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Medical Oncology Association

Southern CA

Medicare Updates

Presented by Cheryl Bradley Provider Outreach and Education (POE)

November 4, 2014

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

November 2014 2

Agenda

• New Costs

• Medicare Hot Topics

• Avoiding Common Errors

• Appeals

• Resources

November 2014 3

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New Costs

November 2014 4

2015 Part B Deductible and

Coinsurance Rates Unchanged

• Deductible-$147.00

• Coinsurance

– 20% of eligible charges

November 2014 5

2015 Part B Premiums

Income Parameters for Part B Premiums

Premium/

Mthly

Individual

Income

Combined Income

(Married)

Married

Filing Separate

$104.90 < $85,000 < $170,000 <$85,000

$146.90 $85,000.01 to

$107,000

$170,000.01 to

$214,000

$209.80 $107,000.01 to

$160,000

$214,000.01 to

$320,000

$272.70 $160,000.01 to

$214,000

$320,000.01 to

$428,000 $85,001.00 to $129,000

$335.70 $214,000.01 > $428,000.01 > $129,001.00 >

November 2014 6

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2015 Part A Deductible

and Co-Pays

• $1,260 deductible

– 1st 60 days of hospitalization

• $315 co-pay

– Days 61-90

• $630 co-pay

– Days 91 – 150 Lifetime Reserve

• $157.50 co-pay

– SNF days 21 - 100

November 2014 7

2015 Part A Premium

• Fewer than 30 quarters

– $407.00 per month

• 30 to 39 Quarters

– $224.00 per month

November 2014 8

Beneficiary Open Enrollment

• Review cost and coverage for 2015

– October 15 – December 7, 2014

• Compare medical plans & make changes

• Questions

– 1-800-MEDICARE

– http://www.medicare.gov/

November 2014 9

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Medicare Hot Topics

November 2014 10

2015 MPFS Proposed Rule

• The current conversion factor is $35.8228

– 0% Update January 1, 2015-March 31, 2015

– Protecting Access to Medicare Act

• Without Congressional Action

– 20.9 percent reduction (April 1st)

– Due to Sustainable Growth Rate

– Hematology/Oncology Impact = + 1%

• CMS will finalize Physician Payment

– Publishes in Federal Register December

– Watch Noridian Website for 2015 MPFS!

November 2014 11

Proposed :

Chronic Care Management

• Non-face-to-face care coordination – 2 (or 4) or more chronic conditions expected to last at least

12 months, or until death,

– Pose significant risk of death, decline in function, or acute

exacerbation or decompensation

• 20 min. of services / 30-day billing cycle – By clinical staff (directly or contract)

– Provide general supervision at all times, not just after hours.

• Also: 24-hour coverage, med review, ongoing post institution

coordination, and patient-centered care plans will continue

• Fee: $43.67 PMPM in an office; $32.58 in a facility,

November 2014 12

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Revalidation: Phase III

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• September 2013 through March 2015

• Continuing with the revalidation process for all

remaining providers/suppliers required by ACA

prior to March 25, 2015

• www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/MedicareProviderSupEnroll/Revalidation

s.html

• CMS continued focus

Working with large chains/organizations

November 2014

Revalidation: Phase III 2

• When you receive notice to revalidate

– Update your enrollment through internet-

based PECOS or complete CMS 855

– Sign the certification statement on the

application

– If applicable, pay the fee $542

• https://pecos.cms.hhs.gov/pecos/feePayment

Welcome.do

– Mail supporting documents to Noridian

November 2014 14

Meaningful Use – New Hardship

Deadline

• CMS extending hardship exception deadline to

November 30, 2014 by 11:59 Eastern Time

• Avoid 2015 payment adjustments, by

demonstrating meaningful use of Certified

Electronic Health Record Technology (CEHRT)

• Hardship application found at

http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/

PaymentAdj_Hardship.html

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PQRS Incentive Payment

and Payment Reductions

• Eligible professionals that do not satisfactorily

report data on quality measures for the January

1, 2014-December 31, 2014 reporting period,

will be subject to the 2.0% adjustment in their

fee schedule amount in 2016.

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•http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

PQRS Incentive Payment

and Payment Adjustments

Program Year Incentive Payment

Adjustment

2011 1.0% None

2012 0.5% None

2013 0.5% None

2014 0.5 None

2015 None 1.5%

Based on 2013 participation

2016 > None 2.0 %

Based on 2014 participation

November 2014 17

PQRS Assistance

• If providers have any Physician Quality

Reporting System (PQRS) questions,

please contact

• QualityNet Help Desk at 1-866-288-8912

or via email at qnetsupport@hcqis.org

November 2014 18

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ICD-10

Will change everything October 1, 2015!

19 November 2014

• CMS invites Family Practice/Internal Medicine

providers to view new webcast @

cms.gov/ICD10 “Road to 10”

• Click “Webcast” tab located in left-hand navigation

– Physician perspective/clinical impact of ICD-10

– Documentation changes and new concepts

– Use of "unspecified" codes in ICD-10

• Other specialty webcasts previously available

(orthopedics, cardiology, etc.)

November 2014 20

Plan Your Journey to ICD-10

• Assess staff training needs

• Educate and Train Staff

• Review Clinical Documentation Practices

• Contact practice management system vendor

• Contact clearinghouses, billing services and payers

• Budget time and costs

• Conduct testing – Trading Partners and clearinghouses

– Allow time for approval

November 2014 21

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• CMS National Provider Call

– Transition to ICD-10

• When: Wednesday, November 5, 2014

• Time: 1:30 PM - 3:00 PM Eastern Time

• Registration

– http://www.eventsvc.com/blhtechnologies

November 2014 22

CPT Modifier 59

• Distinct Procedural Service

– Indicate a procedure or service was distinct or independent from other services performed on the same day

• Most widely used modifier

– Considerable abuse and high level of manual audit

– Lead to even civil fraud and abuse cases • Siphons off funds that should be available to

legitimate providers

November 2014 23

Modifier 59 Misuse

• 2013 CERT Report

– Part B claims

• $2.4 Billion in payment made

– $320 million projected in errors

– Part A claims

• $11 Billion billed

– $450 million projected in errors

November 2014 24

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Distinct Procedural Service

New Modifiers for 2015

November 2014

CR 8863- Specific Modifiers for Distinct

Procedural Services (Modifier 59) Update

• Effective January 1, 2015

• Four new HCPCS modifiers

– Subset of Modifier 59

• Defines a subset of the work of the first code

• Used to identify

– A separate encounter

– A separate anatomic site

– A distinct service

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Subset Modifiers

• XE Separate encounter

• XS Separate Structure • Performed on a separate organ/structure

• XP Separate Practitioner • Performed by a different practitioner

• XU Unusual non-overlapping service • Does not overlap usual components of the main

service

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Modifier 59 and Subset Modifiers

• Modifier 59 still recognized

– Should not be used when a more descriptive

modifier is available

• Subset modifiers

– To be used with certain codes at high risk for

incorrect billing

– More selective versions of modifier 59

– Not to be used with modifier 59 on the same

line

November 2014 28

Modifier 59 Update

• Check NCCI edit tables on CMS website

– Indicator 1 allows for unbundling

– Indicator 0 cannot unbundle codes

• To avoid repeat procedure denials, bill

– Modifier 76 - Repeat procedure by same

physician or

– Modifier 91 - Repeat clinical diagnostic

laboratory test to obtain multiple results

November 2014 29

Avoiding Common Errors

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Avoid and Prevent Duplicate Claim

Submissions CR 8121

• Fraud and Abuse monitoring

– Post to patient’s account appropriately

– Verify payment prior to submission

– Identify duplicate claim submissions internally

– Eliminate processes which may be causing

duplicate submissions

November 2014 31

Top Claim Errors

• Procedure with modifier inconsistent/missing

– Check Fee Schedule, Indicator List, Local

Coverage Determination (LCD) policies and

CPT/HCPCS books

• Missing/invalid referring or ordering provider

• Patient or Insured HIC #/name do not match

• Patient cannot be identified as our insured

November 2014 32

Correct Patient/HIC# Errors • Check patient’s Red, White, Blue Medicare card

• Two last names

– With space = bill with space

– Without space = bill without space

• Hyphenated name

– With hyphen = bill with hyphen

– Patient may need to contact local SSA to remove hyphen

• Check for alpha-prefix vs. alpha-suffix

– Ex. A123-45-6789

– Railroad Medicare – Palmetto GBA

• Need Details? Scroll down to Claim Submission workshop – JE

• https://med.noridianmedicare.com/web/jeb/education/event-materials

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Item 17 – Name of Referring or

Ordering Physician

Paper: Electronic:

Loop Segment Description

2310A

NM103 DN= Referring

Provider Last

Name

NM104 Referring

Provider First

Name

2420E

NM103 DK= Ordering

Provider Last

Name

NM104 Ordering

Provider First

Name

November 2014 34

•Enter the name of the

referring or ordering

physician if the service or

item was ordered or

referred by a physician.

Item 17a & 17b – NPI of Referring or

Ordering Physician

Paper: Electronic:

Loop Segment Description

2310A NM109 DN= Referring

Provider

Primary ID

2420E NM109 DK= Ordering

Provider

Primary ID

November 2014 35

Item 17a

•Leave Blank

Item 17b

•Enter NPI of

referring/ordering physician

Item 11 (possible MSP)

DENIAL SOLUTION COMMENTS

CO16

Claim/service lacks

information which is

needed for adjudication

Add NONE (if no primary

insurance to Medicare)

•Verify Primary

Insurance information

•Verify patient’s eligibility

before billing

MA83

Did not indicate whether

Medicare is primary or

secondary payer

•If Medicare Secondary

Payer (MSP), MUST fill

out items 11 – 11C

•Check dates of service

correctly entered

•MSP incorrect?

Contact Coordination of

Benefits Contractor

(COBC)

•800-999-1118

November 2014 36

•Need details? Scroll down to MSP workshop JE https://med.noridianmedicare.com/web/jeb/education/event-materials

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Top Adjudication issues

• Unlisted codes or NOC

• J3490, J9999, and J3590

– Name of the drug, NDC number and dosage

must

– Block 19

– Electronic equivalent

• Claims not providing information deny

unprocessable.

November 2014 37

Patients Supplying Their Own Drugs • Providers can bill Medicare only when such drugs

are purchased by physician, from the pharmacy and administered in physician’s office – Providers NOT allowed to instruct patients to purchase

drugs themselves and then bring to provider’s office for administration

• Drug charge, if any, must be included in physician’s bill and cost represents expense to physician – Pharmacies can not bill Medicare Part B for drugs

furnished to a physician for administration to a Medicare beneficiary

– Pharmacies, suppliers and providers can not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service, such as refilling an implanted drug pump

November 2014 38

Patients Supplying Their Own Drugs2

• Donated or Free of Charge Patient Supplied Drug

– To avoid chemotherapy/other drug administration denial, drug code must be on same/prior claim

• If the drug is not donated/free of charge, then provider must provide the drug under incident to guidelines

• IOM Publication 100-02, Chapter 15, Sections 50/50.3

November 2014 39

Item Description

19 (Narrative) “Drug Donated” with description, strength and dosage when billing Not Otherwise Classified (NOC) HCPCS

24D Drug (J code) HCPCS

28 Billed amount of $0.00 or $0.01

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Medical Review (MR)

Modifier 25

• If a significant separately identifiable E/M service is performed, the appropriate E/M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or non- chemotherapy injection and infusion service (96360–96549). For an E/M service provided on the same day, a different diagnosis is not required.

• http://www.cms.gov/manuals/downloads/clm1

04c12.pdf

November 2014 41

CPT 99211

• CPT code 99211 is not allowed with or without the modifier 25 on the same day as non-chemotherapy or chemotherapy administration codes.

• CPT 99211 not allowed:

• Phone calls to patients

• Drawing of blood for laboratory analysis or when

performing other diagnostic tests

• Administration of medications when an injection or

infusion code is submitted separately

November 2014 42

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99213-25

• Insufficient Documentation Submitted

– Does not support beneficiary was seen for a

“significant, separately identifiable evaluation

and management service by the same

physician on the same day of the procedure

or other service”

– Submitted progress note states: “Patient is

here for chemo. No new problems. Same as

last visit”

November 2014 43

Signature Requirements

Signatures: –Services provided/ordered must be

authenticated by the author

–Must be legible and should include the practitioner’s first and last name

–Handwritten or Electronic

–No Stamps

November 2014 44

Electronic Signature Guidelines • Systems and software products must include protections

against modification and should apply administrative

safeguards that correspond to standards and laws;

• The individual whose name is on alternate signature method

and provider bears responsibility for authenticity of information

being attested to;

• Physicians are encouraged to check with their attorneys and

malpractice insurers in regard to use of alternative signature

methods;

• Part B providers must use qualified electronic prescribing (e-

prescribing) system; and

• Prescriptions for drugs incident to Durable Medical Equipment

(DME) must be made via qualified e-prescribing system

November 2014 45

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For an attestation

statement to be valid, it

must be signed by the

performing provider

JE –

https://med.noridianmedicare.co

m/documents/10525/78978/Sig

nature+Attestation+Statement/

Unique Signature Situations

Situation: Performed by: Signature

Requirement:

Incident to

Ancillary Staff Must be signed by billing

provider

NPP (Non-Physician

Practitioner)

May be signed by the NPP

or the supervising physician

Split/Shared

Office/Clinic NPP and Physician

Must be signed by billing

provider

Split/Shared hospital

inpatient/outpatient/

Emergency dept. setting

NPP and Physician Must be signed by billing

provider

Scribe Ancillary staff

The scribes name must be

listed in the medical record

and identified as scribe.

Provider must sign

November 2014 47

Medical Record Cloning

• Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

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Amended Medical Records 2

• Provider may add “late” entry within a few days

• Medical reviewers give less weight when making review determinations to documentation created >30 days following date of service.

• If pattern of “late” entries identified, may be referred to Zone Program Integrity Contractor (ZPIC)

49 November 2014

Comprehensive Error Rate

Testing (CERT)

Post Pay Audit Review Program

Who is Reviewing my Claims?

• Multiple post pay contractors are able to

review facility claims

– Comprehensive Error Rate Testing (CERT)

– Noridian Medical Review (MR)

– Recovery Auditor (RA)

– Office of the Inspector General (OIG)

– Zone Program Integrity Contractor (ZPIC)

November 2014 51

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Receive Part B CERT Request?

• CERT post pay audit review random

documentation sampling on previous claims

• Need Part B CERT assistance? Please email:

– Patty.Holton@noridian.com or

CERTQuestion@noridian.com

• Follow email steps:

– “Subject” line enter CERT Claim Identification (CID#)

(seven-digit number starting with “1”)

– “Body of email”, provider office contact information

(name, phone/fax number, CID#, city/state)

November 2014 52

Noridian CERT Checklists • Ambulance Documentation Checklist

• Chiropractic Documentation Checklist

• Dialysis Documentation Checklist

• Evaluation and Management (E/M) Documentation Checklist

• Laboratory Documentation Checklist

• Physical, Occupational and Speech Therapies Documentation Checklist

• Psychiatric-Mental Health Documentation Checklist

• Radiation Oncology Documentation Checklist

• Radiology Documentation Checklist

November 2014 53

Checklist: E/M Documentation

Requests

November 2014 54

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Documentation Tips

• Documentation is important

– “If it is not documented, it did not happen”

• Good documentation practice protects you

– Fraudulent billing results in stiff penalties

• Medical record should be complete and legible

• Coding and billing

– CPT and ICD-9 codes supported

• Appropriate health risk factors identified

• Proper signatures

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Region D

• Aldesleukin wastage

• Observation codes for inpatients

• Bevacizumab 1 unit per 10 mg

• Observation codes for less than 8 hours

• Multi-use vials for HERCEPTIN

• MUE edits

• Rituximab 1 unit per 100 mg

• Reclast once per year @ 1 mg

• Initial hospital E/M once per day includes all E/M

• Neulasta the same day as chemo

• Only one hospital visit per day per specialty

• Region D

– https://racinfo.healthdatainsights.com

Recent Recovery Auditor Issues

Relevant to Physicians

November 2014 56

Recovery Auditor Update

• August 27, 2014 – A contract

modification, allowing the current

Recovery Auditors to restart some reviews

has been completed for Regions A, B, and

D. Most reviews will be done on an

automated basis, but a limited number will

be complex reviews of topics selected by

CMS.

November 2014 57

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2014 OIG Part B Focus**

• Evaluation and Management (E&M) – During global surgery periods

• “Incident To” services

• Laboratory services

• Diagnostic Radiology

• Anesthesia Services – Personally Performed Services

**Not all inclusive

http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf

November 2014 58

Compliance Program

• A proactive program incorporating fundamental elements

– Written policies and procedures

– Compliance professionals

– Effective training

– Effective communication

– Internal monitoring

– Enforcement of standards

– Prompt response

59 November 2014

You Have Appeal Rights!

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Appeal Level Time limit for

Filing Request

Monetary

Threshold

(AIC) - 2013

Where to File

Appeal

Contractor

Time Limit to

Complete

Redetermination

120 days from

date of receipt of

notice initial

determination

None Noridian 60 days from

date of receipt

Reconsideration 180 days from

date of receipt of

Redetermination None QIC

60 days from

date of receipt

Administrative

Law Judge

(ALJ) Hearing

60 days from

date of receipt of

Reconsideration

$150

Effective

1/1/15

MAC or HHS

OMHA field

office, if heard

by a QIC

90 days from

date of receipt

Departmental

Appeals Board

(DAB) Review

60 days from

date of receipt of

the ALJ hearing

decision

None DAB or ALJ

Hearing Office None

Federal Court

Review

60 days from

date of receipt of

DAB decision or

declination of

review by DAB

$1,460

Effective

1/1/15 None

November 2014 61

Redetermination Reminders

• Complete appropriate request form

• Submit all pertinent medical records to support services provided

– Include documentation of physician’s intent and/or order

– Records include physician’s legible signature

• Check for correct DOS on records

• Check records are for correct beneficiary

• Ensure signature on request form

November 2014 62

Resources

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Medicare Quarterly Provider

Compliance Newsletter July 2014

64

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909012.PDF

• Includes RA Findings

– CERT

– Bariatric Surgery

– Obesity Counseling

– E/M services

– Recovery Auditor

Findings

– Archive of Previously

Issued Newsletters

November 2014

CMS Educational Materials

• MLN products downloadable

– Free of charge/free shipping

• Brochures

• Fact sheets

• Quick reference charts

• Web-based training

MLN dedicated web pages • MLN General Information

http://www.cms.gov/MLNGenInfo

• MLN Matters Articles http://www.cms.gov/MLNMattersArticles

• MLN Products http://www.cms.gov/MLNProducts

• MLN Web Guides http://www.cms.gov/MLNEdWebGuide

November 2014 65

Endeavor Online Provider Portal

• Free to providers with Internet – Beneficiary Eligibility

– Claim Status including Reviewer Comments

– Payment Floor / Prior Checks Issued

– Single Claim / Entire Remittance Advice

– Reopening & Redetermination Submission

– Appeal Status

• Additional resources include – Self-Paced tutorial for Part B

– System availability alerts on the Medicare website

– User Manual; valuable, many screen images and guides

– Workshops and presentations

• Eligibility “Main Menu” page next slide

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Part B Web-Based Workshops

Date Time (CT) Workshop Title

11/12/14 1:00 PM Quarterly Release

11/18/14 1:00 PM Recovery Auditor (RA) Program with HDI

11/19/14 1:00 PM Compliance Program

11/20/14 1:00 PM Protecting Your Practice from Fraud and Abuse

Register Now!

JE https://med.noridianmedicare.com/web/jeb/education/training-events

November 2014 67

Resources

• CMS Change Request (CR) 6698

– www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf

• MLN Fact Sheet Signature Requirements

– www.cms.gov/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

• CMS Internet Only Manual (IOM) Publication100-8;Chapter 3, Section 3.4.1.1

– www.cms.gov/manuals/downloads/pim83c03.pdf

• CERT Report

– www.cms.gov/CERT/Downloads/CERT_Report.pdf

November 2014 68

Resources

• https://med.noridianmedicare.com/web/jeb/policies/coverage-articles/chemotherapy-administration

• CMS IOM Pub. 100-04, Chapter 17. Section

20.5.7 – www.cms.gov/manuals/downloads/clm104c17.pdf

• 96360–96549 are not intended to be reported by

the physician in the facility setting – www.cms.gov/Regulations-and-Guidance

/Guidance/Manuals/Downloads/ clm104c04.pdf

November 2014 69