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March 2017
On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) announced that they had awarded the next round of Medicare Fee-for Service Recovery Audit Contractor (RACs) contracts as follows:
Region 1 – Performant Recovery, Inc.Region 2 – Cotiviti, LLC (formerly Connolly)Region 3 – Cotiviti, LLC (formerly Connolly)Region 4 – HMS Federal SolutionsRegion 5 – Performant Recovery, Inc.
Below is a map that shows a breakdown of the Recovery Auditors and respective Regions.
Medicare Fee-For Service Recovery Audit Contractors (RAC) to Begin Audit Activity
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UPDATED INFORMATION: As of the beginning of March, both Performant Recovery (Regions 1 & 5) and Cotiviti (Regions 2 & 3) have posted on their websites that they have received approval from CMS to begin audit activity.
HMS Federal Solutions (Region 4) has not released information yet on when they will begin their audit activity.
An overview of the statement of work (SOW) established for the Part A/B Medicare Fee-for- Service Recovery Medicare Audit Program for Regions 1-4 & Region 5 are as follows:
The RACs in Regions 1-4 will perform post payment reviews to identify Medicare claims that contain improper payments (overpayments or underpayments), which were made under Part A or Part B of Title XVIII of the Social Security Act. This includes review of all Medicare claim and provider types (excluding Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice).
The RAC for Region 5 will be dedicated to perform post payment reviews to identify Medicare DMEPOS and Home Health/Hospice claims.
Reviews for all Regions will include all applicable claim types and a review of claims/providers that have a high propensity for error based on the Comprehensive Error Rate Testing (CERT) program and other CMS analysis.
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Medicare Fee-For Service Recovery Audit Contractors (RAC) to Begin Audit Activity (continued)
What should be done if one of these requests is received?
• In the event your facility should receive one of these requests (or any other ADR, denial, etc.), please contact TMC’s Denial Prevention and Management Department at: [email protected].
• We are committed to partnering with our customers throughout the appeals process and are available for any questions.
New for 2017: PT & OT Evaluation codes:
• 3 New PT Evaluation Codes – Replaces 97001 • 97161 • 97162 • 97163
• 1 New PT Re-Evaluation Code – Replaces 97002 • 97164
• 3 New OT Evaluation Codes – Replaces 97003 • 97165 • 97166 • 97167
• 1 New OT Re-Evaluation Code – Replaces 97004 • 97168
On January 1, 2017 the single evaluation CPT codes that physical and occupational therapists have historically used were replaced by a new tiered set of codes. Each discipline now has 3 evaluation codes and a single reevaluation code. These codes are tiered by level of complexity as follows:
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These codes outline specific elements that are required to bill each individual complexity code. TMC’s proprietary JBS Software Solutions enables safeguards to ensure that billing is consistent with the requirements of the new codes. These safeguards include verification of qualifying elements for each evaluation level of contributing factors: History, Assessment and Body Evaluation, Performance Deficits and Clinical Complexity involved.
These elements are mapped to specific documentation requirements to ensure that CPT codes are billed correctly to ensure claim integrity.
According to the Change Request (CR) 9977 from the Centers for Medicare and Medicaid Services (CMS), the Medicare Administrative Contractors (MACs) were informed of changes to the Medicare Physicians fee schedule payment files. While the changes will be implemented in Medicare’s system on April 3, the changes were e�ective January 1, 2017.
April Update to the 2017 Medicare Physicians’ Fee Schedule – OT & PT Evaluation Codes Included
CMS informed the MACs about changes to the database to include updates to new Physical and Occupational therapy evaluation CPT codes: (OT) codes: 97165, 97166 and 97167 and (PT) codes: 97161, 97162, and 97163.
MACs were instructed not to search files to either retract payment for claims already paid or to retroactively pay claims already processed. However CMS did state that MACs may adjust claims that the provider brings to their attention. If the provider wants to resubmit and in the comment/note/memo section, the provider must include increased fee schedule adjustment for evaluation and resend each one. (Part B evaluations are paid according to the fee schedule)
If you have any questions, a link to the MLN Matters article is provided here.
Be Diligent with your PBJ Data
New for 2017: PT & OT Evaluation codes: (continued)
April Update to the 2017 Medicare Physicians’ Fee Schedule – OT & PT Evaluation Codes Included
An article that posted on Mcknights last week noted that CMS o�cials are urging skilled nursing providers to submit their next round of payroll based journaling data well ahead of the May 15th deadline in order to catch errors for the fiscal quarter lasting from January 1 to March 31, 2017.
Do not wait until the deadline to see if there are “errors and issues”. Be sure to leave time for corrections if needed.
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“We can choose to be a�ected by the world or we can choose to a�ect the world. ”
- Heidi Wills
While PBJ data has not been added to their Five-Star rating yet, there will be an addition of a badge to the Nursing Home Compare website that will show whether or not a facility has submitted sta�ng data. A green badge will indicate that your facility is participating in the PBJ program. A gray badge means your facility isn't participating as of yet.
The badge will include a note that the sta�ng reporting program will “be on Nursing Home Compare by early 2018.”
Providers will have “advance notice” from CMS of when sta�ng submissions will be used to calculate star ratings.
HH Demonstration Goals
The pre-claim review demonstration will test improved methods for identifying, investigating, and prosecuting Medicare fraud occurring in Home Health Agencies (HHAs) while maintaining or improving the quality of care provided to Medicare beneficiaries.
Home Health Pre-claim Review Demonstration expands to Florida e�ective April 1, 2017
2. What is pre-claim review?
a. Pre-claim review is a process through which a request for provisional a�rmation of coverage is submitted for review before a final claim is submitted for payment. Pre-claim review helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted.
3. Will this demonstration delay beneficiaries from getting access to services?
a. No, the demonstration should have minimal e�ect on beneficiaries, as the pre-claim review can occur after home health services have started. The pre-claim review request must be submitted and reviewed before the final claim is submitted for payment.
Be Diligent with your PBJ Data
Frequently Asked Questions about the HH Demo:
1. When does the pre-claim review demonstration for home health services begin?
a. The demonstration began on August 3, 2016 in Illinois. It will begin on April 1, 2017 in Florida. Start dates for Texas, Michigan, and Massachusetts will be determined in the coming months.
Home Health Pre-claim Review Demonstration expands to Florida e�ective April 1, 2017
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“It matters not who you love, where you love, why you love, when you love or how you love, it matters only that you love.” - John Lennon
We started working on lateral weight shifts that eventually turned to single limb stance, necessary for lifting his right leg up
to the stirrup. Strength training for the hip flexors was incorporated to help with elevating the leg high enough as well.
Glute work was included also to provide the proper hip extension necessary to lift his body weight up and
I brought my grandfather’s saddle from home and placed it on a large stability ball for seated balance training. His interest and participation in therapy instantly improved, and so did his mood. His son reported back that he sits on the horse really well now and has a much easier time mounting the saddle with his right side.
Excellence in Action
A patient was in therapy for a few weeks and not progressing well, partly due to a lack of interest and poor mood. He rode horses with
his family on weekends and was starting to have difficulty mounting his horse, having to climb into the back of the truck to mount from his usual right side. Using this information, we started using horses as motivation in order to progress towards his goals of balance and strength.
A success story as told by Paul Rice, Rehab Director, in Centralia, MO
Horsing Around in Therapy
As a side note, the saddle became quite a hit for the staff too. Several people came into our gym to test their balance. It ended up being a lot of fun, and we were able to achieve really positive outcomes in the process.
“His son reported back that he sits on the horse really well now and has a much easier time mounting the saddle with his right side.
What’s Happening at TMC?
Sangita Lewis
(352) [email protected]
Leigh Lachney
(334) [email protected]
Lesley Vogels
(813) [email protected]
Budine Pucylowski
(469) [email protected]
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For more information please contact Business Development:
February Contributions
Many of our teams actively participate in fundraising events to help raise money for Together Making Changes. They do an amazing job sharing their fundraising efforts, and we want to make sure they know how their contributions are making a big difference! Here is a recap of their efforts for the month of February!
Contribution Total: $12,353.53
Fundraising Total:
TMC Store Profit:
Team Member Payroll Deductions:
$5,630.44$119.00$6,604.09 93%
Year to Date Total:
$22,629.44
Top 3 Facility Contributions!
Osage City, KS $286.00
Birch Tree, MO $317.45
Our teams can
track their time
and talent hours
through our
website!
326 hours of
time and talent
were donated in February!
Springfield, MO $622.38