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Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education

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1 Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education
2013 Part A Workshop Series Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education

2 Disclaimer This presentation was current at the time it was published. Medicare policy may change so 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. The Centers for Medicare & Medicaid Services (CMS) 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 publication 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. On your screen is a disclaimer. The information is current as of right now and please remember this is a summary of Medicare program. The official rules are found in the written laws and regulations that apply to the Medicare program and of course any CPT codes used in today’s session are used with permission by the AMA. Should this information be updated, Palmetto GBA provides information through our listservs and posts on our Website. Again just as a reminder, we will publish the PowerPoint on our Website within the next few days.

3 CPT/CDT Copyright CPT only copyright 2012 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved. Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC)

4 Agenda Claim Reviews Medicare Updates Important Billing Information
J11 Medicare Part B Update - Fall 2011 Agenda Claim Reviews Comprehensive Error Rate Testing (CERT) Updates Recovery Audit Contractor (RAC) Redeterminations Medicare Updates Regulations, Change Requests (CRs) and Medicare Learning Network Matters (MLN) Articles Important Billing Information Did You Know? Palmetto GBA Tips and Reminders Palmetto GBA - J11 Part B 4

5 Comprehensive Error Rate Testing (CERT) Updates

6 **Documentation Matters** Do it right the first time!
CERT **Documentation Matters** Do it right the first time!

7 “If it isn’t documented – it wasn’t done!”
CERT Remember this one? “If it isn’t documented – it wasn’t done!”

8 One more… CERT Look at your facility’s medical records…
Based on the principles of basic clinical documentation, would you pay? That’s really what CERT is all about…Charting

9 Last One… CERT We follow the $…
You are ultimately responsible for gathering and presenting all required documentation for any services you billed and received payment for. That’s really what CERT is all about…Charting

10 CERT What is CERT? Federally mandated program created by the Centers for Medicare & Medicaid Services (CMS) to measure the paid claims error rate for Medicare claims submitted to Medicare Administrative Contractors (MACs) Ensures that the Medicare program is paying claims correctly The CERT program measures national, contractor- specific, and service-specific paid claim error rates

11 CERT How is CERT Administered?
The CERT program uses a random and a service- specific sampling of claims. There are two contractors responsible for administering the CERT program on behalf of CMS. The CERT review contractor selects samples of claims from Palmetto GBA. For each claim selected, the CERT documentation contractor (CDC) requests medical records, from the physicians and suppliers that billed for the services, and prepares the documentation for review.

12 CERT Why is the medical record important?
The review contractor uses medical record documentation to verify that the services were billed correctly Ensure Palmetto GBA’s decisions regarding the payment and processing of the claim(s) were accurate and based on sound policy

13 CERT Why should providers be concerned?
Claims billed, paid, or processed incorrectly are categorized as errors. Claims paid to Medicare providers in error are classified as overpayments or underpayments, and Palmetto GBA is mandated to issue refund requests to our providers for all overpayments. In addition, CERT errors can potentially have a negative impact on providers Claims being subject to prepayment and/or post-payment review by our Medical Review Department Found to be out of compliance with the Medicare provider enrollment agreement by not responding to CERT requests

14 CERT Medical Records Request
After a claim is identified as part of the sample, CERT requests the associated medical records and other pertinent documentation from the provider that submitted the claim The initial request for medical records is made via letter If the provider fails to respond to the initial request within 30 days, CERT sends at least three subsequent letters The CERT contractor also places phone calls to the providers to collect the documentation

15 Role of Provider Providers play a role in the reduction of error rates. When a medical records request is received, it is imperative that the provider does the following: Be alert and prepared for medical record requests. You have up to 75 days to return the requested information. Read slide

16 Compliance Benefits Some of the benefits of provider compliance are listed below: Prevents unnecessary denials and need to request an appeal Assures appropriate reimbursement of provider's claims Reflects a positive impression of a provider's industry by having a low error rate May prevent additional medical review of the provider Demonstrates compliance with Medicare provider enrollment agreement

17 Responding to a CERT request
What will you receive from CERT? Information on the CERT process HIPAA compliance information What documentation to submit Timeframe for responding to the request Claim information Note: An ORIGINAL bar coded sheet will be included that you must use with your mailed response or used if you decide to fax your documentation

18 Documentation Your documentation is the basis for determining the CERT error rate! All procedures, diagnoses, and modifiers submitted on a claim to Medicare should be supported by information in the patient’s medical record The “medical need” for services and procedures must also be documented in the patient’s medical record The legible signature of the person that performed the service is required: Change Request 6698 – Signature Requirements Documentation by providers is very important in determining the CERT error rate. Providers must ensure that all procedures, diagnoses, and modifiers submitted on a claim to Medicare should be supported in the patient’s medical record. The medical need for all services and procedures must also be documented in the patient’s medical record. The legible signature of the person that performed the service is required. Again accurate documentation is the key to reducing the CERT error rate.

19 CERT Upon receipt of medical records, CERT medical review professionals conduct a review of the claims and submitted documentation to determine whether the claim was paid properly These review professionals consist of: Nurses Medical doctors Certified coders

20 CERT Before reviewing documentation, the medical reviewers look at:
Common Working File (CWF) Ensure the claim is not a duplicate CMS Eligibility System Confirm the person receiving the services was an eligible Medicare beneficiary Verify there is no other entity responsible for paying the claim (Medicare is primary)

21 CERT When performing claim reviews, CERT ensures compliance with:
Medicare statutes and regulations Billing Instructions National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Coverage in CMS Instructional Manuals (i.e., IOM)

22 CERT Based upon the review of the medical records, claims identified as containing improper payments are categorized into the appropriate error category

23 CERT An improper payment is defined as:
Any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements Overpayments Underpayments

24 CERT Errors The reasons for CERT errors in the latest quarterly report include: No documentation Insufficient documentation Medically unnecessary services Incorrect coding Other Note: Providers need to share these errors with the physicians. It is important that providers have a plan in place to correct CERT error rates. Read slide

25 No Documentation The provider fails to respond to repeated requests for the medical records, OR The provider responds that they do not have the requested documentation

26 Insufficient Documentation
The medical documentation submitted is inadequate to support payment for the services billed Unable to determine if some of the services allowed were actually provided Provided at the level billed, and The services were medically necessary A specific documentation element that is required as a condition of payment is missing: Physician signature on an order, or A form required to be completed in its entirety

27 Medical Necessity Adequate documentation from the medical records submitted and can make an informed decision that the services billed were not medically necessary based upon Medicare coverage policies

28 Incorrect Coding The provider or supplier submits medical documentation supporting A different code than that billed The service was performed by someone other than the billing provider or supplier The billed service was unbundled A beneficiary was discharged to a site other than the one coded on a claim

29 Other Does not fit into any of the other categories
Duplicate payment error Non-covered service A service incurred by the patient that is not covered by Medicare Unallowable service A service incurred by the patient that is not allowed by Medicare

30 CERT and Palmetto GBA Palmetto GBA strives at every workshop and education event to stress the importance of reducing CERT error rates CERT information is updated quarterly Documentation/Signature Guidelines are posted on our website Read slide

31 How Can A Provider Learn More?
CERT resources published on the J11 Part A website at CMS CERT website CMS Program Integrity Manual

32 Recovery Audit Contractor (RAC)
Being Proactive is Key Whether CERT or RAC, being proactive involves responding to the question “What can I do to be ready?” This means looking at your internal compliance program in order to evaluate how you inspect what you expect

33 RAC Recovery Auditors (formerly known as Recovery Audit Contractors or RACs) RACs detect and correct past improper payments CMS Recovery Audit Program Systems/Monitoring-Programs/Recovery-Audit- Program/index.html The RACs detect and correct past improper payments so that CMS and MACs can implement actions that will prevent future improper payments •Providers avoid submitting claims that do not comply with Medicare rules •CMS: can lower its error rate •Taxpayers: future Medicare beneficiaries are protected

34 RAC Regions Medicare RAC Region C: Connolly, Inc.
States: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico and U.S. Virgin Islands Search Approved Audit Issues NOTE: Please check the RAC website audits for your state

35 So What Contractors Do What??
CERT, RAC, ZPIC Responsibilities: Identify improper payments Submit claim adjustment to the MAC Respond to any audit specific questions you may have, such as their rationale for identifying the potential improper payment MAC (Palmetto GBA) Responsibilities: Issue demand letters Perform the claim adjustments based on CERT, RAC, ZPIC’s review Handle administrative concerns such as timeframes for payment recovery and the redetermination (appeals) process Include the name of the initiating CERT, RAC, ZPIC and their contact information in the related demand letter

36 What Contractors Do What??
MAC (Palmetto GBA) Responsibilities… Demand demands will be sent to the same address as any other demand letter that is sent from the MAC The address that is used to mail the demand letters is the provider’s physical address The same address as CERT, ZPIC, etc. demands are currently sent and if those are currently being received, so will the RAC demand letters. Due to HIGLAS limitations, the address that the RAC demand letters will be sent to and a contact person will not be able to be specialized. It will pull from the physical address that is currently listed on the provider file.

37 Redeterminations Also Known As (AKA) Appeals

38 Redeterminations Appeals Process
Provider has 120 days from the date on the remit to file appeal Attach copy of denial letter and Request for Redetermination Form Appeals Forms: Select Resources/Forms/ Part A/Select Your State/Appeals Select Redetermination (appeal) of an initial claim determination adjustment decision First level appeal on a Medicare claim (Palmetto GBA) RAC overpayment appeal CERT overpayment appeal ZPIC overpayment appeal

39 What Is The Status of My Appeal?
Before calling to obtain the status of an appeal, providers should do the following: Has it been more than 60 days since Palmetto GBA received the Appeal? Palmetto GBA has up to 60 days from the date of receipt of the request to complete a review of the documentation and render a decision If it has been more than 60 days since Palmetto GBA received the request, providers should first check the Direct Data Entry (DDE) system to see if a decision has been rendered Once a decision has been rendered on an appeal, information is loaded to the remarks field on the original claim Last Bullet: Providers can view the remarks on claim page 4 in the DDE system If a decision has been made, one of the following will appear in the remarks field: CREV or PCREV – fully favorable, full reversal PPREV – partially favorable, partial reversal AFFIRM or AFFM – unfavorable, denied Access information regarding your appeal rights on the Palmetto GBA Appeals page: Appeals forms are located on this page. You may complete the forms electronically then print and sign the forms, attach supporting documentation and mail to the address indicated on the forms. Or you have the option to submit requests for a redetermination and supporting documentation via Fax at (803) First level of appeal: redetermination. Timeframe: 120 days from the date of the initial determination. Services that are ‘returned to provider’ with remark code MA130 must be corrected and resubmitted, not appealed. Second level of appeal: reconsideration. Timeframe: 180 days from receipt of redetermination. Submit this form to the Qualified Independent Contractor (address is located on form).

40 What Is The Status of My Appeal?
Palmetto GBA does not issue letters for fully favorable appeals For a partially favorable decision, the provider will receive a letter that explains that only partial payment can be made and why When the decision is affirmed, also known as an unfavorable decision, the provider will receive a letter that will explain the reason for the decision as well as further appeal rights In some cases, a request for a redetermination will not be considered valid and will, therefore, be dismissed If a request for a redetermination is dismissed, the provider will receive a letter that explains why the appeal was dismissed First Bullet: When a fully favorable decision is rendered, the claim is adjusted to allow for payment When the processing of the adjustment has been completed, it can be viewed on the provider’s remittance advice (RA). The Type of Bill on the RA will be XXI Second Bullet: The letter will also contain information on further appeal rights for the unpaid portion of the claim The claim will be adjusted to allow for payment of the services deemed to be payable When the processing of the adjusted claim is completed, it can be viewed on the RA Last Bullet: For more information about dismissals, please see the Redetermination Dismissals Job Aid

41 Redeterminations Through Online Provider Services (OPS)
Redeterminations can be submitted online through OPS If you submit a redetermination through OPS, you can then check the status of that redetermination in OPS OPS is available free of charge to Palmetto GBA providers

42 Medicare Updates

43 Medicare Resources Important Medicare Resources
Medicare Fee-for-Service Payment Provider Centers CMS Internet Only Manuals (IOMs) 1st Bullet: Under Medicare Fee-For-Service Medicare > Home Health PPS >>> HH Center Links to new Regulations; Transmittals specific to HHH Link to the Home Health Final Rulings Published in the Federal Register   Link to CMS Q&As ODF; CMS Provider e-News; Billing, Payment and Coding; Oasis ***MLN Matters Articles – with CR but not always***

44 Medicare Resources Resources… http://www.cms.gov/MLNMattersArticles
Explanation of Change Requests, training guides, articles, educational tools, booklets, brochures, fact sheets, web-based training courses Guidance/Regulations-and- Policies/QuarterlyProviderUpdates/index.html?redirect =/quarterlyproviderupdates Comprehensive resource published by CMS on the first business day of each quarter listing all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers

45 Change Request 7260 Modification to CWF, FISS, MCS and VMS to Return Submitted Information when there Is a CWF Name and HIC Number Mismatch Effective date: October 1, 2012 Implementation date: October 1, 2012 Background: When the Common Working File (CWF) receives a valid Health Insurance Claim Number (HICN) with a name that does not match the name associated with that HICN in the CWF record, the CMS shared processing systems assume that the submitter made a mistake in listing the name. Accordingly, when the contractor rejects the claim, it returns the name of the beneficiary that is associated with that HICN within CWF. If the submitter has made an error when entering the HICN, this will likely result in the submitter receiving information belonging to a patient the provider has not treated. This CR changes the current CWF and shared system processes so that if there is a HICN and name mismatch within CWF, the submitter will receive the information it originally submitted when the claim is returned. We are also eliminating from § the bullet point that required the Host to return what it believed to be the proper information on Trailer 10. B. Policy: In accordance with existing CMS policy, provider submitted claims shall be handled differently than beneficiary submitted claims as indicated in the following business requirements. Background: When the Common Working File (CWF) receives a valid Health Insurance Claim Number (HICN) with a name that does not match the name associated with that HICN in the CWF record, the CMS shared processing systems assume that the submitter made a mistake in listing the name. Accordingly, when the contractor rejects the claim, it returns the name of the beneficiary that is associated with that HICN within CWF. If the submitter has made an error when entering the HICN, this will likely result in the submitter receiving information belonging to a patient the provider has not treated. This CR changes the current CWF and shared system processes so that if there is a HICN and name mismatch within CWF, the submitter will receive the information it originally submitted when the claim is returned. We are also eliminating from § the bullet point that required the Host to return what it believed to be the proper information on Trailer 10. B. Policy: In accordance with existing CMS policy, provider submitted claims shall be handled differently than beneficiary submitted claims as indicated in the following business requirements. MM7260 45

46 Change Request 7260 Summary of changes: This CR changes the current CWF and shared system processes so that if there is a HICN and name mismatch within CWF, the submitter will receive the information it originally submitted when the claim is returned Providers should ensure they report the beneficiary’s name and Medicare HICN exactly as they appear on their Medicare card and in CWF. Do not place hyphens or blanks in the HICN field. If the Medicare card and/or CWF displays the beneficiary name with a suffix (e.g. Jr., Sr., II, III, etc.), report the name exactly as shown. If the claims are filed electronically, providers should ensure the Electronic Data Interchange (EDI) loop for the suffix field is populated and that the suffix is not added to the beneficiary’s last name. Instead of calling the Provider Contact Center (PCC) about receiving this error, we suggest that you instead compare the information billed on the claim with the information listed on the beneficiary’s Medicare card and in the CWF and resubmit the claim after making the appropriate corrections.

47 Change Request 8129 Therapy Cap Values for Calendar Year (CY) 2013
Effective Date: January 1, 2013 Implementation Date: January 7, 2013 Summary of changes: Occupational Therapy (OT) cap $1900 Physical Therapy (PT) and Speech Language Pathology (SLP) combined cap $1900 MM8129

48 TDL 13144 The American Taxpayer Relief Act of 2012
Section 601- Medicare Physician Payment Update Zero percent update of Medicare Physician Fee Schedule (MPFS) THROUGH December 31, 2012 Section 603 – Extension Related to Payment for Medicare Outpatient Therapy Services Extends exceptions process Append KX modifier Outpatient therapy in Critical Access Hospitals (CAHs) now counts toward the cap and threshold totals Note: CAH outpatient therapy is NOT limited itself by the caps and thresholds Providers are required to submit the -KX modifier on their therapy claims for medically necessary services Extended Application to therapy services furnished in a hospital outpatient department (OPD NEW this year, now also includes outpatient therapy services furnished in a Critical Access Hospital (CAH) . Question: Are Critical Access Hospitals (CAHs) subject to the outpatient therapy caps and thresholds in 2013? Answer: Critical Access Hospital (CAH) outpatient therapy servcies will be counted in the outpatient therapy cap and threshold totals but the CAH itself will NOT be held to the cap and threshold limitations for payment of their outpatient therapy services.

49 TDL 13144 Section 603 – Extension Related to Payment for Medicare Outpatient Therapy Services continued . . . Extends the “prior authorization” process There is no “prior authorization” process in 2013 Once a claim is received that has outpatient therapy services that exceed the $3700 threshold, the claim will suspend and the provider will receive an additional development request (ADR) Once the documentation is received, it will be reviewed by the medical review department nursing staff and a decision on the processing of the claim will be made Once that decision is made, the claim will adjudicate according to that decision

50 Change Request 8005 Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services Effective for therapy services with dates of service (DOS) on/after January 1, 2013 Effective Testing period January 1 – June 30, 2013 Claims will be returned/rejected for date of DOS on/after July 1, 2013 Q: Are we allowed to start reporting with outpatient therapy referrals received on or after January 1, 2013, or must we start reporting with all outpatient therapy on January 1, 2013, including existing outpatient therapy patients? A: Phasing-in is allowed, but the goal is to have documentation in the medical record and on the claim as of January 1, 2013. MM8005

51 Change Request 8005 Summary of changes: Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act implements a new claims-based data collection requirement for outpatient therapy services requiring reporting with: 42 new non-payable functional G-codes and Seven new modifiers on claims for PT, OT and SLP services The system will collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures. This data will be used in developing an improved payment system

52 Functional reporting on the UB04 claim form applies to:
Change Request 8005 Functional reporting on the UB04 claim form applies to: Skilled Nursing Facility (SNF) Inpatient Part B Type of Bill (TOB) 22X on Part A MAC Claims SNF Outpatient on Part A MAC Claims TOB 23X on Part A MAC Claims Home Health (Part B only) TOB 34X on Part A MAC Claims Outpatient Rehabilitation Facility (ORF) TOB 74X on Part A MAC Claims Skilled Nursing Facility (SNF) Inpatient Part B Type of Bill (TOB) 22X on Part A MAC Claims SNF Outpatient on Part A MAC Claims TOB 23X on Part A MAC Claims Home Health (Part B only) TOB 34X on Part A MAC Claims Outpatient Rehabilitation Facility (ORF) TOB 74X on Part A MAC Claims Comprehensive Outpatient Rehabilitation Facility (CORF) on Part A MAC Claims TOB 75X on Part A MAC Claims Outpatient Hospital, including the emergency room TOB 12X on Part A MAC Claims TOB 13X on Part A MAC Claims Critical Access Hospital (CAH) claims TOB 85X on Part A MAC Claims Functional reporting for outpatient therapy billed on a 1500 claim form applies to: Therapists in Private Practice: Physical Therapists, Occupational Therapists & Speech Language Pathologists Physicians: Medical Doctors (MDs), Doctors of Osteopathy (DOs), Doctors of Podiatric Medicine (DPMs), & Doctors of Optometry (ODs) NPPs: Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), & Physician Assistants (PAs)

53 Change Request 8005 Functional reporting on the UB04 claim form applies to: Comprehensive Outpatient Rehabilitation Facility (CORF) on Part A MAC Claims TOB 75X on Part A MAC Claims Outpatient Hospital, including the emergency room TOB 12X on Part A MAC Claims TOB 13X on Part A MAC Claims NEW Critical Access Hospital (CAH) claims TOB 85X on Part A MAC Claims Note: CAHs are included in functional reporting and their outpatient therapy is counted towards the caps and thresholds totals, but outpatient therapy provided in a CAH is NOT subject to the caps and thresholds limitations

54 Change Request 8005 Documentation Requirements:
Documentation must be included in the beneficiary’s medical record of therapy services for each required reporting Documentation must be completed by: The qualified therapist furnishing the therapy services The physician/NPP personally furnishing the therapy services The qualified therapist furnishing services incident to the physician/NPP The physician/NPP for incident to services furnished by “qualified personnel” who are not qualified therapists The qualified therapist furnishing the PT, OT, or SLP services in a CORF Clinician should document the G-codes and modifiers used on the claim, including how modifier selection was made, where the therapist: Uses a single functional assessment tool Uses more than one functional assessment tool/measurement instrument to determine modifier OR Uses clinical judgment to determine the modifier

55 Change Request 8005 New Progress Report Requirement:
Progress reporting required on or before every 10th treatment day Previously, the progress report was due every 10th treatment day or 30 calendar day, whichever was less

56 Change Request 8005 Palmetto GBA References: Job aids
Outpatient Therapy Functional Reporting Claim Requirements Job Aid Outpatient Therapy Functional Reporting Documentation Requirements Job Aid Frequently Asked Questions (FAQs)

57 Change Request 8105 Update for Amendments, Corrections and Delayed Entries in Medical Documentation Effective date: January 8, 2013 Implementation: January 8, 2013 Summary of changes: The purpose of this CR is to provide instructions to contractors regarding amended, corrected, and delayed entries in medical records This section applies to MACs, CERT, Recovery Auditors, and ZPICs, as indicated. A. Amendments, Corrections and Delayed Entries in Medical Documentation Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service. When making review determinations the MACs, CERT, Recovery Auditors, and ZPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described in section B below. The MACs, CERT, Recovery Auditors, and ZPICs shall NOT consider any entries that do not comply with the principles listed in section B below, even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration. B. Recordkeeping Principles Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must: 1. Clearly and permanently identify any amendment, correction or delayed entry as such, and 2. Clearly indicate the date and author of any amendment, correction or delayed entry, and 3. Not delete but instead clearly identify all original content Paper Medical Records: When correcting a paper medical record, these principles are generally accomplished by using a single line strike through so that the original content is still readable. Further, the author of the alteration must sign and date the revision. Similarly, amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Electronic Health Records (EHR): Medical record keeping within an EHR deserves special considerations; however, the principles wed above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must: a. Distinctly identify any amendment, correction or delayed entry, and b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record. C. If the MACs, CERT or Recovery Auditors identify medical documentation with potentially fraudulent entries, the reviewers shall refer the cases to the ZPIC and may consider referring to the RO and State Agency. MM8105

58 J11 Medicare Part B Update - Fall 2011
Change Request 8007 New Informational Unsolicited Response (IUR) Process to Identify Previously Paid Claims for Services Furnished to Incarcerated Medicare Beneficiaries Effective date: April 1, 2013 Implementation date: April 1, 2013 Background: Under Sections 1862(a)(2) and (3) of the Social Security Act, the Medicare program will not pay for services if the beneficiary has no legal obligation to pay for the services and if the services are paid for directly or indirectly by a governmental entity. Accordingly, the Centers for Medicare &Medicaid Services (CMS) presumes that a State or local government entity that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of medical services and Medicare will, generally, not reimburse claims for services rendered to a beneficiary while he/she is in such custody. Regulations at 42 Code of Federal Regulations (CFR) §411.4(b) state that “Payment may be made for services furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met: (1) State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody, and (2) The State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursing the collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.” Federal benefit entitlement information is provided to CMS by the Social Security Administration (SSA) on a daily basis. Such information is housed in the Enrollment Database (EDB) within the Common Working File (CWF) and is used in the adjudication of claims for healthcare services provided to Medicare beneficiaries. When the SSA learns of a beneficiary’s incarceration, the beneficiary’s record in the EDB is updated to reflect that fact and the effective date (or “Start date”) of the incarceration. CMS Transmittal AB , Change Request (CR) 2022, issued on November 8, 2002, implemented a CWF edit to reject services billed to Medicare when information in the EDB indicates that, on the date of service, the beneficiary was incarcerated. Upon receipt of this CWF rejection, claims administration contractors were instructed to deny the claim(s). The Office of Inspector General (OIG) has recently identified a vulnerability where there may be, in some instances, a period of time between when the beneficiary is incarcerated and when the SSA learns of this status and updates its records (and the CWF is subsequently updated). During this time, it’s possible that Medicare fee-for-service claims for services would be paid erroneously because the beneficiary’s entitlement data in the EDB is not up-to-date when the claims are adjudicated. CMS has identified the Informational Unsolicited Response (IUR) process within CWF as a means to mitigate this vulnerability. An IUR identifies a claim that appears to need to be adjusted by a Medicare claims administration contractor. The CWF does not cancel the claim but returns information in Trailer 24. Upon receipt of the IUR the shared system software reads the trailer for each claim and an automated adjustment is performed. The contractor, when appropriate, initiates overpayment recovery procedures to retract Part A and/or Part B payment and generates an adjustment to update or cancel the claim on CWF and contractor history. Therefore, the intent of this CR is to create a new IUR process to identify and perform retroactive adjustments on any previously paid claims which may have been processed and paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was incarcerated. MM8007 Palmetto GBA - J11 Part B 58

59 Change Request 8007 The intent of this CR is to create a new IUR process to identify and perform retroactive adjustments on any previously paid claims which may have been paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was incarcerated As with all IURs they receive, the MACs shall initiate overpayment recovery procedures to retract any Medicare Part A and/or Part B payments and generate adjustments to update or cancel the claims on CWF and contractor history Medicare does not pay for medical items/services furnished to beneficiary who was incarcerated on the date of service that the items/services were furnished. As such, CWF shall create a new IUR process to identify previously paid claims that contain dates of service (DOS) that partially or fully overlap a period when the beneficiary was incarcerated. ***Details and exceptions noted in the business requirements**

60 Change Request 8009 New Informational Unsolicited Response (IUR) Process to Identify Previously Paid Claims for Services Furnished to Medicare Beneficiaries Classified as "Unlawfully Present" in the United States Effective date: April 1, 2013 Implementation date: April 1, 2013 Background: Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) prohibited aliens who are not “qualified aliens” from receiving Federal benefits, including Medicare benefits. Consistent with this legislation, § of Chapter 1 of the Internet Only Manual (IOM) Publication Medicare Claims Processing Manual states that “Medicare payment may not be made for items and services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service.” Federal benefit entitlement information is provided to the Centers for Medicare &Medicaid Services (CMS) by the Social Security Administration (SSA) on a daily basis. Such information is housed in the Enrollment Database (EDB) within the Common Working File (CWF) and is used in the adjudication of claims for healthcare services provided to Medicare beneficiaries. When the SSA learns of a beneficiary’s status as “unlawfully present” in the United States, the beneficiary’s record in the EDB is updated to reflect that fact and the effective date of that status. CMS Transmittal AB , Change Request (CR) 2825, issued on August 1, 2003, implemented a CWF edit to reject services billed to Medicare when information in the EDB indicates that, on the date of service, the beneficiary was not lawfully present in the United States. Upon receipt of this CWF rejection, claims administration contractors were instructed to deny the claim or claims. The Office of Inspector General (OIG) has identified a vulnerability where there may be, in some instances, a period of time between when the beneficiary is deemed to be unlawfully present in the United States and when the SSA learns of this status and updates its records (and the CWF is subsequently updated). During this time, it’s possible that Medicare fee-for-service claims for services would be paid erroneously because the beneficiary’s entitlement data in the EDB is not up-to-date when the claims are adjudicated. CMS has identified the Informational Unsolicited Response (IUR) process within CWF as a means to mitigate this vulnerability. An IUR identifies a claim that needs to be adjusted by a Medicare claims administration contractor. The CWF does not cancel the claim but returns information in Trailer 24. Upon receipt of the IUR the shared system software reads the trailer for each claim and an automated adjustment is performed. The contractor, when appropriate, initiates overpayment recovery procedures to retract Part A and/or Part B payment and generates an adjustment to update or cancel the claim on CWF and contractor history. Therefore, CMS is creating a new IUR process to identify and perform retroactive adjustments on any previously paid claims which may have been paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was unlawfully present in the United States. MM8009 60

61 Change Request 8009 Summary of changes:
The intent of this CR is to create a new IUR process to identify and perform retroactive adjustments on any previously paid claims which may have been paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was unlawfully present in the United States As with all IURs they receive, the MACs shall initiate overpayment recovery procedures to retract any Medicare Part A and/or Part B payments and generate adjustments to update or cancel the claims on CWF and contractor history Medicare does not pay for medical items/services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service that the items/services were furnished. As such, CWF shall create a new IUR process to identify previously paid claims that contain dates of service (DOS) that partially or fully overlap a period when the beneficiary was unlawfully present in the United States ***Details and exceptions noted in the business requirements**

62 Change Request 8044 Manual Updates to Clarify Skilled Nursing Facility (SNF) Claims Processing Effective date: April 1, 2013 Implementation date: April 1, 2013 MM8044 62

63 Change Request 8044 Summary of changes:
The intent of this CR is to notify providers that CMS has updated the manuals by adding policy CLARIFICATIONS pertaining to the SNF consolidated billing provision and claims processing but no new policies The purpose of CR 8044 is to update the Medicare manuals to clarify key components of SNF claims processing. The changes are intended only to clarify the existing policies. No new policies are contained in CR The updated manuals and sections are as follows: Chapters 1 and 3 of the 'Medicare General Information, Eligibility, and Entitlement Manual' are revised to explain that the various Part A benefit categories are subject to separate and mutually exclusive day limits and explain the start and the end of a benefit period in a SNF Chapter 6 of the 'Medicare Claims Processing Manual' is revised to clarify the meaning of Part B Consolidated Billing (CB) for a SNF and explains that the SNF CB excludes certain practitioner services, emergency services performed in hospitals, hospice services, certain chemotherapy drugs, ambulance services, vaccines, certain therapy services and certain dialysis services Chapters 8 and 15 of the 'Medicare Benefit Policy Manual' are revised to clarify the conditions under which SNF services may be covered; daily skilled services is clarified to mean that, unless there is a legitimate medical need for scheduling a skilled service each day, the 'daily basis' requirement for SNF coverage would not be met; for rental and purchase of DME for home use, assisted living facilities and Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) are provided as specific examples of a type of institution that is not a hospital or SNF and, therefore, can meet the definition of a beneficiary's 'home' in this context.

64 Change Request 8044 Manual clarifications including information on:
The Definition of An Inpatient for Starting or Ending a Benefit Period Part B Consolidated Billing and exclusions Emergency Services Hospice care Certain Chemotherapy Drugs Ambulance Services Screening and Preventive Services Therapy Services The Three Day Qualifying Hospital Stay Daily Skilled Service The Definition of a Beneficiary's Home for Part B Durable Medical Equipment (DME) coverage

65 MLN Matters Article SE1249 HIPAA Eligibility Transaction System (HETS) to Replace Common Working File (CWF) Medicare Beneficiary Health Insurance Eligibility Queries Provider Action Needed The Centers for Medicare & Medicaid Services (CMS) is publishing this article to advise you to immediately begin transitioning to HETS for your eligibility information. This article describes upcoming changes to Medicare beneficiary health insurance eligibility inquiry services that the Centers for Medicare & Medicaid Services (CMS) will implement in the coming months. By April 2013, access to CWF eligibility query functions implemented in the Multi-Carrier System (MCS) and VIPs Medicare System (VMS), also referred to as PPTN and VPIQ, will be terminated. CMS intends to terminate access to the other CWF eligibility queries implemented in the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE), often referred to the HIQA, HIQH, ELGA and ELGH screens and HUQA, soon thereafter. This will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information from Medicare Contractor’s Interactive Voice Response (IVR) units and/or Internet portals. SE1249

66 Important Billing Information

67 PET for Solitary Pulmonary Nodule (SPN)
Palmetto GBA covers PET scan for SPN The following codes must be on the UB04: SPN – ICD-9 Code CPT code 78811, 78812, 78813, 78814, 78815 or 78816 Palmetto GBA covers FDG PET scan for Solitary Pulmonary Nodule (SPN). When submitting a claim the following code must be on the UB04. SPN – ICD-9 Code must be in Form Locator (FL) 67A CPT code 78811, 78812, 78813, 78814, or 78816

68 PET for Solitary Pulmonary Nodule (SPN)
The following must be on the UB04 continued . . . In the 'remarks' section ONE of the following diagnostic reasons must be present: indeterminate prior chest x-ray must be written as: 1XR indeterminate prior CT scan must be written as: 2CT biopsy proven or strong suspicion of malignancy must be written as: 3BX Notes: Remarks must be written exactly as above (i.e. 1XR, 2CT or 3BX) If more than one diagnostic test was performed, submit only the test that lead to performing the PET scan This information must be the ONLY information in remarks on this claim In FL 80 'remarks' section one of the following diagnostic reasons - must be present to indicate the clinical reason for doing the PET scan: indeterminate prior chest x-ray must be written as: 1XR indeterminate prior CT scan must be written as: 2CT biopsy proven or strong suspicion of malignancy must be written as: 3BX When coding this information in FL 80 you must write it exactly as above (i.e. 1XR, 2CT or 3BX). If more than one diagnostic test was performed, submit only the one test that lead to performing the PET scan. This information must be the only information in FL 80 for the claim to process correctly. If any additional verbiage is written in this position, the system will read it as an error and the claim will not process and will be returned.

69 PET for Solitary Pulmonary Nodule (SPN)
Effective for dates of service February 1, and after If the patient has a diagnosis of SPN but the PET scan is being performed for a reason unrelated to the SPN itself, do not code the in the PRIMARY diagnoses field The SPN should be reported on the claim as a SECONDARY diagnosis Effective for dates of service February 1, 2013 and after, if the patient has a diagnosis of solitary pulmonary nodule but the PET scan is being performed for a reason completely unrelated to the solitary pulmonary nodule itself, do not code the (solitary pulmonary nodule) in the primary diagnoses field (Form Locator 67A). In such cases, the solitary pulmonary nodule should be reported on the claim as a secondary diagnosis per CMS On-Line Manual, Pub , Medicare Claims Processing Manual, Chapter 23, § and §

70 HOT OFF THE PRESS - Sequestration Information!
March 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC)

71 TDL 12438 Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration” Medicare FFS claims with dates-of-service or dates-of- discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments Note: Beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months As required by law, President Obama issued a sequestration order on March 1, 2013 March 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC)

72 Data Analysis Palmetto GBA generates monthly data analysis reports
Top 15 billing errors Medical review denials Top CERT claims errors We then make quarterly updates to our website sections

73 Top Billing Error Reason Code 15202
FISS Narrative: When this reason code is received on an inpatient hospital or inpatient Skilled Nursing Facility (SNF) claim (TOB 11x, 21X or 18x), it typically means that a discrepancy exists between the covered days billed and the covered accommodation units billed Important Note: Accommodation units are recognized as revenue codes 010x-021x, excluding 018x (leave of absence) and 019x (sub-acute care) When this reason code is received on an inpatient hospital or inpatient Skilled Nursing Facility (SNF) claim (TOB 11x, 21X or 18x), it typically means that a discrepancy exists between the covered days billed and the covered accommodation units billed. Important Note Accommodation units are recognized as revenue codes 010x-021x, excluding 018x (leave of absence) and 019x (sub-acute care).

74 Top Billing Error Reason Code 15202 continued . . .
Resources and Tips to Avoid or Correct RTP Claim: Verify the covered days and that the accommodation unit/revenue code lines are billed appropriately. Examples of billing issues include: Non-covered Revenue code 018x or 019x are not counted as covered A line level edit has assigned on the accommodation unit/revenue code line Resources and Tips to Avoid or Correct RTP Claim Verify the covered days and that the accommodation unit/revenue code lines are billed appropriately. Examples of billing issues include: Non-covered Revenue code 018x or 019x are not counted as covered A line level edit has assigned on the accommodation unit/revenue code line

75 Top Billing Error Reason Code 15202 continued . . .
Resources and Tips to Avoid or Correct RTP Claim Continued . . . Days billed do not match accommodation unit/revenue code and charges are billed as non- covered An exception to this rule for TOB 11x would be when an occurrence span code 70 is present due to cost outlier situation Resources and Tips to Avoid or Correct RTP Claim Continued Days billed do not match accommodation unit/revenue code and charges are billed as non-covered. An exception to this rule for TOB 11x would be when an occurrence span code 70 is present due to cost outlier situation.

76 Top Billing Error Reason Code 15202 continued . . .
Resources and Tips to Avoid or Correct RTP Claim Continued . . . Non-covered days are present and only accommodation unit/revenue code lines have been billed as non-covered Ancillary charges for non-covered days should be billed as non-covered Outpatient claims should not be billed with days and/or accommodation unit/revenue codes Resources and Tips to Avoid or Correct RTP Claim Continued Non-covered days are present and only accommodation unit/revenue code lines have been billed as non-covered. Ancillary charges for non-covered days should be billed as non-covered. Outpatient claims should not be billed with days and/or accommodation unit/revenue codes

77 Top Billing Error Reason Code 15202 continued . . .
SNF Specific Resources and Tips: All revenue code 0022 units must match the accommodation units/revenue codes If reporting a leave of absence (LOA) with occurrence span code (OSC) 74; must report revenue code 0180 days without charges The OSC 74 dates must reflect the days the patient was absent at midnight from the SNF and match the 0180 unit count When billing with a 30 patient status code; count the day/units as covered SNF Specific Resources and Tips: All revenue code 0022 units must match the accommodation units/revenue codes If reporting a leave of absence with occurrence span code (OSC) 74; must report revenue code 0180 days without charges. The OSC 74 dates must reflect the days the patient was absence at midnight from the SNF and match the 0180 unit count. When billing with a 30 patient status code; count the day/units as covered

78 Top Billing Error Reason Code 15202 continued . . .
SNF Specific Resources and Tips Continued When reporting lower level of care (occurrence code 22); count the day/units Note: that the date the patient moves to a lower level of care, is the “Through” date of that claim. If applicable, refer to Section 40.8 Billing in Benefits Exhaust and No Payment Situations (PDF, 448 KB) SNF Specific Resources and Tips continued: When reporting lower level of care (occurrence code 22); count the day/units. Please note: that the date the patient moves to a lower level of care, is the Through date of that claim. The following claim(s) are billed according to: Section Other Billing Situations (PDF, 448 KB). If applicable, refer to Section 40.8 Billing in Benefits Exhaust and No Payment Situations (PDF, 448 KB)

79 Top Billing Error Reason Code 15202 continued . . .
Explanation and Suggestion: If a correction is required to the accommodation units/revenue code line, you will have to delete the entire line and re-key the line before resubmitting the claim Review the days available in the Common Working File (CWF) If you submitted an outpatient claim, delete days and/or accommodation units/revenue code lines before resubmitting the claim To correct the RTP claim, make the necessary corrections and resubmit the claim Recommendations: If a correction is required to the accommodation units/revenue code line, you will have to delete the entire line and re-key the line before resubmitting the claim. This will ensure any prior reason code assigned on this line is removed. Review the days available in direct data entry (DDE) on the 'ELGA' (eligibility A) screen If you submitted an outpatient claim, delete days and/or accommodation units/revenue code lines before resubmitting the claim To correct the RTP claim, make the necessary corrections and resubmit the claim.

80 Expedite Reimbursement -Track your claims!
What do you do? Expedite Reimbursement -Track your claims!

81 Status/Location S/LOC = Status/Location of the claim
Know the Status and Location of your claims at all times Status tells you what you can or cannot do to the claim Location tells you where the claim is located in the claims processing system Before we go into Claims Inquiries to look at the claims that we’ve submitted…, we need to understand S/LOC. When you are looking at your claims in the DDE system you ALWAYS want to know what status and location they are in. Page 3 of the DDE has detailed descriptions of the most common status and locations.

82 DDE Status/Location Codes
Explanation P The claim is completely processed (either fully or partially paid) D The claim is completely processed and was denied R The claim is completely processed and was rejected S The claim is still in process Note: [no provider intervention can be made other than responding to Additional Documentation Request (ADR) if applicable] T The claim has been returned to provider (RTP) for correction I The Intermediary has either inactivated OR specially processed your claim. *RTPs more than 60 days old and suppressed claims are moved to an “I B9997” status for 3 yrs then purged When you are looking at your claims in the DDE system you will want to know what status and location they are in. 82

83 Status/Location Example: S/LOC = T/B9997
First Position is Claims Current Status ‘T’ status = Claim needs corrections Second Position is the Claim Processing Type ‘B’ = claim is electronic ‘M’ = claim is manual Medical review may be processing The Third and Fourth Positions are the Location of the Claim Last Two Positions are For Additional Location Information This is a breakdown of the status and location positions. READ SLIDE I’ll go through the definitions of each status on the next slides

84 Claims Submission Error Help
The claims submission error help tool is one self-service tool that providers have available to assist them with the top RTP reason codes and how to avid/resolve them if they are received on a claim. These codes are updated monthly on the Web site.

85 Status and Locations of Claims
Additional information available related to the status and location of claims Electronic Data Interchange (EDI) Software and Manuals Direct Data Entry (DDE) Manual

86 Did You Know?

87 Provider Enrollment Revalidation Initiative
Notices will be sent through March 2015! J11 Part A/HHH 475 Revalidations planned to be mailed between 1/31/2013 through 3/29/2013 Provider Enrollment Resources: Provider Enrollment Application Status Lookup tool https://pecos.cms.hhs.gov

88 Event Registration Portal
Every user will need to create a user profile Once created, you must login to the system in order to be able to register for events See our Navigating Palmetto GBA’s Event Registration Portal Job Aid for more detailed instructions: nsf/DocsCat/Providers~Jurisdiction%2011%20H ome%20Health%20and%20Hospice~Learning% 20Education~Job%20Aids~8YZHU82488?open &navmenu=||

89 Event Registration Portal

90 EDI System Status Log

91 Foresee Survey We listen to you!
Based off of content, functionality, look and feel, navigation, search and site performance.

92 Web Site Enhancements Based Off Data Analysis
Self Service Tools have also been created, like the Provider Enrollment Application Status Tool. We are in the process of creating an Appeals status tool as well. These tools will allow providers to access the Web site instead of making a call to the PCC in order to get an answer to their question.

93 Online Provider Services (OPS)
Are You Using OPS?

94 OPS The OPS application provides real-time information access over the Web for the following online services: Eligibility Claims status Remittances Online Financial Information (payment floor and last 3 checks paid)

95 OPS The OPS application provides real-time information access over the Web for the following online services: NEW! Secure Forms- Redeterminations can be submitted online in OPS E-offset- Request immediate offset of demanded overpayments or Request permanent immediate offset for all future overpayments E-check functionality- Submit a check to repay a Medicare overpayment The attachment limit for Redeterminations is 5MG per attachment. The provider can load up to 5 attachments for an appeal. So the total limit is 20MG. This is a limit we established with iFlow. If the customer has a large attachment, they need to break it down into smaller attachments. They can either scan them in separately or break it apart if they have Adobe Acrobat. Make Your Payment ELECTRONICALLY! You can now submit your payment or a request for an immediate offset electronically via Online Provider Services (OPS). The E-check / E-Offset features are easily accessible from the Financial Tools Tab or the Message Inbox drop down menu. Benefits of using E-Check or E-Offset:           ** Save $$ on postage expense and no more lengthy mail time           ** Immediate confirmation of receipt by Palmetto GBA           ** Assigned a document control number allowing you to check status of payment via OPS           ** Electronically attach PDF file for related documentation

96 OPS Goal of Updates Latest Updates Added phone number and extension
validation required Added provider, billing service or clearinghouse selection Goal of Updates Allows OPS staff to be able to contact the OPS user quickly

97 OPS Lock-out Removes or inactivates users if they have not logged in within 90 days of the current date If all Provider Administrators are inactive, all users are removed If there is at least one active Provider Administrator, no active users will be removed

98 OPS The removal process runs nightly
If removed, the Provider User must contact their active Provider Administrator for access and a new User ID If the entire account is removed, the Provider Administrator must register again

99 OPS COMING SOON: Palmetto GBA proposes to implement the following functions: Secure messaging

100 OPS Support/Troubleshooting Contact Us on each page
Frequently Asked Questions (FAQs) on PalmettoGBA.com/J11A Access to Technology Support Center (TSC) for inquiry and issue

101 International Classification of Diseases (ICD-10)
A key element of the data foundation of the United States’ health care system will undergo a major transformation Although the ICD-10 deadline has changed to October 1, 2014, it is important to continue planning for the transition to ICD-10

102 ICD-10 This transition will have a major impact on anyone who uses health care information that contains a diagnosis and/or inpatient procedure code, including: Hospitals Health care practitioners and institutions Health insurers and other third-party payers Electronic-transaction clearinghouses Hardware and software manufacturers and vendors Billing and practice-management service providers Health care administrative and oversight agencies Public and private health care research institutions

103 ICD-10 A critical step in planning for the transition is to conduct an impact assessment of how the new code sets will affect your organization Your impact assessment should include:  Documentation Changes Reimbursement Structures Systems and Vendor Contracts Business Practices Testing Develop internal processes now..

104 Educational Resources
Available on the J11 Part A home page Click on the Resources link and you’ll find links to the following tools: Forms Departmental information such as Appeals, Audit Reimbursement and Provider Enrollment Tools and Calculators Click on the Learning and Education link Job Aids on topics including overpayments, outpatient therapy functional reporting and the Medicare claims processing system

105 Educational Resources
Other Important Resources: Medicare Fee-for-Service Payment CMS Internet Only Manuals (IOMs) Explanation of Change Requests, training guides, articles, educational tools, booklets, brochures, fact sheets, web- based training courses Be sure to check your monthly Medicare Advisory

106 Additional Information
For additional information on any of the topics covered during our presentation today Visit the J11 Part A website at Please direct your questions to the J11 Part A Provider Contact Center (PCC) at

107 Thank You! Thank you for participating in the educational session today Please ensure that you and your staff review the change requests we covered in more detail


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