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Medicare Updates for the Uniform Billing Committee Meeting August 20, 2009 Recent Claims Processing Issues Situation Impact to Providers Status It has been brought to the Claims will be held that meet 08/14/2009 - All FIs and MACs attention of the Centers for the following criteria: will hold claims until the fix is Medicare & Medicaid implemented into production on Services (CMS) that inpatient Type of Bill (TOB) = September 7, 2009. Once claims containing hemophilia 11x; CR6354R1 has been services are not calculating Statement From Date < implemented into production a the add-on payment 7/1/2009; Condition Code 15 shall be correctly. Statement Thru Date applied to the claims and they => 7/1/2009; shall be released for payment. Revenue Code = 636; For claims that were processed Valid Hemophilia between July 6, 2009, and August Clotting Factor 10, 2009, (date of the joint HCPCS; signature memorandum/ Diagnosis Code = technical direction letter 286.0, 286.1, 286.2, (JSM/TDL), FIs/MACs shall 286.3, 286.4, 286.5 or perform adjustments and 286.7; reprocess these claims for PPS Provider = Y. payment. The adjustments shall be completed within three months of the implementation of CR6354R1. The Centers for Medicare & Rural SCH providers were 08/14/2009 - No update at this Medicaid Services (CMS) underpaid for claims submitted time. has identified a claims for blood and blood products processing error affecting under OPPS during 2006, 2007, 08/06/2009 -This claim rural Sole Community and 2008. processing problem will be Hospitals (SCHs), including corrected retroactively on Essential Access Community October 5, 2009 for blood and Hospitals (EACHs), paid blood products provided in rural under the hospital Outpatient SCHs, including EACHs, during Prospective Payment System 2006, 2007, and 2008. Hospitals (OPPS). Due to this error, may, if they choose, collect the rural SCH claims submitted higher copayments from for blood and blood products beneficiaries, and if unsuccessful, under OPPS during 2006, obtain bad-debt reimbursement 2007, and 2008 did not from Medicare following CMS’ receive the rural SCH long-standing policies for bad- adjustment of 7.1 percent. debt reimbursement. If hospitals choose not to seek beneficiary reimbursement for the higher copayments, they may report the foregone income as non- reimbursable bad debt. At that time, adjustments will be made to claims paid in error with all adjustments completed no later than December 31, 2009. It has been brought to our We are holding claims that meet 08/14/2009 - No update at this attention that claims with this criteria until the successful time. 12X TOB and HCPCS Code installation of the software fix C9399 are not pricing on August 3, 2009. At that 08/06/2009 - The implementation correctly. time, we will release and of this fix has been postponed. process the claims being held. Please continue to check the log for updates. 07/31/2009 - The software fix scheduled for August 3, 2009 has been postponed. Please check the log for updates. The Centers for Medicare & Until the SI for Q4115 is 08/14/2009 - No update at this Medicaid Services (CMS) retroactively corrected in the time. has identified a claims October 2009 IOCE Release, processing error that contractors will Return to 08/06/2009 - No update at this incorrectly assigned HCPCS Provider lines billed with time. Code Q4115 (Skin substitute, Q4115 with Edit W7072 alloskin, per square (service not billable to the 07/31/2009 - This issue will be centimeter) effective July 1, FI/MAC). We regret any corrected with the successful 2009, a Status Indicator inconvenience you have implementation of the October (SI)=K in the July Integrated experienced related to this 2009 IOCE Release. Outpatient Code Editor problem. (IOCE). The proper SI for 07/23/2009 - No update at this this code should be SI=M. time. On payments dated June 5th Providers are receiving 08/14/2009 - No update at this through June 12th, some payments, however the time. This will be corrected with providers experienced delays remittance advice detail will not the October 2009 release. in claims payments due to balance to the payment amount. FISS claim number 08/06/2009 - No update at this assignment issues. This time. problem was corrected on June 11th. Providers 07/31/2009 - No update at this impacted by the issue should time. have seen payments appear on their remits beginning 07/23/2009 - No update at this June 15th. An additional time. problem has been identified after the installation of the fix 07/16/2009 - No updates at this on June 11th. Although the time. payment amount is included on provider checks/EFT's, as 07/10/2009 - No updates at this well as in the payment time. amount on the remittance advice, the claim detail is not 06/26/2009 - We are currently present on the remittance waiting on the FISS maintainer to advice. This is creating a evaluate this problem and create situation where an amount a systems fix. equal to the total reimbursement amount of the missing claims is appearing in the adjust to balance field. It is anticipated that once this issue is corrected, the claim detail will appear on the remittance advice following the date the fix is installed. Since providers have already received payment for these claims, the reimbursement amount for these claims will not be included in the providers payment amount on that remittance advice. This will again cause an amount equal to the total reimbursement for these claims to appear in the adjust to balance field on the remit. Claims are continuously These claims are hitting the 08/14/2009 - No update at this cycling between S B9000 and Common Working File and then time. S B9099. cycling back. No reason code is being applied to these claims. 08/06/2009 - No update at this time. Note: Not all claims in these two status/locations are affected 07/31/2009 - No update at this by this issue. These two time. status/locations are part of the normal processing cycle and all 07/23/2009 - This issue is still claims will go through these two being researched. locations prior to finalizing. Please note that claims Cycling claims, however, are involving therapy services not accepted by the Common and/or the use of the ‘KX’ Working File, and thus they modifier can now be corrected continue to cycle between the and released from this cycle two status/locations. Other (See the 06/10/2009 update Fiscal Intermediaries are below). experiencing similar issues. NDC Issue SC providers have been experiencing issues with reason code 32511. Typically, claims are type of bill 131 and do not have HCPCS code C9399 present on the claims. Previously, the Provider Contact Center had been instructing providers to remove the NDC code from the claim in order that it would process. However, providers have raised concerns with this process since the NDC may need to crossover to Medicaid. After reviewing several claims from various providers, it appears that these claims are editing in error. FISS has been made aware of this issue and a release is scheduled for early September that will prevent this improper editing. Please bear in mind that when reporting the NDC number, the other two “key components” must be reported, including “NDC QTY and QTY QUAL”. Many of the claims that have been researched have lacked these key pieces of information. In addition, the only time Medicare actually requires the NDC to be reported is when C9399 is present on the claim. Providers will begin to see future claim submissions editing properly once the fix is put in. At such time that the fix goes in, providers will be instructed as to how they should proceed with previously submitted claims. Clarification of the Coding and Billing for Injection Services On July 24, 2009, Palmetto GBA re-issued an article regarding the clarification for the coding and billing of IV injection and infusion services, including common questions and answers related to this subject. One question in particular relating to when sequential infusion can be billed has raised questions with several of our providers. Thus, clinical and billing associates in Palmetto GBA will once again be revisiting this article to provide additional clarification. When the article has been updated, it will be sent out to providers via the Palmetto GBA list serv and will also be placed on the Web site. Online Eligibility/Claims Status Tool Palmetto GBA is pleased to announce that providers will soon be able to utilize an online eligibility and claim status tool on the Palmetto GBA Web site. Providers have requested this tool during the last few years, as other private insurers currently offer it. However, Palmetto GBA had to wait for approval from CMS before proceeding. Currently, this tool is scheduled to be rolled out to all SC/NC Part A providers by the end of the calendar year. All other contracts will utilize this tool at a later date. Palmetto GBA will be looking to utilize a pilot group so that feedback can be given on the “prototype.” One of CMS’ key factors in approving this tool was the security of the information housed in the system and the validity of persons authorized to use it. Thus, providers who have been deemed as EDI submitters will be the ONLY users allowed for this tool. This will ensure that only those people who need to look at the information have that ability. 2009 Hospital Workshop Palmetto GBA will offer a one-day workshop for hospital providers throughout South Carolina. The workshop session will be held Thursday, September 3, 2009 at the Palmetto GBA office in Columbia, South Carolina. Registration will be held from 8:45 a.m. to 9:15 a.m. and the workshop will be held from 9:15 a.m. to 4 p.m. The cost for each workshop session is $30.00 per attendee. A continental breakfast and afternoon snack will be provided. The objective for this workshop series is to educate and update providers about changes to Medicare coverage and policies. Agenda topics include: Eligibility after Admission Radiopharmaceutical Billing High Dollar Edit for Inpatient Services Coverage Exclusions Injection and Infusion Billing Medical Review Billing Procedures to Avoid Medically Unlikely Edits (MUEs) Maximum Allowable Units (MAUs) Hospital Readmissions Three Day Payment Window Billing Non-Covered Days Outlier Billing End Stage Renal Disease (ESRD) Billing for Non-ESRD Facilities Medicare Clinical Trial Policy Use of the Q0 and Q1 Modifiers We encourage patient financial services directors, managers, supervisors, billers, and billing/follow-up staff to attend this workshop. To register for the workshop session please visit the Palmetto GBA Web site and choose “Learning and Education” and “Workshops.” If you have questions about online registration, call Mary Dunham at (803) 763-1424. Maximum Allowed Units (MAUs) Palmetto GBA has implemented automated system edits for many Healthcare Procedure Coding System (HCPCS) drug codes. This endeavor assists providers in identifying vulnerabilities in the Fiscal Intermediary Shared System (FISS) on units of service for drugs that were identified in conjunction with Comprehensive Error Rate Testing (CERT) and Recovery Audit Contractor (RAC) errors. These edits were previously implemented for Part B in December 2008; however, Palmetto GBA will begin implementing these edits for Part A in late August 2009. These edits are designed to reduce entry and math errors and are not designed to limit utilization. Drugs and biologicals submitted with quantities that exceed the Palmetto GBA established Maximum Allowed Units (MAUs) will be denied. Specific MAU limits (per 12 hour period) will be published for the provider community by HCPCS codes via the Palmetto GBA Web site. Tips for submitting accurate claims: Each J HCPCS code is associated with a specific number of units and type of units. Describe the specific units of measure utilized for each administration. Verify the number and type of units administered with the J HCPCS code before calculating the quantity on your claim. Verify calculations with a physician or pharmacist if needed. Submit the number of units (based on the HCPCS code) actually administered and not the number of units in the entire vial (there are some exceptions for discarded drugs). You may request individual consideration to allow doses that exceed the MAU for a specific beneficiary. This will be handled through the appeals process. You may request MAU Reassessment to change the MAU amount for all beneficiaries. Submitting Requests to Change the MAU (for all beneficiaries): MAU Reassessment Palmetto GBA encourages you to provide input regarding MAUs for the identified drugs and biologicals. If you request a MAU Reassessment please submit peer-reviewed medical literature to support a MAU revision in the same manner in which you now request a reconsideration of a Local Coverage Determination (LCD). To request an MAU Reassessment, please enter the HCPCS code and reassessment in the subject line of your e-mail or fax and attach peer-reviewed medical literature and a detailed description of your request to: Elaine Jeter, MD Fax: (803) 935-0199 E-mail: B.Policy@PalmettoGBA.com Note: Please allow 30 days after the reassessment consideration date for system updates. If you disagree with an initial claim determination, you must request a Redetermination, within the specified time frames, for denied or reduced claims.
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