1. Medicare Updates from WPS GHA
AAHAM Hawthorn Chapter
& HFMA of Greater St. Louis

2. (CMS Internet-Only Manual (IOM) 100-09, Chapter 6, Section 20.8.6.)
CMS prohibits any entity other than WPS GHA or CMS from recording this presentation.
(CMS Internet-Only Manual (IOM) , Chapter 6, Section )

3. Agenda Program News and Updates Medicare Outpatient Observation Notice
Discarded Drugs – JW modifier
Social Security Number Removal Initiative
Changes for Quality of Care Reviews

4. Agenda Announcements Midwestern UPIC
New Recovery Audit Contractor (RAC)
WPS GHA Portal
Multi-Factor Authentication
A Day With Medicare

5. Program News and Updates
Recent and Upcoming Changes
Program News and Updates

6. Medicare Outpatient Observation Notice (MOON)
The NOTICE Act
Medicare Outpatient Observation Notice (MOON)

7. NOTICE Act Inform patient of implications of observation status
Not a Part A benefit
Possible increase in cost sharing
Does not count toward 3 day qualifying stay
Required for SNF coverage

8. Required March 8, 2017 The MOON
Standardized notice required by all hospitals
Including critical access
Required March 8, 2017

9. Who Receives the MOON Given to beneficiaries who are:
Entitled to Medicare benefits
Even if:
No Part B coverage
Member of MA plan
Medicare isn’t primary
Receiving observation services > 24 hours
Even if subsequently admitted as inpatient or transferred

10. Written and Oral Notice
Deliver written notice
No later than 36 hours after start of observation services
Sooner if discharged or admitted as inpatient
Oral explanation also required
In conjunction with written notice
Document that explanation was provided

11. Signature Requirement
Must be signed by patient or their representative
Staff giving notice signs if patient refuses
Must include:
Name and title of staff member
Statement certifying notice was presented
Date and time of refusal

12. 24 Hour Timeframe Clock time documented in chart
Patient begins receiving observation services
In accordance with physician’s order
24 hours measured in “elapsed” time
Not billed time

13. Observation Time Ends
All medically necessary observation services are completed
Could coincide with or occur before discharge

14. Modifier JW
Discarded Drugs

15. Policy for JW Modifier
Indicates drug discarded/not administered to any patient
Single dose vial
Single use package
Mandatory as of January 1, 2017
Prior use at MAC discretion
Document discarded drug in medical record

16. Applies To
Physician’s office
CAH
OPPS
Status indicator “G” or “K”
ASC

17. Does Not Apply To Inpatient settings RHC FQHC
Pharmacies and compounding pharmacies

18. Inappropriate Use Multi-dose vials Unlisted drugs
No payment expected from any payer
Drugs under Competitive Acquisition Program (CAP)
Amount discarded cannot be quantified
Services packaged into APC rates
Status indicator “N”
Drugs dispensed, but not administered

19. Documentation Medical record must contain Amount of drug administered
Amount of drug discarded

20. Billing 2 separate lines on same claim
Number of units administered
Number of units discarded
With JW modifier
Charges for each line should reflect amount billed
Coinsurance and deductible applied

21. Example 1 Single use vial 90 units administered 10 units discarded
100 units of drug
90 units administered
Billed on one line
10 units discarded
Billed on second line with JW modifier

22. Example 2 Single use vial 20 mg administered 5 mg discarded
1 unit = 25 mg
20 mg administered
5 mg discarded
Single line billed with 1 unit
JW not appropriate

23. Overfill
Discarded drug policy does not apply to “intentional overfill”
ASP based on FDA approved label
Amount in excess
No expense to provider
Cannot bill Medicare

24. Social Security Number Removal Initiative
New Numbers, New Cards
Social Security Number Removal Initiative

25. Background HIC contains SSN of primary beneficiary
Prefix or suffix gives additional details
New rules mandated by MACRA
Decrease risk of identity theft
Increase safety of Program funds
Unique numbers and redesigned cards
Deceased, active and new beneficiaries

26. Medicare Beneficiary Identifier
Where:
C – Numeric 1 thru 9
A – Alphabetic Character (A...Z); Excluding (S, L, O, I, B, Z)
N – Numeric 0 thru 9
AN – Either A or N
***NOTE: Alphabetic characters are Upper Case ONLY
Position 1 – numeric values 1 thru 9
Position 2 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
Position 3 – alpha-numeric values 0 thru 9 and A thru Z
(minus S, L, O, I, B, Z)
Position 4 – numeric values 0 thru 9
Position 5 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
Position 6 – alpha-numeric values 0 thru 9 and A thru Z
Position 7 – numeric values 0 thru 9
Position 8 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
Position 9 – alphabetic values A thru Z (minus S, L, O, I, B, Z)
Position 10 – numeric values 0 thru 9
Position 11 – numeric values 0 thru 9

27. Transition Timeline Systems ready by 4/1/18
HIC or MBI used until 12/31/19

28. During Transition Message on eligibility response when new card sent
RA will include MBI if HIC was used
Beginning 10/1/18
Limited use of HIC after transition period
Appeals, adjustments, etc.

29. Changes for Quality of Care Reviews
QIO Manual Update
Changes for Quality of Care Reviews

30. Beneficiary Complaints
Quality of Care Reviews
Providers
14 days to send medical records
Once record request received
Faxing records recommended
QIO
30 days to complete review

31. Good to Know
Announcements

32. Integrating Safeguard Functions
Midwestern UPIC

33. Integrating Integrity
UPIC
ZPIC/PSC
Medicare
Medicaid MIC

34. Midwestern Jurisdiction
Administered by AdvanceMed
Eliminate duplication
Improve efficiency
Detection and prevention of fraud, waste and abuse

35. New Recovery Audit Contractor (RAC)
Cotiviti
New Recovery Audit Contractor (RAC)

36. Cotiviti Recovery Auditor for Regions 2 & 3
Teleconference held 02/09/17
Recording of call in WPS GHA’s Learning Center

37. Combining Websites to Serve You Better
WPS GHA Portal

38. And the Two Shall Become One
WPSGHA
.com
(Portal)
MedicareInfo
.com
(C-SNAP)
WPSMedicare.com

39. Welcome to the WPS GHA Portal
WPS GHA’s new provider on-line experience

40. Public vs. Transactional Functions
No PHI or PII
No login required
LCDs
News
Education information
Articles
Departmental information
Fees
Contains PHI and/or PII
Unique user name and password required for login
Used to check:
Eligibility
Claim status
Redetermination status
Online RAs

41. Multi-Factor Authentication
Don’t Delay, Opt-In Today!
Multi-Factor Authentication

42. Multi-Factor Authentication (MFA)
CMS requirement
Voluntary
For now!
Unique temporary code to verify identification
To access transactional side of Portal

43. Education Opportunities!
WPS GHA’s Learning Center & ADWM
Education Opportunities!

44. WPS GHA’s Learning Center
Online access to WPS GHA education
Live Events
On-Demand training
Certificate of Achievement
Available after completion of all course content
May include pre/post assessment
May include a follow up survey
May be turned into accrediting organizations for CEUs

45. WPS GHA’s Learning Center

46. A Day With Medicare Who What Why When Where How (much)
Any provider in Jurisdiction 5
What
12 breakout sessions
Keynote speaker
Q & A forum
Why
Opportunity for education
Improve National Paid Claims Error Rate
When
April 25, 2017
July 11, 2017
July 13, 2017
Where
St. Charles, MO
Salina, KS
Des Moines, IA
How (much)
Free!

47. Questions

48. Disclaimer
WPS GHA has produced this material as an informational reference. Every reasonable effort has been made to ensure the accuracy of this information at the time of publication. WPS GHA makes no guarantee that this information is error-free and bears no liability for the results or consequences of the misuse of this information. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at

49. Thank You!