Novitas Solutions 2014 Medicare Update

PAHCOMJanuary 29, 2014

Disclaimer• All Current Procedural Terminology (CPT) codes and descriptors used in this presentation

are copyright© by the American Medical Association. All rights reserved.

• The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

• Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

• Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

• This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

• Novitas Solutions does not permit videotaping or audio recording of training events.

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Novitas Solutions

• Education specific to providers in Medicare Administrative Contractor Jurisdiction L (JL) include: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania

• This education contains specific contractor guidance

• If you are not a provider in Jurisdiction L, please contact your Medicare contractor for specific guidance.

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Agenda

• Medicare Updates

• ICD-10 Update

• Preventive Services

• Comprehensive Error Rate Testing Program

• Contractor Initiatives

• New vs. Establish Patient Office Visits

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Objectives

• Provide a clear understanding of the changes in Medicare and to assist the provider community in complying with new guidelines by providing educational information and resources

• Explain the Comprehensive Error Rate Testing (CERT) Program and provide tips in preventing the most frequent errors

• Review of the New verses Established patient coding rules.

• Identify and promote the use of self service options and preventive services

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Medicare Updates

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Medicare Learning Network MLN Matters® Articles

• Medicare Learning Network Matters Articles or MLN Matters® articles developed by the Centers for Medicare & Medicaid Services (CMS) to help health care professionals avoid improper activities

• List is updated as related articles are issued and

revisedo http://www.cms.gov/Outreach-and-Education/Medicar

e-Learning-Network-MLN/MLNProducts/Downloads/ProvCmpl_Articles.pdf

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Update to Medicare Deductible, Coinsurance, and Premium Rates for 2014

• Change Request # 8527

• Effective: January 1, 2014, Implementation: January 6, 2014

• Key Points:o 2014 PART A

Deductible- $1,216.00 Coinsurance

– $304.00 a day for 61st-90th day – $608.00 a day for 91st-150th day (lifetime reserve days) – $152.00 a day for 21st-100th day (Skilled Nursing Facility coinsurance)

o 2014 PART B Deductible- $147.00 a year Coinsurance- 20 percent

• For more information:o http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8527.pdf

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Enrollment Denials WhenOverpayment Exists• Change Request # 8039

• Effective: October 1, 2013, Implementation: October 7, 2013

• Key Points:o Medicare contractors may deny a Form CMS-855 enrollment

application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or Change of Ownership (CHOW) is filed

• For more information:o MLN Matters® Number: MM8039

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8039.pdf

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Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims

• Change Request # 8401

• Effective: January 1, 2014, Implementation: January 6, 2014

• Key Points:o It will be mandatory to report a clinical trial number on claims for items and services

provided in clinical trials that are qualified for coverage as specified in the "Medicare National Coverage Determination (NCD) Manual," Section 310.1

o For institutional paper or direct data entry (DDE) claims, the 8-digit clinical trial number is to be placed in the value amount for paper only value code D4/DDE claim UB-04 (Form Locators 39-41)

Electronic Submission - Loop 2300 REF02 (REF01=P4) o For professional claims, the 8-digit clinical trial registry number proceeded by the 2

alpha characters “CT” will be placed in Field 19 of the paper Form CMS-1500 Electronic Submission – Loop 2300 REF02(REF01=PF)

• For more information:o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNM

attersArticles/Downloads/MM8401.pdf

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Incarcerated Beneficiary Update• Recently, the Centers for Medicare & Medicaid Services (CMS) initiated recoveries from

providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated when the items and services were furnished.

• A beneficiary that is considered to be incarcerated is one that is not only confined within a ‘penal facility’ but may also include a beneficiary who is on a supervised release, on medical furlough, residing in a half way house or similar situation.

• As a result, a large number of overpayments were identified, demand letters released, and, in many cases, automatic recoupment of overpayments made. CMS has since learned that the information related to these periods of incarcerations was, in some cases, incomplete for CMS purposes.

• CMS is actively reviewing these data and will be taking action to improve the process used to identify periods of incarceration. As part of this effort, CMS is working to quickly identify claims that resulted in our recent recovery actions and take steps, as appropriate, to correct any inappropriate overpayment recoveries.

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Incarcerated Beneficiary Continued• CMS has posted frequently asked questions (FAQs) about  incarcerated beneficiary claim denials. These

FAQs will be updated as more information becomes available o http://

www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs-11-20-13.pdf

• Review IOM 100-04, chapter 1, section 10.4 for CMS guidelines on items or services furnished to Medicare beneficiaries in state or local custody under a penal authority o http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf

• New fact sheet titled: Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody Under a Penal Authorityo http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-Servi

ces-Furnished-to-Beneficiaries-in-Custody-Under-Penal-Authority-Fact-Sheet-ICN908084.pdf

• For any questions regarding the Social Security records indicating that the patient was in custody when the service was rendered please call the Customer Contact Center (CCC)o The CCC can tell you for your date of service if the beneficiary was incarcerated or not, but will not be able to provide

the from and through dates of incarcerationo This information is not available through the Interactive Voice Response (IVR) or on-line eligibility verification systems

The automated response to your inquiry provides the dates for the period of inactivity, but it does not provide the reason for such inactivity

• Providers and beneficiaries do have the right to appeal any claims that were denied in error

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Redaction of Health Insurance Claim Numbers (HICNs) in Medicare Redetermination Notices (MRNs)

• Change Request # 8268• Effective: January 1, 2014, Implementation: January 6, 2014• Key Points:

o Health Insurance Claim Numbers (HICN) redacted from all Medicare Redetermination Notices

o 5 or more values of the HICN replaced with X’s or asterisks (*)

o Last 4 or 5 digits of the HICN is displayed• For more information:

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8268.pdf

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Remittance Advice

• Remark Code & Claim Adjustment Reason Codeo Stay currento Updates made every 4 monthso http://www.wpc-edi.com/codes

• Centers for Medicare & Medicaid Services (CMS) Manual: Understanding the Remittance Adviceo http://www.cms.gov/Outreach-and-Education/Medicar

e-Learning-Network-MLN/MLNProducts/downloads/ra_guide_full_03-22-06.pdf

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Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years• Change Request # 8165

• Effective: 10/1/2013, Implementation: 10/7/2013

• Key Pointso Recovery Auditor identified claims for new patient visits paid more than once in three

year period by same physician or physician groupo Contractor will be prompted to validate new patient claims when more than one

service is identified in a three year periodo The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that

Medicare interprets the phrase “new patient” to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years

• For more informationo http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNM

attersArticles/Downloads/MM8165.pdf

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Ordering/Referring Physician Requirements

• MLN Matters® Number: SE1305 • Related Change Requests #: 6421, 6417, 6696, 6856 • Effective January 6, 2014• Key Points:

o Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider:

is not identified on the claim is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer

• For more information o http://www.cms.gov/Outreach-and-Education/Medicare-Learning

-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf

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Revised CMS 1500 Paper Claim Form: Version 2/12

• OMB approved revised CMS 1500 claim form, version 02/12, OMB control number, 0938-1197

• Changed the form to adequately accommodate and implement ICD-10-CM diagnosis codes

• Revisions add the following functionality:o Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes. o Expansion of the number of possible diagnosis codes to 12. o Qualifiers to identify the ordering, referring and supervising provider roles (on item 17)

• Tentative timeline for implementation (subject to change)o January 6, 2014: Medicare begins receiving and processing paper claims submitted on the

revised CMS 1500 claim form (version 02/12) o January 6- March 31, 2014: Dual use period during which Medicare continues to receive

and process paper claims submitted on the old CMS 1500 claim form (version 08/05)o April 1, 2014: Medicare receives and processes paper claims submitted only on the revised

CMS 1500 claim form (version 02/12)

• For more information:o http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-

06-27Enews.pdf 17

Hospice Related Services – Part B

• MLN Matters® Number: SE1321

• Key Points:o Providers need to identify if a beneficiary is enrolled in hospiceo Beneficiary should contact the Hospice provider to arrange for care

they needo Services related to a Hospice terminal diagnosis provided during a

Hospice period are included in the Hospice paymento Contractors will deny services submitted without GV or GW modifiers

GV - Attending physician not employed or paid under arrangement by the patients hospice provider

GW – Service not related to terminal condition

• For more information:o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Networ

k-MLN/MLNMattersArticles/Downloads/SE1321.pdf

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Place of Service Coding for Physician Services in an Outpatient Setting

• MLN Matters® Number : SE1313

•Key Points:o Recovery Auditors identified physicians incorrectly reporting the

place of service as office (11) when the services were provided in an outpatient hospital (22) setting

o Improper payment exists when billed with an incorrect place of service based on the setting where the services were rendered

•For more information:o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Ne

twork-MLN/MLNMattersArticles/Downloads/SE1313.pdf

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Additional/Subsequent Procedures Performed During 90 Day Global Period

• MLN Matters® Number: SE1323

• Key Points:o Recovery Auditors identified providers incorrectly billing E/M services

provided by the surgeon the day before major surgery, the day of minor surgery, 0-10 days after minor surgery, and up to 90 days after major surgery

o Global Surgical Package was established by CMS to ensure all components of surgery are bundled into one payment

o Ensure billing staff are not billing E/M services that are already included in payment for global surgery

• For more information:o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Networ

k-MLN/MLNMattersArticles/Downloads/SE1323.pdf

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Add-on HCPCS/CPT Codes Without Primary Codes

• MLN Matters® Number: SE1320

•Key Points:o Recovery Auditors identified providers billing only add-on

codes without respective primary codes o Add-on codes is a code that describes a service, that is

performed in conjunction with another primary service

•For more information:o http://www.cms.gov/Outreach-and-Education/Medicare-Learni

ng-Network-MLN/MLNMattersArticles/Downloads/SE1320.pdf

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Part B Recurring Updates

• New Waived Tests effective January 1, 2014o http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8439.pdf

• Annual Medicare Physician Fee Schedule (MPFS) Files Delivery and Implementationo http://

www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2799CP.pdf

• 2014 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments o http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8463.pdf

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Special Edition Articles

• Transitional Care Management Serviceshttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1332.pdf

• Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1338.pdf

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ICD-10 Update

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ICD-10 Implementation

• October 1, 2014 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures)

• No more delays

• ICD-10-CM will be used by all providers in every health care setting

• ICD-10-PCS will be used only for hospital claims for inpatient hospital procedureso ICD-10-PCS will not be used on physician claims,

even those for inpatient visits 25

ICD-10 Implementation

• Single implementation date of October 1, 2014 for all userso Date of service for ambulatory and physician

reporting Ambulatory and physician services provided on or after

October 1, 2014 will use ICD-10-CM diagnosis codes

o Date of discharge for hospital claims for inpatient settings Inpatient discharges occurring on or after October 1,

2014 will use ICD-10-CM and ICD-10-PCS codes

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Split Claim Billing

Claims that Span October 1, 2014 • Outpatient claims - SPLIT claim and Use

FROM date • Inpatient claims – Use ONLY THROUGH

date/DISCHARGE date – use ICD-10 codes • http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1325.pdf

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CPT and HCPCS

• No impact on Current Procedure Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes

• CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients

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ICD-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination

• Change Request # 8109 and # 8197• Key Points:

o Medicare contractors and Shared System Maintainers create and update National Coverage Determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes plus all associated coding infrastructure, such as procedure codes, Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, denial messages, frequency edits, Place of Service (POS), Type of Bill (TOB) and provider specialties, etc.

o Operational changes that are necessary to implement the conversion of the Medicare system diagnosis codes specific to the Medicare National Coverage Database (NCD) spreadsheets attached to CR8109 and 8197.

• For more information:o MLN Matters® Number: MM8109 and MM8197o http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html

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Display of ICD-10 Local Coverage Determinations (LCDs) on the Medicare Coverage Database (MCD)

• Change Request # 8348

• Effective: October 2, 2013, Implementation: April 10, 2014

• Key Points:o All ICD-10 LCDs and associated ICD-10 Articles shall be

published on the MCD no later than April 10, 2014 o All LCDs and Articles will receive a new LCD/Article ID number

• For more information:o http://www.cms.gov/Regulations-and-Guidance/Guidance/Trans

mittals/Downloads/R1293OTN.pdf

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ICD – 10 Testing

• All Medicare Administrative Contractors to implement an ICD-10 testing week with trading partners

• The ICD-10 testing week was created to generate awareness and interest, and to instill confidence in the community of the MACs readiness for implementation

• The testing week will allow trading partners access to the MAC for testing with real time help desk support

• The event will be done virtually and will be posted to our websiteo March 3, through March 7, 2014

• Change Request 8465o http://www.cms.gov/Regulations-and-Guidance/Guidance/Trans

mittals/Downloads/R1303OTN.pdf

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ICD-10 Resources• ICD-10

o http://www.cms.gov/Medicare/Coding/ICD10/index.html

• Provider Resourceso http://cms.gov/Medicare/Coding/ICD10/ProviderResources.html

• Medicare Fee-For-Service Resourceso http://cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html

• CMS Sponsored ICD-10 Teleconferences o http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html

• MedScape Moduleso http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedscapeModulesAvailableonICD10.pdf

• Sign up for the Centers for Medicare & Medicaid Services (CMS) ICD-10 Industry Email Updates-o http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html

• Follow @CMSGov on Twitter 

• Subscribe to Latest News Page Watch - https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609

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ICD-10 MLN Resources• MLN Matters Articles:

o Special Edition Article SE1239 – Updated ICD-10 Implementation Information

o Special Edition Article SE1240 – Partial Code Freeze Prior to ICD-10 Implementation

o Special Edition Article SE1325 – Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date

o MLN Article MM7492 – Medicare FFS Claims Processing Guidance for Implementing ICD-10

• MLN Productso ICD-10-CM/PCS Myths and Factso ICD-10-CM/PCS The Next Generation of Codingo ICD-10-CM Classification Enhancementso General Equivalence Mappings Frequently Asked Questions

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Preventive Services

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Preventive Services• Annual Wellness Visit• Bone Mass Measurements• Cancer Screenings• Cardiovascular Disease

Screening• Colorectal Cancer Screening• Depression Screenings• Diabetes Screening Tests• Diabetes Self-Management

Training• Glaucoma Screening• Hepatitis B Vaccine• Human Immunodeficiency

Virus (HIV) Screening• Influenza Virus Vaccine

• Initial Preventive Physical Examination

• Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)

• Medical Nutrition Therapy• Prostate Cancer Screening• Pneumococcal Vaccine• Screening Mammography• Screening Pap Test• Screening Pelvic Exam• Smoking and Tobacco Use

Cessation Counseling• Ultrasound Screening for

Abdominal Aortic Aneurysm35

Medicare Learning Network (MLN) Products for Preventive Services

• Help Keep Your Medicare Patients Healthy In 2014!

• Ensure your patients take advantage of Medicare-covered preventive services.

• Medicare covers a wide array of preventive services for eligible beneficiaries, including cancer screenings, certain immunizations, among others.

• The Medicare Learning Network (MLN) Preventive Services Educational Products Web Page provides descriptions and ordering information for MLN preventive services educational products and resources for health care professionals and their staff. o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-N

etwork-MLN/MLNProducts/PreventiveServices.html 36

Influenza Vaccine Payment Allowances - Annual Update for 2013-2014 Season • Change Request # 8433

• Effective: August 1, 2013, Implementation: by October 25, 2013

• Key Points:o Influenza vaccine payment allowance for 2013-2014 seasono Payment allowances effective for August 1, 2013- July 31, 2014o Reminders

o Part B deductible and coinsurance amounts do not apply o Must take assignment on the claim for the vaccine

• For more information:o http://

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1336.pdf

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8433.pdf

o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8249.pdf

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Preventive Services

• Quick Reference Chart for Medicare Preventive Serviceso https://www.cms.gov/Medicare/Prevention/Pre

vntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

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Comprehensive Error Rate Testing (CERT)

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Comprehensive Error Rate Testing (CERT)

• National Claim Paid Error Rateo 6.8 % Inpatient hospitalso 4.8 % Non-inpatient hospital facilitieso 9.9 % Physician/Lab /Ambulance

• Impacts all providers submitting Fee for Service claims

• Limited random claim sample

• Record requests must be received within 30 days from the initial CERT letter

• Right to Appeal? Yes

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JL Part B Common Errors

• Insufficient documentation:o Procedure/service billedo Missing or illegible documentation and/or physician signature  o No valid physician’s order   o No physical therapy certified plan of care/treatment plan 

• Incorrect coding errors:o Evaluation and Management (E/M) codeso Critical care, discharge day management, physical therapy   o Units of medication/infusion services   o Laboratory services

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Comprehensive Error Rate Testing (CERT) Center

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Error Due to Illegible or Missing Signature

• Mark or sign by individual on document to signify knowledge, approval, acceptance or obligation

o If illegible, will consider signature log or attestation statement

o If missing from other medical documentation, shall accept signature attestation statement from author

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Signature Log

• Lists typed or printed name of author associated with initials or illegible signature

• May be on page of documentation or separate document

• Providers encouraged to list credentials (e.g. MD, DO) in log

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Signature Attestation Statement

• To be valid for Medicare Medical Review:

o Must be signed and dated by author of medical record entry

o Must contain sufficient information to identify beneficiary

o Sample Attestation • http://www.novitas-solutions.com/webcenter/spaces/

MedicareJL/page/pagebyid?contentId=00004967

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Electronic Signature Examples• Listed below are examples of acceptable phrases for

electronic signatures:o Electronically signed by” with provider’s name o Verified by” with provider’s name o “Reviewed by” with provider’s name o “Signed by” with provider’s name o “Signed:  John Smith, M.D.” with provider’s name o This is an electronically verified report by John Smith, M.D. o Authenticated by John Smith, M.D o Authorized by: John Smith, M.D o Confirmed by with provider’s name o Electronically approved by with provider’s name  o Novitas expects the phrase/signature to be dated

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Coding Guidelines for New and Established Office Visits

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New Patient - Definition

• Per the Centers for Medicare and Medicaid Services, interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., Evaluation and Management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.

• Publication 100-04, Chapter 12, Section 30.6.7http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Determining if the Patient is New or Established

Face-to-Face

• Face-to-face is defined as the time spent between the physician and the patient

• Examples:o Surgical procedures o Evaluation and Management Services

• Interpretation of electrocardiogram (EKG) or X-rays, or other diagnostic testing that does not include a face-to-face component are not considered face-to-face services

Face-to-Face

• Face-to-face is defined as the time spent between the physician and the patient

• Examples:o Surgical procedures o Evaluation and Management Services

• Interpretation of electrocardiogram (EKG) or X-rays, or other diagnostic testing that does not include a face-to-face component are not considered face-to-face services

Nonphysician Practitioners

• Nonphysician practitioners (NPPs) can perform a new patient visit

• Must meet the face-to-face criteria

• May only designate primary licensure

• Assume the specialty of the group practice

New Patient Office/Outpatient Visits – Require Three Key Components

Component 99201 99202 99203 99204 99205

History Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehensive

Exam Problem Focused Expanded Problem Focused Detailed Comprehensive Comprehensive

Medical Decision Making

Straightforward Straightforward Low Moderate High

Time(average)

10 Minutes 20 Minutes 30 Minutes 45 Minutes 60 Minutes

Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved.

Coding of Established Patient Visits

• Level of service determined by evaluating documentation of all three key components (history, exam, and medical decision making)

• Lowest key component can be ignored• Can be used in office and hospital

outpatient places of service

Established Patient Office/Outpatient Visits – Requires Two of the Three Key Components

Component 99211 99212 99213 99214 99215

History

Minimal problem that may not

require presence of a physician

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Exam

Minimal problem that may not

require presence of a physician

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Medical Decision Making

Minimal problem that may not

require presence of a physician

Straightforward Low Moderate High

Average Time(minutes)

5 Minutes 10 Minutes 15 Minutes 25 Minutes 40 Minutes

Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved.

Consultation Codes

• No longer recognized by Medicare

• Use codes which represent where the visit occurs and identify the complexity of the visit performed

• Consultations in the office or outpatient setting, use codes 99201-99215

• New and established patient rules apply

Current Procedural Terminology (CPT) only copyright 2012 American Medical Association. All rights reserved.

Multiple Visits on Same Day

• Cannot be paid for same patient on the same day by physician or physician of same specialty from the same group practice

• Exception when documentation reveals visits were for:o Unrelated problems; and o Could not be provided during the same

encounter

Documentation Tips for the Key Components of an Evaluation and Management Service

Documentation Tips-Chief Complaint

• The medical record should clearly reflect the chief complainto Follow-up for hypertensiono Complaining of back pain

• Chief complaint easily inferredo Patient complaining of “productive cough,

nasal drainage, and headache”

Documentation Tips- “Double Dipping”

• Review of Systems (ROS) are questions concerning the system(s) directly related to the problem(s) identified in the History of Present Illness (HPI).

• Not considered “double dipping” to use the system(s) addressed in the HPI for credit in the ROS

Documentation Tips -Non-Contributory

• The term "non-contributory" may be appropriate documentation when referring to a patient's family history during an Evaluation and Management visit, if the family history is not pertinent to the presenting problem. 

Documentation Tips-History

• Not required to re-record Review of Systems (ROS) and Past Family Social History (PFSH) from a previous encounter. Must show evidence of physician review and update

• Ancillary staff may record ROS and/or PFSH o Physician must review and supplement or notate

confirmation of information recorded

• Unable to obtain history, physician must indicate why and the attempts made

Documentation Tips - Exam• Physician’s “hands on”• Type of content of the exam is based on clinical

judgment and nature of the presenting problem• 1995 guidelines- eight or more body areas or

organ systemso Cannot combine body areas and organ systems to

determine the level of the exam

• 1997 guidelines provide specialty exams• Documentation of “normal” sufficient• Documentation of “abnormal” requires elaboration

“4 X 4”

• Four or more items in Four or more body areas or organ systems = DETAILED exam

• Example:o Constitutional- 1) BP 2) Temp 3) Pulse 4) Respirationo Respiratory- 1) Chest clear to auscultation 2) Non-labored

breathing 3) No rhonchi 4) No raleso Cardiovascular- 1) Regular Rate 2) and Rhythm 3) Normal S1 4)

and S2o Gastrointestinal - 1) Abdomen soft 2) Normal bowel sounds 3)

No hernia 4) Abdomen flat• Clinical inference overrides “4 X 4” tool• 1997 single organ system exams may be more beneficial in

scoring

Documentation Tips- Medical Decision Making

• Number of Diagnosis or Treatment Optionso Additional workup- anything that is being done

beyond that encounter • Amount and/or Complexity of Data Reviewed

o Two points may be given for independent visualization if indicated in the documentation

• Risk of Complications and/or Morbidity or Mortalityo The level of risk is based on the content of the

entire note for the encounter

Time Documentation

References

• Novitas Solutions Evaluation and Management Centero http://www.novitas-solutions.com/webcenter/spaces/EvaluationandMana

gement_JL

• Evaluation and Management Service Guideo https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Netw

ork-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf

• Frequently Asked Questions o http://www.novitas-solutions.com/webcenter/spaces/FAQs_JL

• Centers for Medicare and Medicaid Services Internet Only Manual, Publication 100-4; Chapter 12, Section 30.6.7, Payment for Office and Other Outpatient Evaluation and Management Visits o http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Dow

nloads/clm104c12.pdf

Contractor Initiatives

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Website Improvements

• Novitas Solutions Web site improvements were implemented September 29, 2013

• New features include:o Separate Website for Jurisdiction H (JH) and Jurisdiction L

(JL)o Improved Search Functionalityo Navigation Enhancements

• Webinars are scheduled in January - register now at:o JL     

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008049

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Novitas Home Page

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JL Navigation

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Navigation Help

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Tips for Searching

• Use Search Filters

• Use commas to separate the words

• Adding OR between words

• Placing two periods between two numbers returns all resultso 1..4 returns all documents with 1,2,3, or 4

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JL Local Coverage Determinations (LCDs)

• The following MAC Local Coverage Determinations (LCDs) are now effective:o Bariatric Surgical Management of Morbid Obesity (L34495)o Biomarkers Overview (L33640)o Hemophilia Factor Products (L33658)o Molecular Diagnostics: Genitourinary Infectious Disease Testing (L32567)o Oral Maxillofacial Prosthesis (L33654)o Prostate Mapping Biopsy (L33656)o Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (L33652)

• The following MAC Local Coverage Determinations (LCDs) have been revised:o Scanning Computerized Ophthalmic Diagnostic Imaging (L27529)o Transcranial Magnetic Stimulation (TMS) for the Treatment of Depression (L32055)o Trigger Point Injections (L27540)

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Retired Local Coverage Determinations (LCDs)

• Novitas began directing customers to the Medicare Coverage Database (MCD) for retired LCDs and previous versions for currently active LCDs

• Medical Policy page has been updated with a link to the MCD o http://www.cms.gov/medicare-coverage-database/

• Active and Draft policies can be found on our websiteo http://

www.novitas-solutions.com/webcenter/spaces/MedicalPolicy_JL

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Jurisdiction L Customer Contact Information

• Providero 1-877-235-8073o Hours of Operation, Eastern Time (ET)

Monday - Thursday: 8:00 am – 4:00 pm ET Friday: 8:00 am – 2:00 pm ET

• Interactive Voice Response (IVR)o Hours of Operation

Eligibility and General Information – 24 Hours a day 7 Days a week

Full IVR Options– Mon- Fri 6:00am – 9:00pm ET– Saturday 6:00am - 4:00pm ET

Step-by-Step Guide http

://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004403

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004415

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Beneficiary Contact Information

• Patient / Medicare Beneficiaryo 1-800-MEDICARE (1-800-633-4227)

http://www.medicare.gov/index.html

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Fax to Image

• Were you aware records for an Additional Development Request (ADR) can be faxed directly to Novitas Solutions?

• The fax to image option allows for documentation to be submitted directly to Novitas Solutions. o Available 24 hours a day, 7 days a weeko Fax ADR response to 1-877-439-5479

• Faxes should not exceed 200 pages

• The original ADR request must be submitted as the cover sheet to the records

• Supporting documentation, or requested medical records, should follow the ADR letter

• Each ADR request must be faxed separately

• Additional Tipso http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?

contentId=00007732

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Part B Redetermination Request

• Correct clerical errors or omission by calling the Claims Correction lineo JL Providers 1-877-235-8073o JH Providers 1-855-252-8782

• Part B Redetermination Requests may be faxed o Available 24 hours a day, 7 days a weeko 1-888-541-3829

• Appeals Status Inquiry Tool now availableo JL

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00002677

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Overpayments

• Novitas identifies overpayment and sends demand lettero Copy of demand letter sent with checko No form involved with demanded debt

• Provider identifies overpaymento Voluntarily sends unsolicited checko Use return of monies form

• http://www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00008243

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Provider Enrollment

• Provider Enrollment Status Inquiry Toolo JL

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004864

• Release of Informationo Individual Physician or Practitionero Authorized Delegated Official

• Upcoming Revalidation Mailingso http://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/MedicareProviderSupEnroll/Revalidations.html

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Stay Up-to-Date

• Weekly Podcasto Weekly podcast of the latest Medicare Updates

and other informative topicso Subscribe-

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008119

• Web Updateso Daily E-mail of the latest Medicare Updates

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00007968

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Calendar of Events

• Our Training and Events Center offers a wide variety of education

• Join us for Workshops, Teleconferences, and Webinars

• To view the most current calendar of events, visit:JL

http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008204

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Novitasphere

• Coming Soon

• Part B Provider Portal

• Connect via internet to Novitas

• Available options include:o Claim submission;o Claim status; ando Eligibility

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Centers for Medicare & Medicaid Services (CMS)

• The CMS website offers valuable resources such as: o CMS Internet Only Manuals (IOMs)o Medicare Learning Network (MLN) Matters Articleso Open Door Forumo MLN Connects

http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf

• For additional resources visit:o http://www.cms.gov/

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Thank You

Janice Mumma, CPC, CPC-HSupervisor, Provider Outreach and Education

717-526-3645

Janice.mumma@novitas-solutions.com

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