Transcript Comprehensive Error Rate Testing (CERT) Center

MD AAHAM
Medicare Part A Presents:
Manual Medical Review Therapy Exception
Process and Therapy Coverage
November 16, 2012
Disclaimer
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All Current Procedural Terminology (CPT) codes and descriptors used in this presentation
are copyright© by the American Medical Association. All rights reserved.
The information enclosed was current at the time it was presented. Medicare policy
changes frequently; links to the source documents have been provided within the
document for your reference. This presentation was prepared as a tool to assist providers
and is not intended to grant rights or impose obligations.
Although every reasonable effort has been made to assure the accuracy of the information
within these pages, the ultimate responsibility for the correct submission of claims and
response to any remittance advice lies with the provider of services.
Novitas Solutions employees, agents, and staff make no representation, warranty, or
guarantee that this compilation of Medicare information is error-free and will bear no
responsibility or liability for the results or consequences of the use of this guide.
This presentation is a general summary that explains certain aspects of the Medicare
program, but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings.
Novitas Solutions does not permit videotaping or audio recording of training events.
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Agenda
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Change Requests 8036 and 7881
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Frequently Asked Questions
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Coverage and Documentation
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Part A Claim Requirements
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Comprehensive Error Rate Testing Program
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Self Service Options
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Manual Medical Review of
Therapy Services
Change Request 8036
Change Request 7881 Expiration of 2012 Therapy
Cap Revisions and User-Controlled Mechanism to
Identify Legislative Effective Dates
Middle Class Tax Relief and
Job Creation Act of 2012
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Section 3005 -Middle Class Tax Relief and
Job Creation Act of 2012
Effective October 1, 2012
All requests for therapy services above
$3700 need to be pre approved
No automatic exception to this new process
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Manual Medical Review of Therapy
Services Provider Bulletin
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Issued September 7, 2012
Outlines Novitas Solutions structure on how we
are handing Manual Medical Review of Therapy
Coversheets for submitting a request included
with the bulletin
For more information, please view the bulletin:
https://www.novitassolutions.com/bulletins/all/news-09072012.html
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Therapy Cap
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Certain providers are required to submit a
request for an exception in advance of
furnishing therapy services above the
threshold of $3,700.
The request will be manually medically
reviewed.
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Provider Settings
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Part B Skilled Nursing Facilities
Comprehensive Outpatient Rehabilitation
Facilities
Outpatient Rehabilitation Facilities
Private Practices
Home Health
Hospital Outpatient
◦ Except Critical Access Hospitals
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Caps/Threshold
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$3,700 for both Physical Therapy and
Speech Language Pathology
◦ $1,880; -KX with automatic exception
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$3,700 for Occupational Therapy
◦ $1,880; -KX with automatic exception
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Services on or after October 1 - December
31, 2012
◦ Without automatic exception, continue reporting
◦ -KX
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Phases
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Phase I
◦ October 1, 2012 through December 31, 2012
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Phase II
◦ November 1, 2012 through December 31, 2012
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Phase III
◦ December 1, 2012 through December 31, 2012
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Knowing Your Phase
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Therapy Provider Phase Information
◦ https://data.cms.gov/dataset/Therapy-ProviderPhase-Information/ucun-6i4t
◦ Listed by National Provider Identifier
◦ If not listed, placed in Phase III
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Submitting Pre-Claim Review
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Submit pre-approval no sooner than the
15th of the month prior to assigned Phase
Request pre-approval for a specific number
of days
Days should not exceed 20 per discipline
Decision will be made within 10 business
days
◦ By letter, phone, or fax
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Documentation Required for
Pre-Approval
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Beneficiary Last Name
Beneficiary First Name
Beneficiary Middle Initial
Beneficiary Medicare Claim Number (HICN)
Beneficiary Date of Birth
Beneficiary Address and Telephone Number
Name and address of Provider Certifying
Plan of Care
Telephone and Fax Number of Provider
Certifying Plan of Care
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Documentation Required for
Pre-Approval continued
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National Provider Identifier (NPI) of
Physician/Non-Physician Practitioner Certifying
Plan of Care
Name of Performing Provider
Address of Performing Provider
NPI of the Performing Provider
Telephone and Fax Number of Performing
Provider
Number of Treatment Days Requested
Expected Date Range of Services
Date of Submission
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Approvals
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Approvals
◦ Providers and Beneficiaries
 Notified within 10 business days by letter, phone or
fax
◦ Failure to make decision = automatic approval of
request
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Denials
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Denials
◦ Providers and Beneficiaries
 Notified within 10 business days by letter, phone or
fax
◦ Include detailed reason(s) for the determination
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Unapproved services rendered will be
denied
◦ Submit an Appeal
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Unapproved Services
Not Rendered
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Send a new preapproval request only when
◦ The original request was denied
◦ Additional information is available
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Pre-Claim Review Requests
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All requests require the Therapy Cap Cover/
Transmittal Sheet
Can be requested by fax or mail
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Part A Therapy Cap Cover/
Transmittal Sheet
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To view the entire Part A form, refer to:
◦ https://www.novitassolutions.com/claims/therapy-cap/pdf/ther-capa.pdf
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Part A Pre-Claim Review
Requests
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Place the Therapy Cap Cover/Transmittal
Sheet on top of the Pre-authorization
request
Submit request
◦ By fax: 412-802-1833
◦ By mail:
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Novitas Solutions, Inc.
Therapy Cap Part A
Post Office Box 890365
Camp Hill, PA 17089-0365
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Beneficiary Liability
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When conditions for exception are not met
the beneficiary is financially responsible
There is no legal requirement to issue an
Advanced Beneficiary Notice (ABN)
◦ Voluntary ABNs are strongly recommended
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For Additional information, refer to:
◦ http://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/MedicalReview/TherapyCap.html
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Frequently Asked Questions
What Should I Expect?
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Upon receipt of the all requested records,
Novitas Solutions, Inc. will review the records
and make a decision (number of days approved
and/or denied).
This determination will be made using the
coverage and payment policy requirements
contained within Pub. 100-02, Section 220 of
the Medicare Benefit Policy Manual and any
applicable local coverage decisions when
making decisions as to whether a service shall
be preapproved.
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How will I know if my
Request is Approved?
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If Novitas Solutions, Inc. approves your request,
you will be notified of this decision within 10
business days via letter, telephone, or fax. The
beneficiary will also be notified of this approval
via telephone, fax, or letter.
If Novitas Solutions, Inc. fails to make a decision
within 10 business days, this will lead to an
automatic approval of the request. The provider
and beneficiary will be notified of this automatic
approval via telephone, fax, or letter.
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How will I know if my
Request is Denied?
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If the request for an exception is denied, Novitas Solutions will
provide notification via telephone, fax, or letter of denial to the
provider and beneficiary. This notification will include detailed
reason(s) for the determination.
If the provider furnishes the denied services and submits a claim, this
claim would not be payable under Medicare. The claim will be denied
and the beneficiary would be held liable.
A provider may render the services that are unapproved and submit
the claim, which shall be denied by Novitas Solutions, Inc. At that
time, the provider may request an appeal.
If the provider chooses to not render the unapproved services, they
may send in a new preapproval request only if they have additional
information to supply and the original request was denied.
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What Does the $3,700
Threshold Represent?
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The threshold represents the total allowed
charges under Part B for services furnished
by independent practitioners, and
institutional services under Part B (hospital
outpatient departments, skilled nursing
facilities).
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Does Therapy Provided in a
Critical Access Hospital (CAH)
Count?
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Services provided in a CAH are not counted,
and CAHs are not subject to the manual
medical review provision.
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How do I Determine if a Patient is
close to the cap or $3700 threshold?
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Total therapy dollars used is available in:
◦ Interactive Voice Response(IVR)
◦ Health Insurance Query Access (HIQA)
◦ The Common Working File (CWF)
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Reporting Requirements
New Part A Claim
Reporting Requirements
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Effective 10/1/2012, for outpatient therapy
services, Report Name and NPI of the
physician/NPP certifying the therapy plan of
care in the Attending Physician field
◦ UB-04 Paper Claims: Field Locator 76
◦ Direct Data Entry: Bottom of Page 3 (MAP1713)
◦ Electronic Claims: Loop 2310A
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Existing Claim Reporting
Requirements
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Continue to use therapy modifiers:
◦ Modifier GN: Service delivered personally by a speechlanguage pathologist or under an outpatient speechlanguage pathology plan of care
◦ Modifier GO: Service delivered personally by an
occupational therapist or under an outpatient
occupational therapy plan of care
◦ Modifier GP: Service delivered personally by a physical
therapist or under an outpatient physical therapy plan of
care
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KX Modifier on claims
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Reminder: Use of the KX Modifier is an
attestation from Provider or Supplier that:
◦ The services are reasonable and necessary
◦ There is documentation of medical necessity in
the patient’s medical record
◦ Other requirements specified in Internet Only
Manuals are met
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Append KX Modifier to applicable claims for
services above:
◦ The therapy caps of $1880
◦ The therapy thresholds of $3700
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Claims Exceeding the
$3700 Threshold
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All Claims for beneficiaries that meet or
exceed the $3700 threshold will suspend
◦ If provider is NOT in Phase, Novitas will process
your claim regularly
◦ If provider IS in Phase, then we’ll check:
 If pre-approval was granted, claim will be processed
 If pre-approval was denied, claim will be denied
 If pre-approval request was not submitted, we will
request medical records
Comprehensive Error Rate Testing (CERT)
Comprehensive Error Rate
Testing (CERT)
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National Claim Paid Error Rate
◦ Part A Institutional Facilities
 7.9% Inpatient hospitals
 4.4% Non-inpatient hospital facilities
◦ Part B Physician/Non-physician providers
 9.2% Physician, lab and ambulance
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Impacts all providers submitting Fee for Service claims
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Limited random claim sample
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Record requests must be received within 30 days from
the initial CERT letter
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Right to Appeal? Yes
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Common Part A Errors
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Insufficient documentation:
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Medical necessity errors:
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Missing physician's orders for billed dialysis treatments and/or diagnostic laboratory tests associated with the dialysis
treatments;
Missing valid orders for Epogen or Venofer and/or insufficient documentation to support Epogen dosing per the submitted
protocols and dosing algorithms;
Missing physician's progress notes or occupational therapy notations to support severity of conditions, comorbidities, or other
complexities necessitating the use of the KX modifier;
Medical record did not contain a valid physician’s order, documented order intent or clinical indication for the service, e.g.,
laboratory testing, medications, inpatient admission;
Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed;
No documentation submitted to support prior conservative treatment for the patient; therefore subsequent procedures were
deemed not medically reasonable and necessary, e.g., inpatient admission, medications, supplies; and
Lack of documentation (hospital inpatient discharge summary) to support 3 day qualifying stay prior to Skilled Nursing Facility
(SNF) admission.
Inpatient stays that were determined to not be medically reasonable and necessary based on the submitted
documentation. The medical record documentation that was submitted did not substantiate the beneficiary’s need for an
inpatient stay, but rather justified that the beneficiary’s condition could have been treated on an outpatient/observation
basis; and
Related services that were required as a result of the primary service were denied because the medical necessity of the primary
service was not justified, e.g. venipuncture, pathology services.
Incorrect coding errors:
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Incorrect number of units of medications billed specifically the administration of Epogen related to chronic kidney disease;
Incorrect laboratory tests billed, e.g. Complete Blood Count (CBC) with automated differential was performed (85025) and
billed when the physician only ordered a CBC (85027).
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Comprehensive Error Rate
Testing (CERT) Center
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Medical Record Requests
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Common Errors
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Articles and Frequently Asked Questions
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References and Contact Information
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https://www.novitassolutions.com/cert/index.html
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Website Changes
New Medical Policy Center
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New Medical Policy Search
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Self Service Options
Customer Service Center
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Customer Service Center
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Some of the items you can find in this new center
◦ Single Toll Free
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Call Flow
Step-by-Step guide to using the Interactive Voice Response (IVR)
◦ System Access
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Part A Fiscal Intermediary Standard System (FISS) User Guide
Part B Professional Provider Telecommunication Network (PPTN) Guide
◦ Frequently Asked Questions (FAQs)
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Top Provider Inquiries
◦ References
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AB Reference Manual
Part A Claims Issues Log
◦ Contact Information
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Inquiry Guide
Contact Us
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Customer Contact
Information
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Provider
◦ 1-877-235-8073
◦ Hours of Operation
 Monday: 8:00 am – 2:00 pm
 Tuesday – Friday: 8:00 am – 4:00 pm
◦ Call Flow
 Customer Service Center
 https://www.novitas-solutions.com/csc/index.html
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Interactive Voice Response (IVR)
◦ Hours of Operation
 Monday: 6:00 am – 8:00 pm
 Tuesday - Friday: 4:00 am – 8:00 pm
 Saturday: 6:00 am – 4:00 pm
◦ Step-by-Step Guide
 Customer Service Center
 https://www.novitas-solutions.com/csc/index.html
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Beneficiary Contact
Information
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Patient / Medicare Beneficiary
◦ 1-800-MEDICARE (1-800-633-4227)
 http://www.medicare.gov/default.aspx
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Part A Annual Recertification of Fiscal
Intermediary Standard System Logon
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Recertify active users with access to Direct
Data Entry (DDE) and the Health Insurance
Query Access (HIQA)
◦ Initial letter
 60 days to respond
◦ Second letter
 30 days to respond
◦ No response will result in the deletion of the
Resource Access Control Facility (RACF)
identification (ID) associated with the Provider
Transaction Access Number (PTAN)
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Fax to Image
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Were you aware records for an Additional Development Request (ADR) can be
faxed directly to Novitas Solutions?
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The fax to image option allows for documentation to be submitted directly to
Novitas Solutions.
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Available 24 hours a day, 7 days a week
Fax ADR response to 1-877-439-5479
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Faxes should not exceed 200 pages
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The original ADR request must be submitted as the cover sheet to the records
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Supporting documentation, or requested medical records, should follow the
ADR letter
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Each ADR request must be faxed separately
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Additional Tips
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https://www.novitas-solutions.com/bulletins/parta/newsletter/2012/jan.html
https://www.novitas-solutions.com/bulletins/partb/med-reports/pdf/mr0312.pdf
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Medicare Insights Weekly
Podcast
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Weekly podcast covering important
Medicare news and events
Automatically delivered
Easy to subscribe, just copy the link to your
podcast software
https://www.novitassolutions.com/podcasts/
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Medicare Part A & Part B
Center
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Our website offers a wide variety of valuable
resources including:
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A/B Reference Manual
Appeals
Cost Reporting & Reimbursement
Electronic Billing (EDI)
Frequently Asked Questions
News and Bulletins
Self-Service Tools
For additional resources visit:
◦ https://www.novitas-solutions.com/parta/index.html
◦ https://www.novitas-solutions.com/partb/index.html
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Mailing List
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Subscribe to our E-Mail Lists
◦ https://www.novitassolutions.com/mailinglists.html
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Available mailing lists
◦ Jurisdiction 12 Part A or Part B General Education
 Receives All Updates, except Electronic Data
Interchange (EDI)
◦ Jurisdiction 12 Part A or Part B Electronic Billers
(EDI)
◦ Part A & Part B PC-ACE Pro32 Users (EDI)
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Evaluation and Management
(E/M) Center
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Evaluation and Management (E/M) Center
◦ Offers an array of educational resources which
will assist you in coding E/M services
◦ The E/M Center allows you to access information
from one convenient location
◦ https://www.novitassolutions.com/em/index.html
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Part A Fiscal Intermediary
Standard System Hours
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District of Columbia (DC), Maryland (MD),
New Jersey (NJ), Pennsylvania (PA)
◦ Monday – Friday
 6 am – 9 pm
◦ Saturdays
 6 am – 4 pm
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Delaware (DE)
◦ Monday – Friday
 6 am – 6 pm
◦ Saturdays
 6 am – 4 pm
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Calendar of Events
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Our Training and Events Center offers a
wide variety of education
Join us for Workshops, Teleconferences, and
Webinars
To view the most current calendar of
events, visit:
◦ https://www.novitassolutions.com/training/index.html
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Centers for Medicare &
Medicaid Services (CMS)
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The CMS website offers valuable resources
such as:
◦ CMS Internet Only Manuals (IOMs)
◦ Medicare Learning Network (MLN) Matters Articles
◦ Open Door Forum
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For additional resources visit:
◦ http://www.cms.gov/
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Send In Your Survey Electronically
and Thanks for Your Participation
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We value your feedback to measure the
effectiveness of this program and to
prepare for future events
Send the survey electronically; it is easy,
just click and submit
◦ Webinars:
 https://www.novitassolutions.com/calendar/parta/webinar/index.html
 https://www.novitassolutions.com/calendar/partb/webinar/index.html
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