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Medicare Updates for the Uniform Billing Committee Meeting August

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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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