2-10-10 Medicare Webinar Agenda.xls - HomeTownHealth

Document Sample
2-10-10 Medicare Webinar Agenda.xls - HomeTownHealth Powered By Docstoc
					                               Welcome to the HomeTown Health MEDICARE UPDATE

9:50 AM - Webinar Etiquette & Tools                                         Welcome Page


10:00 AM - OPENING COMMENTS                                                     Kathy Whitmire
PEPPER Report - Now available for download!

10:10 AM - CAHABA / CONNOLLY / CMS MEDICARE Updates                             Dale Gibson

CAHABA Communications / Issues Update

Adoption of New Rehabilitation Facility Coverage Requirements
Coverage of inpatient rehabilitation services.docx
Coverage of Inpatient Rehabilitation Services - Document 2.doc

MM 6753 - Positron Emission Tomography (PET) (FDG) for Cervical Cancer
Positron Emission Tomography (PET) (FDG) for Cervical Cancer MM6753.pdf

R617 OTN - Medically Unlikely Edits (MUEs)
Medically Unlikely Edits R617OTN.pdf

R1873 CP - Place of Service (POS) and Date of Service (DOS) Instructions for the Interpretation (Professional Component) and
Technical Component of Diagnostic Tests
Place of Service R1873CP.pdf

R1530 CP - Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)
Critical Care R1530CP.pdf

Confirmation on CBC Orders on CPT Code 85025 and 85027

NEW Voluntary and Non-Voluntary ABN REGULATIONS

Medicare Secondary Payer (MSP) Billing

PHYSICIAN Lunch and Learn Feb. 16th at 12:30 - New HIPPA Regulations

New Issues Posted to Connolly Website
Recent Letters Received from Connolly
Issues listed by provider type at

PECOS - All physicians that have not updated their enrollment since 2003 must reenroll by extended to April 1

11 AM Question & Answer Session

11:15 AM Adjourn

                                                  Notes from today's meeting can be found at

                    To learn more about HomeTown Health visit our website at
Thanks for participating in today's meeting!

Please see the attached Med Learn Matter from CMS. MM6740
It impacts Critical Access Hospital effective January 1, 2010.
If the CAH are billing for physician consults then the codes are changing.
In the past hospital used hcpcs codes 99241-99245 and 99251-99255). 
CAH will now use E/M codes to reflect the physician charge.
Also, if the physician is the primary physician there are to use a Modifier AI to reflect this.
There is to be no financial impact to this change.
The entire document reflects information concerning this change.
If you have any CAH billing for physician fees they need to carefully read this document.


1.Expiration of Moratorium That Allowed Independent Laboratories to Bill for the TC of Physician
Pathology Services Furnished to Hospital Patients

The Centers for Medicare & Medicaid Services (CMS) continues to work with Congress on significant
legislation which affects the Medicare program. We believe this and other provisions may be extended
as part of this legislation. We encourage you to monitor Congressional activity and stay apprised of
the status of potential legislation. In the meantime, if such legislation is enacted, CMS will
notify Medicare fee-for-service claims processing contractors to again process claims for those
affected services. Providers may choose to hold their claims in the event legislation about this
issue is enacted. However, current law mandates the following change:

In the final physician fee schedule regulation published in the Federal Register on November 2,
1999, CMS stated that it would implement a policy to pay only the hospital for the Technical
Component (TC) of physician pathology services furnished to hospital patients. At the request of the
industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements,
the implementation of this rule was administratively delayed. Subsequent legislation formalized a
moratorium on the implementation of the rule.

The most recent extension of the moratorium was established by the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA). Section 136 of the MIPPA expires on December 31, 2009,
thus ending the moratorium. Therefore, independent laboratories may no longer bill Medicare for the
TC of physician pathology services furnished to patients of a hospital, regardless of the
beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was
performed. This prohibition is effective for claims with dates of service on and after January 1,

We will continue to be in communication with you should there be further information regarding
payment of claims impacted by the above guidance. In addition, be on the alert for more information
about this and other legislative provisions which may affect you.

2.Expiration of Therapy Cap Exceptions Process
The Centers for Medicare & Medicaid Services (CMS) continues to work with Congress on significant
legislation which affects the Medicare program. We believe this and other provisions may be extended
as part of this legislation. We encourage you to monitor Congressional activity and stay apprised of
the status of potential legislation. In the meantime, if such legislation is enacted, CMS will
notify Medicare fee-for-service claims processing contractors to again process claims for those
affected services. Providers may choose to hold their claims in the event legislation about this
issue is enacted. However, current law mandates the following change:

The exceptions to outpatient therapy caps expire on December 31, 2009. Outpatient therapy service
providers should not submit claims with the KX modifier for services furnished on or after January
1, 2010. The therapy caps are determined on a calendar year basis, so all patients will begin a new
cap year on January 1, 2010. For physical therapy and speech language pathology services combined,
the limit on incurred expenses is $1,860.00. For occupational therapy services, the limit is
$1,860.00. Deductible and coinsurance amounts applied to therapy services count toward the amount
accrued before a cap is reached.

Note that patients who have reached their limit(s) on outpatient therapy services, other than those
who reside in a Medicare-certified part of a skilled nursing facility, may obtain medically
necessary therapy services that exceed the caps if the services are furnished and billed by the
outpatient department of a hospital. In other settings, outpatient therapy services in excess of the
caps are not covered, and the therapy provider may charge the beneficiary for those services.

We will continue to be in communication with you should there be further information regarding
payment of claims impacted by the above guidance. In addition, be on the alert for more information
about this and other legislative provisions which may affect you.

Updated Information Regarding the Holding of Claims for Services Paid Under The 2010 Medicare
Physician Fee Schedule

This is a clarification to the listserv message that was issued on December 21, 2009.  The President
has signed the Department of Defense Appropriations Act of 2010 which provides for a zero percent
(0%) update to the 2010 Medicare Physician Fee Schedule for a two month period, January 1, 2010
through February 28, 2010.

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers,
and the beneficiary community to avoid disruption in the delivery of health care services and
payment of claims for physicians, non-physician practitioners, and other providers of services paid
under the Medicare physician fee schedule, beginning January 1, 2010.  In this regard, CMS has
instructed its contractors to hold claims for services paid under the Medicare Physician Fee
Schedule (MPFS) for up to the first 10 business days of January (January 1 through January 15) for
2010 dates of service. This should have minimum impact on provider cash flow because, by law, clean
electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the
date of receipt.  Meanwhile, all claims for services delivered on or before December 31, 2009, will
be processed and paid under normal procedures.
The holding of claims allows Medicare contractors time to receive the new, updated payment files and
perform necessary testing before paying claims at the new rates. CMS has instructed contractors to
begin processing claims at the new rates no later than January 19, 2010.  Please note that most
contractors are closed on the January 18 Martin Luther King Day holiday.  Therefore, even absent a
new update, most claims likely would not have been paid any sooner than January 19, 2010, given the
aforementioned statutory 14-day payment floor.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to
March 17, 2010– therefore, the enrollment period now runs from November 13, 2009, through March 17,

The effective date for any Participation status change during the extension, however, remains
January 1, 2010, and will be in force for the entire year.

Contractors will accept and process any Participation elections or withdrawals, made during the
extended enrollment period that are received or post-marked on or before March 17, 2010.

MM 6752 - POS CODE

This article, based on CR 6752, advises you that the current place of service (POS) code set has been updated to add a
new code of 17 (Walk-in Retail Health Clinic). The code’s description is as follows: “a walk-in health clinic, other than an
office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is
located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.”

CR 6563 ABN Modifier Changes
Policy: EFFECTIVE APRIL 1, 2010 HCPCS level 2 modifiers have been updated in order to distinguish between
voluntary and required uses of liability notices. Modifier –GA has been redefined to mean “Waiver of Liability Statement
Issued, as Required by Payer Policy.” This modifier is only to be used to report when a required ABN was issued for a
service. As stated in previous instructions, the -GA modifier should not be reported in association with any other liability-
related modifier and should continue to be submitted with covered charges. However, Medicare systems will now deny
these claims as a beneficiary liability (rather than subjecting them to possible medical review), and the beneficiary will
have the right to appeal this determination.
A new modifier, -GX, has been created with the definition “Notice of Liability Issued, Voluntary Under Payer Policy.” This
modifier is to be used to report when a voluntary ABN was issued for a service. Providers may use the –GX modifier to
provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute. In
these cases, the –GX modifier may be reported on the same line as certain other liability-related modifiers. The –GX
modifier must be submitted with non-covered charges only and will be denied by the Medicare contractor as a beneficiary
                                                                                           REVIEW OF 2009
“Federal regulations (42 CFR § 409.27(c)) state that the SNF benefit includes medically necessary ambulance tran
resident during a covered Part A stay. Accordingly, when an ambulance supplier erroneously bills Medicare Part
included in the SNF’s Part A consolidated billing payment, Medicare pays for the same service twice, once to the
Transmittal 112 - Criteria for Rehab inpatients - Effective Date 1-4-2010
Under the new coverage policy, the decision to admit the patient to the IRF is the key to determining whether the admis
Thus, these manual revisions include the following subjects: Documentation Requirements; Required Preadmission Scr
Physician Evaluation; Required Individualized Overall Plan of Care; Required Admission Orders; Required Inpatient Reh
Assessment Instrument (IRF-PAI); Inpatient Rehabilitation Facility Medical Necessity Criteria; Multiple Therapy Discipli
Services; Ability to Actively Participate in Intensive Rehabilitation Therapy Program; Physician Supervision; Interdiscipli
of Care; and Definition of Measurable Improvement.
New inpatient deductibles for 2010 - Effective Date Jan 1, 2010

Table 1--Part A Deductible and Coinsurance Amounts for Calendar Years 2009 and 2010
                                                                                      Value                    Number paid (in millions)
              Type of cost sharing                         ---------------------------------------------------------------
                                                                             2009               2010               2009       2010
Inpatient hospital deductible...................                          $1068               $1100                   8.70      8.80
Daily coinsurance for 61st-90th day.............                             267                275                 2.27      2.30
Daily coinsurance for lifetime reserve days.....                             534               550                 1.12       1.13
SNF coinsurance.................................                            133.50              137.50               40.79     41.74

TOB 13X: Correct Billing of CPT 64470, 64472, 64475 and 64476 (Injection, Anesthetic Agen
Paravertebral Facet Joint of Facet Joint Nerve)
Medical Review data analysis and medical record review identified provider billing errors for claims submitted with CPT 6
Review of the medical records and submitted claims identified the following billing and documentation errors:

Documentation did not support the number of services billed on the claims; more facet injections were billed than were
The two primary codes, CPT 64470 and 64475 are used to bill a single injection in the cervical/ thoracic or lumbar sacra
CPT 64472 and 64476, the associated add-on codes, should be used when injections are provided at multiple levels. C
to bill the appropriate modifiers to indicate unilateral and bilateral injections. Unilateral injections performed on one side
the RT or LT modifier.
Bilateral injections performed on the right and left side of the joint level must be billed with modifier 50.
NOTE: Effective January 1, 2010, the facet block CPT codes will change. The most noted change is that fluoroscopy wi
and thus not separately billable. Providers are encouraged to become familiar with the upcoming CPT changes for 2010
. MLN MattersR Number: MM6518 Revised

Part A Intermediary
Medicare Part A Medical Records: Signature Requirements, Acceptable and Unacceptable Practices
Handwritten signatures or initials
Electronic signatures:
Digitized signature - an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen
Electronic signatures usually contain date and timestamps and include printed statements, e.g., 'electronically signed by,' or '
practitioner’s name and preferably a professional designation. Note: The responsibility
Digital signature - an electronic method of a written signature that is typically generated by special encrypted software that al

New Observation Ordering / documentation requirements

Clarification Related to Condition Code 44
CR 6626 also makes changes to the Medicare Claims Processing Manual, Chapter 1, Section 50.3, incorporate minor
Condition Code 44. The revised section of the manual is attached to CR 6626.


Trailblazer - Section 1011 - Feb 25th Payment -
Part A Intermediary
Medicare Part A Medical Records: Signature Requirements, Acceptable and Unacceptable Practices

While the Centers for Medicare & Medicaid Services’ (CMS’) guidelines mandate the presence of signatures specifically for all medic
pertaining to any procedures billed to Medicare Part A are potentially subject to review by not only Palmetto GBA, but other CMS co
to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.

The contents of this article are applicable to every Medicare claim processed by or medical record submitted to Palmetto GBA. These
documentation requirements for specific situations.

Signature’s Purpose
Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each en
practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials, e.g., Physician’s 
(D.O.) or Doctor of Medicine (M.D.)

The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findi
services have been accurately and fully documented, reviewed and authenticated. Furthermore, it confirms the provider has certified t
the service(s) submitted to the Medicare program for payment consideration.

Medicare Requirements for Valid Signatures

Acceptable methods of signing records/test orders and findings include: 

Handwritten signatures or initials

Electronic signatures:
Digitized signature - an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tab
Electronic signatures usually contain date and timestamps and include printed statements, e.g., 'electronically signed by,' or 'verif
practitioner’s name and preferably a professional designation. Note: The responsibility and authorship related to the signature s
Digital signature - an electronic method of a written signature that is typically generated by special encrypted software that allow

Note: Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-signature' systems, some of wh
review an entry before signing. Indications that a document has been, 'Signed but not read' are not acceptable as part of the medical r

Acceptable Signature Examples 

Chart 'Accepted By' with provider’s name

'Electronically signed by' with provider’s name

'Verified by' with provider’s name

'Reviewed by' with provider’s name

'Released by' with provider’s name

'Signed by' with provider’s name

'Signed before import by' with provider’s name
'Signed: John Smith, M.D.' with provider’s name

Digitalized signature: Handwritten and scanned into the compute.

'This is an electronically verified report by John Smith, M.D.'

'Authenticated by John Smith, M.D.'

'Authorized by: John Smith, M.D.'

'Digital Signature: John Smith, M.D.'

'Confirmed by' with provider’s name

'Closed by' with provider’s name

'Finalized by' with provider’s name

'Electronically approved by' with provider’s name

Unacceptable Signatures

Signature 'stamps' alone in medical records are no longer recognized as valid authentication for Medicare signature purposes an
Reports or any records that are dictated and/or transcribed, but do not include valid signatures 'finalizing and approving' the do
reimbursement purposes. Corresponding claims for these services will be denied.
See unacceptable signature examples:
o 'Signing physician' when provider's name is typed

Example: Signing physician: ______________________ 

John Smith, M.D. 

o 'Confirmed by' when a provider's name is typed

Example: Confirmed by: ______________________ 

John Smith, M.D. 

o 'Signed by' followed by provider's name typed and the signing line above, but done as part as the transcription.

o 'This document has been electronically signed in the surgery department' with no provider name.

o 'Dictated by' when provider's name is typed

Example: Dictated by: ______________________

John Smith, M.D. 
o Signature stamp

Electronic Medical Records: Recommendations
The electronic system you select should include a process that verifies the individual signing their name has reviewed the contents o
they intended.

Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic signatures, by whatever
individual to whom it is assigned. It is to be unique to him/her, and not reassigned nor reused by someone else. Furthermore, measure
between electronic health information and signatures which prevent unapproved alteration through removal, copying or transfer.

To avoid unnecessary payment denials, rejections or overpayment situations, we strongly urge providers to check with their technica
current record-keeping and signature processes are in compliance with CMS instructions. Software/hardware should meet or exceed i
integrity of documentation and signatures.

If using electronic medical records and or electronic signatures maintain documentation that explains the process and have the inform
records are requested. This is very important when verify physician involvement in ordering of diagnostic tests and procedures.

For reference and exceptions, please refer to the following

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section B (PDF, 644 KB)

MLN Matters article, MM 5971 (PDF, 64 KB) 
                                            Denial Code N432
CMS confirmed that RAC denials will also appear on the Remittance advice statements, and to mak
easier to track these RAC adjustments, there is a special code assigned to them: the code is N432,
which stands for "adjustment based on recovery audit."

Be sure to include your Patient Financial Services (Business Office) in the RAC process as they will deal w
actual RAC financial actions. Of note, hospitals will be notified of pending RAC recoupments with the use o
new Remittance Advice (RA) code "N432." An RA with "N432" will report the recoupment amount designate
corresponding demand (denial) letters received by the hospital.

Beneficiaries will be notified of the denial when the MAC adjusts the claim and issues the RA with the N432
code. CMS initially said that providers must refund the secondary insurance and beneficiary at this time
regardless of whether the denial is appealed. CMS later stated they would review this requirement again an
will follow-up with OHA.

                                                   RAC Letters
Complex Reviews (medical record required)
1.      The request for medical records is called the “Additional Documentation Request” or ADR and will
explain the focus of the audit.
2.      Connolly issues a “Review Results Letter” to the provider once the review is complete (within 60 day
record submission). This letter will not detail the improper payment amount or appeal rights.
3.      Connolly will send the overpayment determinations to the MAC (TrailBlazer~Cahaba or WPS). MAC w
make an adjustment and issue a remittance advice with remark code “N432.”
4.      Connolly issues a “Demand Letter” which includes the dollar amount in question and appeal rights. T
date of the demand letter starts the clock for the appeals process.

Automated Reviews (no medical record needed)
·         Begins at Step 3 from above. The first notification of a denial due to an automated review will likely be t
“N432” remark code on the remittance advice once the MAC has made an adjustment. The only letter issu
for an automated review is the Demand Letter.

                                             Automated Review
Automated review occurs when a RAC makes a claim determination without a human review of the
medical record. The RAC uses software designed to detect errors. For example, an automated revi
could identify when a provider is billing for more units than allowed on one day. A provider will not kn
that the RAC is looking at a particular claim until the provider is notified of an overpayment on a
Remittance Advice (Remark Code N432 – “Adjustment based on a Recovery Audit.)
NEW MEDICARE TERMS/Acronyms in 2008:

RAC’s – Recovery Audit Contractors

POA’s – Present on Admission Indicators

MSPRC – MSP Recovery Contractors

MAC’s – CMS is replacing its current claims payment contractors - fiscal intermediaries and carriers -
with new contract entities called Medicare Administrative Contractors (MACs). CMS plans to award a total
of 19 MAC contracts through three procurement cycles.  Fifteen of these contracts will be with entities that
will cover the majority of Part A and Part B services, i.e., A/B MACs   GA, AL & TN are in J10 to be
awarded by year end.

MCR - Medicare Contracting Reform (MCR).

MUEs - Medically Unbelievable/Unlikely Edits. Last year, CMS started a new initiative under its
Comprehensive Error Rate Testing (CERT) program, which it originally titled the Medically Unbelievable
Edit program (MUE). CMS staff said the program would establish a set of edits for coding situations which
should never legitimately be billed.  Effective Jan 2007

VBP - Value-Based Purchasing -
Value-based purchasing (VBP), which links payment to performance, is a key policy mechanism that CMS
is proposing to transform Medicare from a passive payer of claims to an active purchaser of care.

HAC’s –Original  8 Hospital Acquired Conditions (Effective 10-1-08)
Under the proposal, hospitals still would be paid for hospitalizations but would not be allowed to code and
charge for the following as "complicating conditions" if they develop during a patient's stay:
Surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or
ligation and stripping of varicose veins.
Legionnaires' disease.
Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma.
Iatrogenic pneumothorax.
Ventilator-associated pneumonia.
Deep-vein thrombosis or pulmonary embolism.
Staphylococcus aureus septicemia.
Clostridium difficile-associated disease. CDAD

PEPPER - Program for Evaluating Payment Patterns Electronic Report

CERT - Comprehensive Error Rate Testing  

Medicare Improvements for Patients and Providers Act of 2008 

Qualified Independent Contractors (QICs) are companies that perform the second level of appeal for
Medicare fee-for-service claims. Maximus


PCA - Progressive Corrective Action

EP - Eligible Professional

HRA - Health Reimbursement Arrangement

HDHP - High deductable Health Plan


PECOS - Provider Enrollment, Chain, and Ownership System

ADRs - Additional Documentation Requests 
                    Medicare 2010 Acronyms Contest

RAC =  R ____________   A _____________ C ________________

MAC = M____________   A _____________ C ________________

HAC = H ____________   A _____________ C ________________

POA =  P ____________   O _____________ A ________________

MUE = M ____________   U _____________ E ________________

MSP = M ____________   S _____________ P ________________

HRA = H ____________   R _____________ A ________________

ADR = A ____________   D _____________ R ________________

VBP =  V ____________   B _____________ P ________________
CERT = C____________ E___________ R___________ T____________

Shared By: