1 billing compliance committee meeting september 15, 2011
TRANSCRIPT
1
BILLING COMPLIANCE COMMITTEE MEETING
September 15, 2011
MEETING AGENDA
1. Introductions of New Compliance Staff2. Active Medicare Local Coverage
Determinations (“LCD”)3. Upcoming Medicare Training and
Education Sessions4. Medicare Advanced Beneficiary Notice
(“ABN”) Form Change5. Provider Enrollment Revalidation
Requirements for Providers Participating in Medicare, Medicaid and the Children’s Health Insurance Program (“CHIP”)
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AGENDA MEETING (cont’d)
6. Medicare and Medicaid Audit Updates
7. FY 2012 Compliance Audit Work Plan
8.Discussion of Each Clinics’ Responsibility to Maintain Internal Billing Guidelines and Conduct Self Audits
9.Compliance News and Updates
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• Source: https://www.highmarkmedicareservices.com/policy/
Active LCDS• Acute Care: Inpatient, Observation and Treatment Room
Services• B-Type Natriuretic Peptide (BNP) Assays• Blepharoplasty/Blepharoptosis• Blood Glucose Monitoring in a Skilled Nursing Facility• C-Reactive Protein Testing• Cardiac Rehabilitation Program Services• Erythropoiesis Stimulating Agents (ESAs)
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Medicare Active LCDs
• Cardiac Rhythm Device Evaluation• Cardiovascular Nuclear Medicine• Cardiovascular Stress Testing• Cataract Surgery• Complex Cataract Extraction• Chiropractic Services• Co-Management of Surgical Procedures• Computed Tomographic Angiography of the Chest• Continuous Glucose Monitoring• Coverage of services and Procedures in Nursing Facilities• End-Diastolic Pneumatic Compression Therapy• Evaluation and management Services Provided in a Nursing
FacilityApril 19, 2023 5
Medicare Active LCDs Cont’d
• Cytogenetic Analysis• Debridement of Mycotic Nails• Diagnostic Laryngoscopy• Dynamic Electrocardiography• Electrocardiography• Electromyography (EMG) and Nerve Conduction Studies• Extended Ophthalmoscopy• Fluorescein and Indocyanine Green Angiiography• Fundus Photography• Human Skin Equivalents• Hyperbaric Oxygen Therapy• Infrared Photocoagulation (IRC) of Hemorrhoids• Intraoperative Neurophysiological TestingApril 19, 2023 6
Medicare Active LCDs Cont’d
• Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture
• Isolated Ultrafiltration for Managemnet of Fluid Overload in Cardiac Disease
• Loss of heterozygosity Based Topographic Genotyping with PathFinder TG
• Luteinizing Hormone-Releasing Hormone (LHRH) Analogs• Magnetic Pelvic Floor Stimulation (MPFS)• Magnetic Resonance Angiography (MRA)• Magnetic Resonance Imaging (MRI) of the Breast• Moh’s Micrographic Surgery• Monitored Anesthesia Care• Non Covered Services
April 19, 2023 7
Medicare Active LCDs Cont’d
• Non-Invasive Cerebrovascular Arterial Studies• Non-Invasive Peripheral Venous Syudies• Non-Vascular Extremity Ultrasound• Ophthalmic A and B Scans• Ophthalmic Biometry for Intraocular Lens (IOL) Power
Calculation• OVA – 1 Assay• Paraathormone (Parathyroid Hormone)• Physical Medicine & Rehabilitation Services; PT, OT• Proton Beam Therapy• Psychiatric Therapeutic Procedures• Pulmonary Rehabilitation Services Program• Wound CareApril 19, 2023 8
Medicare Active LCDs Cont’d
• Qualitative Drug Testing• Radiation Therapy Services• Radiofrequency Treatment for Urinary Incontinence• Radiologic Examination of the Chest• RAST Type Tests• Real-Time Outpatient Cardiac Telemetry• Removal of Benign or Premalignant Skin Lesions• Removal of Impacted Cerumen• Routine Foot Care• Scanning Computerized Ophthalmic Imaging• Visual Fields• Vitamin B12 Assays• Vitamin D Assay TestingApril 19, 2023 9
Medicare Active LCDs Cont’d
• Serotypes A and B Botulinum• Sleep Disorders Testing• Speech Language Pathology (SLP) Services;Communication
Disorders• SLP Services: Dysphagia;Includes VitalStim Therapy• Stereotactic Body RadiationTherapy (SBRT)• Surgical Treatment of Nails• Thermotherapies (MISTS) for Benign Prostatic Hyperplasia• Transesophageal Echocardiography (TEE)• Transforaminal Epidural, Paravertebral Facet and Sacroiliac
Joint Injections • Treatment of Varicose Veins of the Lower Extremeties• Trigger Point InjectionsApril 19, 2023 10
Medicare Active LCDs Cont’d
Upcoming Medicare Education and Training Sessions
• Observation Services Workshop
• Rehabilitation Billing• Blood Glucose• SNF Rehabilitation
Resource Utilization Group (RUGs)
• Hyperbaric Oxygen• Billing Laboratory and
Radiology Services
• Inpatient Versus Observation for Acute Care Facilities
• Chemotherapy , Injection and Infusion Services
• Sleep Studies• Wound Care• Modifiers for Part A
providers
Medicare Advanced Beneficiary Notice (“ABN”) Form Change
• Revised ABN form CMS R-131 has a mandatory use date of 11/1/2011. We must get rid of all old versions of the ABN and discontinue using them.
• All required sections of the ABN must be completed for the form to be valid. (Medicare Claims Processing Manual, Chapter 30, section 50.6.3)
• The ABN must list the specific items or services believed to be non-covered.
• The estimated cost provided on the ABN must be within $100 or 25 percent of the actual costs.
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Required Medicare and Medicaid Provider Enrollment Revalidation
• On 8/10/11 CMS published a MLN Matters article SE1126 to inform providers of new enrollment revalidation and screening processes.
• Rules apply to any provider who enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (“CHIP”) on or before 3/25/11.
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Required Medicare and Medicaid Provider Enrollment Revalidation• CMS will issue letters between now and
March 2013 to all providers that need to revalidate enrollment.
• Do not revalidate until requested by CMS• Assistance in completing the application
process is available. Please contact Stephanie Mackowiak at (410)955-8577
• No Medicare or Medicaid enrollment or revalidation forms should be submitted without review by Compliance!!
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Medicare Recovery Audit Contractor (“RAC”) Updates
**Approved for Maryland**
RAC Medical Necessity Reviews
1.Cardiac Catherization for Ischemic Heart Disease
2.Chest Pain
3.Syncope
4.Transient Ischemia
5.Vertigo and Other Labyrinth Disorders
6.Chronic Obstructive Pulmonary Disease
April 19, 2023 15
Medicaid RACs
• Currently on hold until States can better operationalize. No firm date to start in sight. Will look for overpayments and underpayments and supplement the work of current Medicaid audit programs (e.g., MICs, MCFCU, etc.)
• Recommend close tracking of cases so no duplication occurs. Medicaid does not have the ability to track like Medicare.
• Insights from Maryland’s (DHMH) Office of the Inspector General
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FY 2012 Compliance Audit Work Plan
• Health System Wide Compliance Initiatives
- Practitioner Licensure and Credentialing Verifications
- Education Initiatives to include: 1.Observation Services
2. Medicare One-Day Stays
3. ED Visit Documentation and Billing RulesApril 19, 2023 17
FY12 Compliance Audit Work Plan Cont’d
JHBMC Scheduled Audits
1.Pulmonary Rehabilitation Services
2.Community Psychiatry IOP Program
3.Cardiology Diuresis Clinic
4.PET Scan Services
5.Wound Care
6.ATS ProgramApril 19, 2023 18
FY12 Compliance Audit Work PlanCont’d
JHH Scheduled Audits
1.Interventional Radiology Services
2.Wilmer Eye Low Vision Clinic
3.Outpatient Psychiatric Services
4.Weinberg Outpatient Pharmacy
5.Infusion Services
6.Radiation OncologyApril 19, 2023 19
FY12 Compliance Audit Work Plan Cont’d
HCGH Scheduled Audits
1.Blood Transfusion Services
2.ED Visit Level Billing
3.Pain Management Services
4.Medical Nutrition Services
5.Wound Care Services
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FY12 Compliance Audit Work Plan Cont’dSuburban Hospital Scheduled Audits
1.Cardiac Rehabilitation Follow Up
2.Ultrasound Services
3.Partial Hospitalization Services
4.Ambulatory Surgery Center
5.Eye Surgeries
6.Outpatient Breast Reconstruction Surgeries
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FY12 Compliance Audit Work Plan Cont’d
Sibley Scheduled Audits
1.Outpatient Infusion Services
2.Inpatient Rehabilitation Services and 3 Day SNF Qualifying Stay
3.ED Visit Billing
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FY12 Compliance Audit Work Plan
JHHCG Scheduled Audits
1.Home Health Face to Face Encounter Requirement
2.Medicaid Home Health Agency Claims Review to Include Adult and Pediatric Lines of Business
3.DME & IV Credit Balance Review
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FY12 Compliance Audit Work Plan Cont’d
JHHCG Scheduled Audits
4. Review of Compliance with DMEPOS Supplier Standard #28
5. Pharmaquip Compliance with Medicare Coverage Requirements for CPAP Devices
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FY12 Compliance Audit Work Plan Cont’d
Other JHHS Scheduled Audits
1.Potomac Home Health Agency
2.Cardiovascular Specialists of Central Maryland (via the CPA)
3.HCGH OB/GYN Associates Series
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Discussion of Internal Billing Guidelines and Self Audit Processes
• Each department should have a policy or procedure that describes how you document and bill services
• Self Audits should be performed monthly to insure billing policies and procedures are being followed.(JHHS Finance Policy Fin 125)
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Compliance News & Updates
• Medicare Focused Review activities• New OIG reviews show OIG targeting multiple risk
areas at the same time inclusive of a review of internal controls and compliance program effectiveness review (See OIG report number A-01-10-00527, Fletcher Allen Health Care)
• Updates on Medicare Appeals and ALJ Hearings
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What’s on the Horizon…
• New ICD 9 CM procedure codes go into effect
October 1, 2011. The CMS website link is :https://ww.cms.gov/ICD9ProviderDiagnosticCodes/04-addendum.asp
• Clarifications to Condition code 44 policy issued 9/2/11
and effective 10/1/11. (See Medicare Transmittal 2296 and Medicare Claims Processing Manual, Chapter 1, section 50.3.1 and 50.3.2
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QUESTIONS??
**The BCC presentation and all handouts are available on the Compliance Website:
www.insidehopkinsmedicine.org/JHHSCompliance
THANKS FOR YOUR PARTICIPATION!
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