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Woodland Hills AAPC Medicare Seminar Presented by Kathy A. Montoya Senior Provider Relations Representative Palmetto GBA.

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Presentation on theme: "Woodland Hills AAPC Medicare Seminar Presented by Kathy A. Montoya Senior Provider Relations Representative Palmetto GBA."— Presentation transcript:

1 Woodland Hills AAPC Medicare Seminar Presented by Kathy A. Montoya Senior Provider Relations Representative Palmetto GBA

2 The information provided in this presentation was current as of May 1, Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at

3 Objectives  To enhance the knowledge base of Medicare coverage and billing guidelines  To decrease the National Paid Claims Error Rate  To protect the Medicare Trust Fund  To ensure the delivery of quality care to our Medicare beneficiaries

4 Agenda  Updates/Reminders JE bid Fee Schedule changes Therapy Services Ordering/Referring

5 Agenda  Documentation Principles of documentation Common Errors Amendments

6 A/B MAC Jurisdiction E May 2013

7 Jurisdiction E Awarded  Announced September 20, 2012  Noridian Administrative Services (NAS)

8 Jurisdiction E  Noridian launched JE website April 16, 2013 /je/ /je/ Outlines implementation timeline Presents calendar of transition events States physical presence in California

9 https://www.noridianmedicare. com/je/

10 Implementation Dates  Noridian will be the MAC for Jurisdiction E: Part A – August 26, 2013 Part B –September 16, 2013 May

11 Communication Resources Website/Listserv: Contact provider organizations/associations Meet and Greet meetings with providers Mailings to providers Web based provider workshops/ACTs 11 May 2013

12 Listserv 2  For providers not registered with J1 prior to March 1, 2013 Go to: and select “ Newsletter Sign Up” at the bottom of the left hand navigation menu. Instructions listed in Listserv article on JE website May

13 Key Website Items  Contact Information phone numbers and mailing addresses implementation questions  Current news and relevant changes  IVR  Schedule of Events 13 May 2013

14 Key Website Items  Cutover dates  Payment cycles  FAQs  EDI - focus on vendors and direct submitters  Provider Portal 14 May 2013

15 Contact Information  Single Toll-free number after JE Implementation Provider Contact Center (PCC) Electronic Data Interchange Support Services (EDISS) Telephone Reopenings Provider Enrollment User Security May

16 Contact Information  Questions regarding implementation to or Call Implementation Hotline at  Hot Line available 8:00 am to 5:00 pm (PT), Monday-Friday May

17 Welcome  Noridian is proud to be your Medicare Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1. They look forward to working with you in the near future to serve your Medicare needs.

18 New Costs

19 2013 Part B Deductible and Coinsurance Rates  Deductible-$  Coinsurance 20% of eligible charges

20 2013 Part A Deductible and Co-Pays  $1,184 deductible 1 st 60 days of hospitalization  $296 co-pay Days  $592 co-pay Days 91 – 150 Lifetime Reserve  $148 co-pay SNF days

21 2013 Part B Premiums Income Parameters for Part B Premiums Premium/MthlyIndividual Income Combined Income (Married) $104.90< $85,000< $170,000 $146.90$85, to $107,000$170, to $214,000 $209.80$107, to $160,000$214, to $320,000 $272.70$160, to $214,000$320, to $428,000 $335.70$214, >$428, >

22 2013 Part A Premium  Fewer than 30 quarters $ per month  30 to 39 Quarters $ per month

23 Updates

24 Payment Reduction April 1, 2013  The Budget Control Act of 2011 Requires Federal spending reductions, sequestration  The American Taxpayer Relief Act of 2012 postponed sequestration for two months President Obama issued a sequestration order on March 1, 2013

25 Payment Reduction April 1, 2013  Medicare FFS claims Part B - dates-of-service ≥ April 1, 2013 Part A - dates-of-discharge ≥ April 1, 2013 Two percent reduction  CR7825

26 Transitional Care Management Services (TMC)  New codes and Established patient Moderate to high complexity medical decision making

27 Transitional Care Management Services (TMC) Transition period from an inpatient setting (IP, LTC, SNF, rehab) to the patient’s community setting TMC begins on date of discharge + 29 days One face-to-face visit combined with non FTF services provided by physician or clinical staff

28 Transitional Care Management Services (TMC)  Medical decision making/date of the first face-to-face visit are used to select the code TMC service  Communication with patient/caregiver within 2 business days  Moderate complexity  Face to face within 14 calendar days of discharge

29 Transitional Care Management Services (TMC) TMC service  Communication with patient/caregiver within 2 business days  High complexity  Face to face with 7 calendar days of discharge

30 Transitional Care Management Service (TMC)  Date of Service = 30 th day  Place of Service = POS for face to face visit  What if patient dies during the 30 day period Bill E/M code only

31 Psychiatry  Initial Psychiatric Evaluation and were deleted Distinction made between service by MD and one by non physician

32 Psychiatry – New Codes  = Initial evaluation with physician services  = Initial evaluation done by a non physician  = New add on code for interactive complexity

33 Multiple Procedure Payment Reduction (MPPRs)  CR7848  Effective January 1, 2013  Reduction to Technical Component (TC) Diagnostic Cardiovascular Ophthalmology procedures

34 Multiple Procedure Payment Reduction  Multiple services to same patient, same date  Affected codes Guidance/Guidance/Transmittals/Downl oads/R1149OTN.pdf Guidance/Guidance/Transmittals/Downl oads/R1149OTN.pdf  Remittance Advice Adjustment Reason Code 59

35 Multiple Procedure Payment Reduction  Cardiovascular Services  Same physician, or multiple physicians in same group Full TC payment with highest value Subsequent TC paid at 75%

36 Multiple Procedure Payment Reduction  Ophthalmology services  Same physician, or multiple physicians in same group Full TC payment with highest value Subsequent TC paid at 80%

37 MPPRs Cardiovascular Payment Reduction Example Sample Cardiovascular Payment Reduction Code Code Total Currant Total 2013 Payment Payment Calculation PC$77.00$65.00$ No reduction TC$427.00$148.00$575.00$538.00$427 + (.75 x $148) Global$504.00$213.00$717.00$680.00$142 + $427 + (.75 x $148)

38 MPPRs Ophthalmology Payment Reduction Example Sample Ophthalmology Payment Reduction Code Code Total Currant Total 2013 Payment Payment Calculation PC$46.00$23.00$69.00 No reduction TC$92.00$53.00$145.00$134.40$92 + (.80 x $53) Global$138.00$76.00$214.00$203.40$69 + $92 + (.80 x $53)

39 CR7260  Health Insurance Claim Number (HICN) and Name Mismatch  Effective October 1, 2012  Claims will reject MA 130 and MA61  Take information exactly as shown on Medicare card


41 Therapy Services

42 Multiple Procedure Payment Reduction (MPPR) for Selected Therapy Services  CR 8206  Effective April 1, 2013  MPPR increased to 50% from 20% for all settings Applies to the practice expense Applies to HCPCS codes on the “always therapy” list

43 2013 Financial Limitation for Outpatient Therapy Services  Effective January 1, 2013  2013 Therapy Cap amounts: $1,900 for OT $1,900 combined PT and SLP

44 2013 Financial Limitation for Outpatient Therapy Services  Section 603 of American Taxpayer Relief Act of 2012  Outpatient Therapy claims cap Extended through DOS December 31, 2013 $3,700 for PT and SLP $3,700 for OT  Manual Review of claims > $3,700

45 Changes for Therapy Services in 2013  Reporting requirements Use Functional status codes Use Functional Limitation modifiers Every 10 treatments or 30 calendar days, whichever is earlier

46 Functional Reporting G-Codes G CodesFunctional Limitation G8978, G8979, G8980Mobility: Walking & Moving Around G8981, G8982, G8983Changing & Maintaining Body Position G8984, G8985, G8986Carrying, Moving & Handling Objects G8987, G8988, G8989Self Care G8990, G8991, G8992Other PT/OT Primary Functional Limitation G8993, G8994, G8995Other PT/OT Subsequent Functional Limitation G8996, G8997, G8998Swallowing

47 Functional Reporting G-Codes G CodesFunctional Limitation G8999, G9157, G9158Motor Speech G9159, G9160, G9161Spoken Language Comprehension G9162, G9163, G9164Spoken Language Expression G9165, G9166, G9167Attention G9168, G9169, G9170Memory G9171, G9172, G9173Voice G9174, G9175, G9176Other SLP Functional Limitation

48 Functional Status Codes  Three codes Current status Goal status Discharge status

49 Severity Complexity Modifiers ModifierImpairment Limitation Restriction CH0 % impaired, limited or restricted CIAt least 1% but less than 20% impaired, limited or restricted CJAt least 20% but less than 40% impaired, limited or restricted CKAt least 40% but less than 60% impaired, limited or restricted CLAt least 60% but less than 80% impaired, limited or restricted CMAt least 80% but less than 100% impaired, limited or restricted CN100% impaired, limited or restricted

50 Functional Reporting  Use of G codes and modifiers is required At the onset of therapy episode of care At least once every 10 treatment days

51 Functional Reporting Same date of service that an evaluation/re-evaluation procedure At the time of discharge from therapy episode of care On the same date of service the reporting of a functional limitation is ended

52 Claim Reporting  Onset of therapy and each reporting period Report two G codes with modifiers  Current status, goal status  Discharge Report two G codes with modifiers  Current status, discharge status

53 Manual Medical Review  CMS Update March 21, 2013  Recovery Auditors (RA) to conduct MMR at $3,700 thresholds (PT and SLP, OT) Prepayment Review Demo – California Pos-tpayment Review – Nevada, Hawaii

54 Manual Medical Review Reference statistics-data-and-systems/monitoring- programs/medical- review/therapycap.html

55 Manual Medical Review  Prepayment Review California  Palmetto GBA to send a Additional Documentation Request (ADR) to provider  Request documentation be sent to the RA  The Recovery Auditor will conduct prepayment review  Within 10 business days of receiving documentation  Will notify Palmetto of payment decision

56 Manual Medical Review  Postpayment Review Hawaii and Nevada  Palmetto GBA to send a Additional Documentation Request to the provider  Request documents be sent to the RA  The Recovery Audition will conduct a post payment review  Will notify Palmetto GBA of the payment decision

57 Ordered and Referred Services Reminders and Updates

58 Phase 1 Ordering/Referring Rejects  Affordable Care Act §6405 Required Ordering/Referring providers to be enrolled in Medicare Name and NPI needed on claim  Phase 1 Began October 5, 2009 Incorrect, Missing information – rejected claim Informational messaging on Remittance Advices

59 New Edit Phase 2  Planned Effective/Implementation May 1, Delayed  Claims will be denied when Ordering/Referring provider needed  Provider not enrolled in Medicare  No NPI on claim  Wrong specialty for service/supply  Denied as Non-covered

60 Denial Reason Codes  N264 = Missing/incomplete/invalid ordering provider name  N265 = Missing/incomplete/invalid ordering provider primary identifier

61 New Edit Resources  SE1305  CRs 6421, 6417, 6696, 6856  Ensure your in PECOS Look up your NPI vider-Enrollment-and- Certification/MedicareProviderSupE nroll/index.html vider-Enrollment-and- Certification/MedicareProviderSupE nroll/index.html

62 Order or Referral Must Include  Specific services requested CPT/HCPCS code Indicate preventive or diagnostic Use appropriate gender specific codes if applicable

63 Order or Referral Must Include  Applicable ICD-9-CM code Screening versus diagnostic codes Sign or symptoms Patient diagnosis Use appropriate gender specific codes if applicable

64 Order or Referral Must Include  Ordering/Referring Provider’s Name and NPI number  Ordering/Referring Provider’s signature if necessary  Plan of Care if applicable

65 Reporting Ordering/ Referring Information  Don’t use nicknames  Don’t enter credentials (Dr.)  First name first, Second name second John Smith  Use individual not group information

66 Resources  Fact Sheet vider-Enrollment-and- Certification/MedicareProviderSupE nroll/index.html  NPI registry PPES/

67 Resources  Enrollment vider-Enrollment-and- Certification/MedicareProviderSupE nroll/index.html

68 Documentation Important for Billing Important for Audits

69 Basic Coverage Rule  Social Security Act in Section 1862 (A) 1 No payment for expenses not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

70 855 I, Section 15, Bullet 4  Abide by Medicare laws, regulations and program instructions Provider must know  Claim payment based upon  Claim  Underlying transaction  Supplier’s compliance with conditions of participation

71 Medicare Audits  They happen  Be prepared Create thorough documentation Read request carefully Use Medicare Self Help tools Learn from mistakes

72 Medicare Audits  Medical Review of Palmetto GBA  Comprehensive Error Rate Testing (CERT) program  Recovery Audit Contractors (RACs)  Zone Program Integrity Contractors (ZPICs)

73 Audits  Pre-payment or post payment  Documentation Follow industry, specialty, CMS and Palmetto GBA guidelines

74 Additional Documentation Request (ADR)  Outlines requested information  Indicates date of service(s)  Outlines timeline for return of documents  Provides return address

75 Use Medicare Self Help Tools And Articles  CERT section Articles section ADR Checklists

76 Learn From Mistakes  Review results Medical review audits CERT and RAC audits Office of Inspector General (OIG)

77 Code of Federal Regulations 42 CFR (a) (6)  Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

78 Medical Record Documentation  Thorough proper documentation Verifies service/level provided Key to audit success Ensures payment for services rendered Protects patients and provider


80 Medical Record Documentation  Evaluate, plan and monitor  Communication, coordination and continuity  Claims payment and review  Utilization and quality evaluations  Research and education

81 Principles of Documentation  Complete and legible Transcribe if necessary  Reason for encounter  Relevant history  Physical examination

82 Principles of Documentation  Diagnostic test Rationale for ordering Results  Assessment, clinical impression or diagnosis  Plan for care  Date and legible signature

83 Principles of Documentation  Past and present diagnoses  Identify health risk factors  Patient's progress  Response to and changes in treatment  Revision of diagnosis  Support CPT and ICD-9-CM code selection

84 General Documentation Tips  Patient name on each page and date of service  Templates/forms OK, but must be individualized  Computerized notes OK, but must be individualized

85 General Documentation Tips  Document time when coding is based on time (face to face)  Must be legible, when in doubt transcribe  Each entry must be signed (first, middle, last) with credentials Signature log O.K. to use Electronic signature O.K. to use

86 Illegibility  Read by others for treatment/care  Proof of services rendered  Illegibility leads to denials  ‘If it isn’t documented it didn’t happed’  Auditors cannot use inference in evaluation of records

87 Missing Provider Signatures  Acceptable signature required Each entry First, middle and last name Include credentials Date  Use signature log or attestation statement  (CR) PI.pdf 327PI.pdf

88 Insufficient Documentation  Documentation should answer What was wrong? How was it manifested? What did it look like? What was the procedure to fix it? What was the plan of care

89 Insufficient Documentation  Paint picture of need for service  Vague statements not detailed enough ‘Status quo’, ‘no change’ or ‘patient stable’ Give details

90 Insufficient Documentation Medical documentation submitted does not include pertinent patient facts (e.g., patient’s overall condition, diagnosis, extent of services performed)  Use narrative with chart templates  Document need for a complete or comprehensive services

91 Incorrect Date Of Service  Incorrect date of service received  Read ADR letter carefully  Check before responding  Send multiple dates if asked

92 Missing Patient Name  Missing patient name on documentation  Check copies before mailing Both sides Beware of photocopies

93 New Patient Versus Established Patient Denials  ‘New patient’ Not seen within the previous three years From physician or physician group practice (same physician specialty) Hospital services count

94 Combined Billing  Physicians in same group, different specialties Bill and paid regardless of group

95 Combined Billing  Physician in same group, same specialties Bill and paid as single physician Only one E/M per day Unless unrelated problems Select E/M level to incorporate all

96 Documenting Services  Comments Field – NTE 02 Provide explanation of multiple physician treatment Identify subspecialty if applicable  Send documentation when requested or for appeals Show need for1+ visits per day Identify subspecialty if applicable

97 E & M Guidelines  “1995 Documentation Guidelines for Evaluation and Management Services”  “1997 Documentation Guidelines for Evaluation and Management Services.”  Use either set  Use only one per E & M service

98 E & M Guideline Resources  IOM , Chapter 12, §30.6 nloads/clm104C12.pdf nloads/clm104C12.pdf  CMS “Evaluation and Management Services Guide” ide/25_EMDOC.asp ide/25_EMDOC.asp

99 ads/eval_mgmt_serv_guide.pdf

100 E & M Services  Grouped by categories and subcategories Setting Type of service 3 to 5 levels of service

101 Components of E/M Services  Chief complaint  History  Exam  Decision making

102 Components of E/M Services  Counseling  Coordination of care  Nature of presenting problem  Time

103 Evaluation and Management Scoresheet Tool

104 Basic Patient Information

105 History Components

106 Review of Systems

107 Physical Examination

108 Medical Decision Making

109 Amount and Complexity of Data Reviewed

110 Assessment of Risk

111 Counseling and/or Coordination of Care

112 Select ‘Update” for CPT code selection Select ‘Print’ to print a copy of scoresheet Selection of Code

113 Common E/M Documentation/Coding Errors

114 Common E/M Documentation Errors  Missing documentation Beneficiary’s name Date of Service Rendering physician’s/NPP’s signature Supporting documentation (referred to ROS, PFSH, or orders)  Minimum documentation requirements not met (down coded)

115 Common E/M Documentation Errors  Medical necessity/reasonableness was not established  Illegible documentation  Billed in error (per physician/NPP)  Cloned records

116 Common E/M Documentation Errors  The chief complaint/reason for visit was not clearly documented  Billed higher level services  Extensive PFSH was documented for lower-level services

117 Common E/M Documentation Errors  Complete PFSH was missing  New patient or initial services  Expansive ROS was documented for lower-level services  Missing ROS for the system(s) related to the presenting problem or system(s) related to the presenting problem were “negative”

118 Common E/M Documentation Errors  Documented diagnoses under ROS  Extensive examination was documented for lower level services  Unable to determine if diagnosis/problem is stable or worsening

119 Common E/M Documentation Errors  The assessment contained a list of diagnoses/problems that were not addressed during the encounter  Documented “labs reviewed” without further information  Unable to determine if the physician/NPP independently reviewed image, tracing, or specimen

120 Common E/M Documentation Errors  Didn’t summarize old records/history from others  Ancillary staff/scribe documentation requirements were not met  Counseling/coordination of care missing time/documentation  Incident to requirements were not met

121 Medical Record Amendments

122  General Medicare requirements After medical records are sign & dated  Additional information can be added in form of an appropriate Amendment or addendums  On rare occasions & not used as common practice

123 Accepted as an Appropriate Addendum to Medical Records  Must be added timely within a few days/one week  Must contain individualized, patient-specific clinical information for each date of service amended. Blanket statements, declarations or attestations not accepted

124 Accepted as an Appropriate Addendum to Medical Records  Should be chronological in records  Must be legible, signed and dated  Should address additional, clinically relevant information Not added to meet regulatory requirements Not added to support downcoded claim

125 Making Corrections to the Medical Record  Follow legal requirements Never write over, erase, or obliterate an entry Draw a single line through incorrect information  Write correction near deletion  All information should still be legible  Should be signed and dated

126 Making Corrections to the Medical Record  A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed A full explanation of why the record was in error Practitioner should sign and date the correction


128 Questions? Please fill out Evaluations

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