

Watch for EXCITING myCGS enhancements!!!

myCGS Redeterminations

NEW!

Submit Redeterminations through myCGS!

 Those who have access to myCGS can submit Redeterminations securely through the web portal • The Provider Administrator must grant access to Provider User – The Provider Administrator is the first person to register for each NPI/PTAN • Access is granted under the ADMIN tab © 2014 Copyright, CGS Administrators, LLC.

Spring 2014

myCGS Redeterminations

NEW!

Submit Redeterminations through myCGS!

Forms Tab

Spring 2014

myCGS Redeterminations

NEW!

Submit Redeterminations through myCGS!

Complete the Beneficiary Information section in its entirety. Complete the Provider Information section in its entirety.

myCGS Redeterminations

Complete the

Claims Information

section in its entirety. Enter the CPT/HCPCS codes and modifiers in question. Click ADD. Codes will appear in window.

Once all codes and modifiers are added, click ADD CLAIM INFORMATION. If entered correctly, information will appear here.

Be sure to note whether an overpayment exists on the claim(s) being appealed.

Enter reason for request (in 1200 characters or less, then click VALIDATE.

Medical records, remittance advices, etc., may be attached by clicking on BROWSE and selecting the documents from your system.

myCGS Redeterminations

You must attach at least ONE document. It must be in a

PDF

5MB in size.

format and no more than Enter your name and click SUBMIT.

Spring 2014 An eSignature window will open to confirm you are authorized to submit appeals for the provider. If agree, click OK.

myCGS Redeterminations

NEW!

Submit Redeterminations through myCGS!

Messaging Tab  After submitting the online form, you will receive a secure message confirming receipt of your request.

 Once CGS assigns a Submission ID to the request, a second secure message will be sent.

• This message will include instructions on how to check the status of your appeal using the Submission ID (DCN).

 Once a determination is made and the appeal is complete, a secure message will be sent confirming this.