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Novitas Solutions
2014 Medicare Update
PAHCOM
January 29, 2014
Disclaimer
•
All Current Procedural Terminology (CPT) codes and descriptors used in this presentation
are copyright© by the American Medical Association. All rights reserved.
•
The information enclosed was current at the time it was presented. Medicare policy
changes frequently; links to the source documents have been provided within the
document for your reference. This presentation was prepared as a tool to assist providers
and is not intended to grant rights or impose obligations.
•
Although every reasonable effort has been made to assure the accuracy of the information
within these pages, the ultimate responsibility for the correct submission of claims and
response to any remittance advice lies with the provider of services.
•
Novitas Solutions employees, agents, and staff make no representation, warranty, or
guarantee that this compilation of Medicare information is error-free and will bear no
responsibility or liability for the results or consequences of the use of this guide.
•
This presentation is a general summary that explains certain aspects of the Medicare
program, but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings.
•
Novitas Solutions does not permit videotaping or audio recording of training events.
2
Novitas Solutions
• Education specific to providers in Medicare
Administrative Contractor Jurisdiction L (JL)
include: Delaware, District of Columbia, Maryland,
New Jersey, and Pennsylvania
• This education contains specific contractor
guidance
• If you are not a provider in Jurisdiction L, please
contact your Medicare contractor for specific
guidance.
3
Agenda
•
•
•
•
Medicare Updates
ICD-10 Update
Preventive Services
Comprehensive Error Rate Testing
Program
• Contractor Initiatives
• New vs. Establish Patient Office Visits
4
Objectives
• Provide a clear understanding of the changes in
Medicare and to assist the provider community in
complying with new guidelines by providing educational
information and resources
• Explain the Comprehensive Error Rate Testing (CERT)
Program and provide tips in preventing the most
frequent errors
• Review of the New verses Established patient coding
rules.
• Identify and promote the use of self service options and
preventive services
5
Medicare Updates
6
Medicare Learning Network
MLN Matters® Articles
• Medicare Learning Network Matters Articles or
MLN Matters® articles developed by the Centers
for Medicare & Medicaid Services (CMS) to help
health care professionals avoid improper activities
• List is updated as related articles are issued and
revised
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ProvCmpl_Articles.pdf
7
Update to Medicare Deductible,
Coinsurance, and Premium Rates for 2014
•
Change Request # 8527
•
Effective: January 1, 2014, Implementation: January 6, 2014
•
Key Points:
o
2014 PART A
 Deductible- $1,216.00
 Coinsurance
–
–
–
o
$304.00 a day for 61st-90th day
$608.00 a day for 91st-150th day (lifetime reserve days)
$152.00 a day for 21st-100th day (Skilled Nursing Facility coinsurance)
2014 PART B
 Deductible- $147.00 a year
 Coinsurance- 20 percent
•
For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8527.pdf
8
Enrollment Denials When
Overpayment Exists
•
Change Request # 8039
•
Effective: October 1, 2013, Implementation: October 7, 2013
•
Key Points:
o Medicare contractors may deny a Form CMS-855 enrollment
application if the current owner of the enrolling provider or supplier or
the enrolling physician or non-physician practitioner has an existing or
delinquent overpayment that has not been repaid in full at the time an
application for new enrollment or Change of Ownership (CHOW) is
filed
•
For more information:
o MLN Matters® Number: MM8039
 http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM8039.pdf
9
Mandatory Reporting of an 8-Digit
Clinical Trial Number on Claims
•
Change Request # 8401
•
Effective: January 1, 2014, Implementation: January 6, 2014
•
Key Points:
o
o
It will be mandatory to report a clinical trial number on claims for items and services
provided in clinical trials that are qualified for coverage as specified in the "Medicare
National Coverage Determination (NCD) Manual," Section 310.1
For institutional paper or direct data entry (DDE) claims, the 8-digit clinical trial number
is to be placed in the value amount for paper only value code D4/DDE claim UB-04
(Form Locators 39-41)
 Electronic Submission - Loop 2300 REF02 (REF01=P4)
o
For professional claims, the 8-digit clinical trial registry number proceeded by the 2
alpha characters “CT” will be placed in Field 19 of the paper Form CMS-1500
 Electronic Submission – Loop 2300 REF02(REF01=PF)
•
For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8401.pdf
10
Incarcerated Beneficiary
Update
•
Recently, the Centers for Medicare & Medicaid Services (CMS) initiated recoveries from
providers and suppliers based on data that indicated a beneficiary was incarcerated on the
date of service. Medicare will generally not pay for medical items and services furnished to
a beneficiary who was incarcerated when the items and services were furnished.
•
A beneficiary that is considered to be incarcerated is one that is not only confined within a
‘penal facility’ but may also include a beneficiary who is on a supervised release, on
medical furlough, residing in a half way house or similar situation.
•
As a result, a large number of overpayments were identified, demand letters released, and,
in many cases, automatic recoupment of overpayments made. CMS has since learned that
the information related to these periods of incarcerations was, in some cases, incomplete
for CMS purposes.
•
CMS is actively reviewing these data and will be taking action to improve the process used
to identify periods of incarceration. As part of this effort, CMS is working to quickly identify
claims that resulted in our recent recovery actions and take steps, as appropriate, to
correct any inappropriate overpayment recoveries.
11
Incarcerated Beneficiary
Continued
•
CMS has posted frequently asked questions (FAQs) about incarcerated beneficiary claim denials. These
FAQs will be updated as more information becomes available
o
•
Review IOM 100-04, chapter 1, section 10.4 for CMS guidelines on items or services furnished to
Medicare beneficiaries in state or local custody under a penal authority
o
•
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf
New fact sheet titled: Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody
Under a Penal Authority
o
•
http://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Downloads/Incarcerated-Beneficiary-FAQs11-20-13.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ItemsServices-Furnished-to-Beneficiaries-in-Custody-Under-Penal-Authority-Fact-Sheet-ICN908084.pdf
For any questions regarding the Social Security records indicating that the patient was in custody when
the service was rendered please call the Customer Contact Center (CCC)
o
o
The CCC can tell you for your date of service if the beneficiary was incarcerated or not, but will not be able to provide
the from and through dates of incarceration
This information is not available through the Interactive Voice Response (IVR) or on-line eligibility verification systems

•
The automated response to your inquiry provides the dates for the period of inactivity, but it does not provide the reason for
such inactivity
Providers and beneficiaries do have the right to appeal any claims that were denied in error
12
Redaction of Health Insurance Claim
Numbers (HICNs) in Medicare
Redetermination Notices (MRNs)
• Change Request # 8268
• Effective: January 1, 2014, Implementation: January 6, 2014
• Key Points:
o Health Insurance Claim Numbers (HICN) redacted from
all Medicare Redetermination Notices
o 5 or more values of the HICN replaced with X’s or
asterisks (*)
o Last 4 or 5 digits of the HICN is displayed
• For more information:
o http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/MM8268.pdf
13
Remittance Advice
• Remark Code & Claim Adjustment Reason Code
o
o
o
Stay current
Updates made every 4 months
http://www.wpc-edi.com/codes
• Centers for Medicare & Medicaid Services (CMS)
Manual: Understanding the Remittance Advice
o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/ra_guide_full_03-2206.pdf
14
Reject for a New Patient Visit Billed by the
Same Physician or Physician Group within
the Past Three Years
•
Change Request # 8165
•
Effective: 10/1/2013, Implementation: 10/7/2013
•
Key Points
o
o
o
•
Recovery Auditor identified claims for new patient visits paid more than once in three
year period by same physician or physician group
Contractor will be prompted to validate new patient claims when more than one
service is identified in a three year period
The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that
Medicare interprets the phrase “new patient” to mean a patient who has not received
any professional services, i.e., evaluation and management service or other face-toface service (e.g., surgical procedure) from the physician or physician group practice
(same physician specialty) within the previous 3 years
For more information
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8165.pdf
15
Ordering/Referring
Physician Requirements
•
•
•
•
MLN Matters® Number: SE1305
Related Change Requests #: 6421, 6417, 6696, 6856
Effective January 6, 2014
Key Points:
o
Medicare will deny claims for services or supplies that require an
ordering/referring provider to be identified and that provider:
 is not identified on the claim
 is not in Medicare’s enrollment records, or
 is not of a specialty type that may order/refer
• For more information
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1305.pdf
16
Revised CMS 1500 Paper
Claim Form: Version 2/12
•
OMB approved revised CMS 1500 claim form, version 02/12, OMB control
number, 0938-1197
•
Changed the form to adequately accommodate and implement ICD-10-CM
diagnosis codes
•
Revisions add the following functionality:
o
o
o
•
Tentative timeline for implementation (subject to change)
o
o
o
•
Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes.
Expansion of the number of possible diagnosis codes to 12.
Qualifiers to identify the ordering, referring and supervising provider roles (on item 17)
January 6, 2014: Medicare begins receiving and processing paper claims submitted on the
revised CMS 1500 claim form (version 02/12)
January 6- March 31, 2014: Dual use period during which Medicare continues to receive
and process paper claims submitted on the old CMS 1500 claim form (version 08/05)
April 1, 2014: Medicare receives and processes paper claims submitted only on the revised
CMS 1500 claim form (version 02/12)
For more information:
o
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/201306-27Enews.pdf
17
Hospice Related Services – Part B
• MLN Matters® Number: SE1321
• Key Points:
Providers need to identify if a beneficiary is enrolled in hospice
Beneficiary should contact the Hospice provider to arrange for care
they need
o Services related to a Hospice terminal diagnosis provided during a
Hospice period are included in the Hospice payment
o Contractors will deny services submitted without GV or GW modifiers
o
o
 GV - Attending physician not employed or paid under arrangement by the
patients hospice provider
 GW – Service not related to terminal condition
• For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1321.pdf
18
Place of Service Coding for
Physician Services in an Outpatient
Setting
•
MLN Matters® Number : SE1313
• Key Points:
o
o
Recovery Auditors identified physicians incorrectly reporting the
place of service as office (11) when the services were provided
in an outpatient hospital (22) setting
Improper payment exists when billed with an incorrect place of
service based on the setting where the services were rendered
• For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1313.pdf
19
Additional/Subsequent Procedures
Performed During 90 Day Global
Period
• MLN Matters® Number: SE1323
• Key Points:
Recovery Auditors identified providers incorrectly billing E/M services
provided by the surgeon the day before major surgery, the day of minor
surgery, 0-10 days after minor surgery, and up to 90 days after major
surgery
o Global Surgical Package was established by CMS to ensure all
components of surgery are bundled into one payment
o Ensure billing staff are not billing E/M services that are already included
in payment for global surgery
o
• For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1323.pdf
20
Add-on HCPCS/CPT Codes
Without Primary Codes
•
MLN Matters® Number: SE1320
• Key Points:
Recovery Auditors identified providers billing only add-on
codes without respective primary codes
o Add-on codes is a code that describes a service, that is
performed in conjunction with another primary service
o
• For more information:
o
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/SE1320.pdf
21
Part B Recurring Updates
• New Waived Tests effective January 1, 2014
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8439.pdf
• Annual Medicare Physician Fee Schedule (MPFS)
Files Delivery and Implementation
o
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R2799CP.pdf
• 2014 Annual Update for the Health Professional
Shortage Area (HPSA) Bonus Payments
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8463.pdf
22
Special Edition Articles
• Transitional Care Management Services
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1332.pdf
• Improve Your Patients’ Health with the Initial
Preventive Physical Examination (IPPE) and
Annual Wellness Visit (AWV)
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1338.pdf
23
ICD-10 Update
24
ICD-10 Implementation
• October 1, 2014 – Compliance date for
implementation of ICD-10-CM (diagnoses) and
ICD-10-PCS (procedures)
• No more delays
• ICD-10-CM will be used by all providers in every
health care setting
• ICD-10-PCS will be used only for hospital claims
for inpatient hospital procedures
o
ICD-10-PCS will not be used on physician claims,
even those for inpatient visits
25
ICD-10 Implementation
• Single implementation date of October 1,
2014 for all users
o
Date of service for ambulatory and physician
reporting
 Ambulatory and physician services provided on or after
October 1, 2014 will use ICD-10-CM diagnosis codes
o
Date of discharge for hospital claims for inpatient
settings
 Inpatient discharges occurring on or after October 1,
2014 will use ICD-10-CM and ICD-10-PCS codes
26
Split Claim Billing
 Claims that Span October 1, 2014
• Outpatient claims - SPLIT claim and Use
FROM date
• Inpatient claims – Use ONLY THROUGH
date/DISCHARGE date – use ICD-10
codes
• http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1325.pdf
27
CPT and HCPCS
• No impact on Current Procedure
Terminology (CPT) and Healthcare
Common Procedure Coding System
(HCPCS) codes
• CPT and HCPCS will continue to be used
for physician and ambulatory services
including physician visits to inpatients
28
ICD-10 Conversion from ICD-9 and Related Code
Infrastructure of the Medicare Shared Systems as They Relate
to the Centers for Medicare & Medicaid Services (CMS)
National Coverage Determination
• Change Request # 8109 and # 8197
• Key Points:
Medicare contractors and Shared System Maintainers create and update
National Coverage Determination (NCD) hard-coded shared system edits
that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis
codes plus all associated coding infrastructure, such as procedure codes,
Healthcare Common Procedure Coding System (HCPCS) and Current
Procedural Terminology (CPT) codes, denial messages, frequency edits,
Place of Service (POS), Type of Bill (TOB) and provider specialties, etc.
o Operational changes that are necessary to implement the conversion of
the Medicare system diagnosis codes specific to the Medicare National
Coverage Database (NCD) spreadsheets attached to CR8109 and 8197.
o
• For more information:
o
o
MLN Matters® Number: MM8109 and MM8197
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/index.html
29
Display of ICD-10 Local Coverage
Determinations (LCDs) on the
Medicare Coverage Database (MCD)
• Change Request # 8348
• Effective: October 2, 2013, Implementation: April 10, 2014
• Key Points:
o
o
All ICD-10 LCDs and associated ICD-10 Articles shall be
published on the MCD no later than April 10, 2014
All LCDs and Articles will receive a new LCD/Article ID number
• For more information:
o
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1293OTN.pdf
30
ICD – 10 Testing
• All Medicare Administrative Contractors to implement an ICD10 testing week with trading partners
• The ICD-10 testing week was created to generate awareness
and interest, and to instill confidence in the community of the
MACs readiness for implementation
• The testing week will allow trading partners access to the
MAC for testing with real time help desk support
• The event will be done virtually and will be posted to our
website
o
March 3, through March 7, 2014
• Change Request 8465
o
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1303OTN.pdf
31
ICD-10 Resources
•
ICD-10
o
•
Provider Resources
o
•
http://www.cms.gov/Medicare/Coding/ICD10/CMS-Sponsored-ICD-10-Teleconferences.html
MedScape Modules
o
•
http://cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html
CMS Sponsored ICD-10 Teleconferences
o
•
http://cms.gov/Medicare/Coding/ICD10/ProviderResources.html
Medicare Fee-For-Service Resources
o
•
http://www.cms.gov/Medicare/Coding/ICD10/index.html
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedscapeModulesAvailableonICD10.pdf
Sign up for the Centers for Medicare & Medicaid Services (CMS) ICD-10 Industry Email
Updateso
http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html
•
Follow @CMSGov on Twitter
•
Subscribe to Latest News Page Watch https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609
32
ICD-10 MLN Resources
• MLN Matters Articles:
o
o
o
o
Special Edition Article SE1239 – Updated ICD-10
Implementation Information
Special Edition Article SE1240 – Partial Code Freeze Prior to
ICD-10 Implementation
Special Edition Article SE1325 – Institutional Services Split
Claims Billing Instructions for Medicare FFS Claims that Span
the ICD-10 Implementation Date
MLN Article MM7492 – Medicare FFS Claims Processing
Guidance for Implementing ICD-10
• MLN Products
o
o
o
o
ICD-10-CM/PCS Myths and Facts
ICD-10-CM/PCS The Next Generation of Coding
ICD-10-CM Classification Enhancements
General Equivalence Mappings Frequently Asked Questions
33
Preventive Services
34
Preventive Services
•
•
•
•
•
•
•
•
•
•
•
•
Annual Wellness Visit
Bone Mass Measurements
Cancer Screenings
Cardiovascular Disease
Screening
Colorectal Cancer Screening
Depression Screenings
Diabetes Screening Tests
Diabetes Self-Management
Training
Glaucoma Screening
Hepatitis B Vaccine
Human Immunodeficiency
Virus (HIV) Screening
Influenza Virus Vaccine
• Initial Preventive Physical
Examination
• Intensive Behavioral Therapy
(IBT) for Cardiovascular
Disease (CVD)
• Medical Nutrition Therapy
• Prostate Cancer Screening
• Pneumococcal Vaccine
• Screening Mammography
• Screening Pap Test
• Screening Pelvic Exam
• Smoking and Tobacco Use
Cessation Counseling
• Ultrasound Screening for
Abdominal Aortic Aneurysm
35
Medicare Learning Network (MLN)
Products for Preventive Services
• Help Keep Your Medicare Patients Healthy In 2014!
• Ensure your patients take advantage of Medicare-covered
preventive services.
• Medicare covers a wide array of preventive services for eligible
beneficiaries, including cancer screenings, certain
immunizations, among others.
• The Medicare Learning Network (MLN) Preventive Services
Educational Products Web Page provides descriptions and
ordering information for MLN preventive services educational
products and resources for health care professionals and their
staff.
o
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/PreventiveServices.html
36
Influenza Vaccine Payment
Allowances - Annual Update for
2013-2014 Season
•
Change Request # 8433
•
Effective: August 1, 2013, Implementation: by October 25, 2013
•
Key Points:
o
o
o
Influenza vaccine payment allowance for 2013-2014 season
Payment allowances effective for August 1, 2013- July 31, 2014
Reminders
o Part B deductible and coinsurance amounts do not apply
o Must take assignment on the claim for the vaccine
•
For more information:
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1336.pdf
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8433.pdf
o
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8249.pdf
37
Preventive Services
• Quick Reference Chart for Medicare
Preventive Services
o
https://www.cms.gov/Medicare/Prevention/Pre
vntionGenInfo/Downloads/MPS_QuickRefere
nceChart_1.pdf
38
Comprehensive Error Rate Testing
(CERT)
39
Comprehensive Error
Rate Testing (CERT)
• National Claim Paid Error Rate
6.8 % Inpatient hospitals
o 4.8 % Non-inpatient hospital facilities
o 9.9 % Physician/Lab /Ambulance
o
• Impacts all providers submitting Fee for Service claims
• Limited random claim sample
• Record requests must be received within 30 days from the initial
CERT letter
• Right to Appeal? Yes
40
JL Part B Common Errors
• Insufficient documentation:
o
o
o
o
Procedure/service billed
Missing or illegible documentation and/or physician signature
No valid physician’s order
No physical therapy certified plan of care/treatment plan
• Incorrect coding errors:
o
o
o
o
Evaluation and Management (E/M) codes
Critical care, discharge day management, physical therapy
Units of medication/infusion services
Laboratory services
41
Comprehensive Error Rate
Testing (CERT) Center
42
Error Due to Illegible or
Missing Signature
• Mark or sign by individual on document to
signify knowledge, approval, acceptance or
obligation
o
If illegible, will consider signature log or
attestation statement
o
If missing from other medical documentation,
shall accept signature attestation statement from
author
43
Signature Log
• Lists typed or printed name of author
associated with initials or illegible signature
• May be on page of documentation or
separate document
• Providers encouraged to list credentials (e.g.
MD, DO) in log
44
Signature Attestation
Statement
• To be valid for Medicare Medical Review:
o
Must be signed and dated by author of medical record
entry
o
Must contain sufficient information to identify
beneficiary
o
Sample Attestation
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid
?contentId=00004967
45
Electronic Signature
Examples
• Listed below are examples of acceptable phrases for
electronic signatures:
o
o
o
o
o
o
o
o
o
o
o
Electronically signed by” with provider’s name
Verified by” with provider’s name
“Reviewed by” with provider’s name
“Signed by” with provider’s name
“Signed: John Smith, M.D.” with provider’s name
This is an electronically verified report by John Smith, M.D.
Authenticated by John Smith, M.D
Authorized by: John Smith, M.D
Confirmed by with provider’s name
Electronically approved by with provider’s name
Novitas expects the phrase/signature to be dated
46
Coding Guidelines for New and
Established Office Visits
47
New Patient - Definition
• Per the Centers for Medicare and Medicaid
Services, interpret the phrase “new patient” to
mean a patient who has not received any
professional services, i.e., Evaluation and
Management service or other face-to-face
service (e.g., surgical procedure) from the
physician or physician group practice (same
physician specialty) within the previous 3 years.
• Publication 100-04, Chapter 12, Section 30.6.7
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104
c12.pdf
Determining if the Patient is
New or Established
Face-to-Face
• Face-to-face is defined as the time spent
between the physician and the patient
• Examples:
o
o
Surgical procedures
Evaluation and Management Services
• Interpretation of electrocardiogram (EKG) or
X-rays, or other diagnostic testing that does
not include a face-to-face component are not
considered face-to-face services
Face-to-Face
• Face-to-face is defined as the time spent
between the physician and the patient
• Examples:
o
o
Surgical procedures
Evaluation and Management Services
• Interpretation of electrocardiogram (EKG) or
X-rays, or other diagnostic testing that does
not include a face-to-face component are not
considered face-to-face services
Nonphysician
Practitioners
• Nonphysician practitioners (NPPs) can
perform a new patient visit
• Must meet the face-to-face criteria
• May only designate primary licensure
• Assume the specialty of the group practice
New Patient Office/Outpatient Visits –
Require Three Key Components
99201
99202
99203
99204
99205
History
Problem Focused
Expanded
Problem Focused
Detailed
Comprehensive
Comprehensive
Exam
Problem Focused
Expanded
Problem Focused
Detailed
Comprehensive
Comprehensive
Medical
Decision
Making
Straightforward
Straightforward
Low
Moderate
High
Time
(average)
10 Minutes
20 Minutes
30 Minutes
45 Minutes
60 Minutes
Component
Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved.
Coding of Established
Patient Visits
• Level of service determined by
evaluating documentation of all three
key components (history, exam, and
medical decision making)
• Lowest key component can be ignored
• Can be used in office and hospital
outpatient places of service
Established Patient Office/Outpatient
Visits – Requires Two of the Three Key
Components
Component
99211
99212
99213
99214
99215
History
Minimal problem
that may not
require presence
of a physician
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive
Exam
Minimal problem
that may not
require presence
of a physician
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive
Medical
Decision
Making
Minimal problem
that may not
require presence
of a physician
Straightforward
Low
Moderate
High
Average Time
(minutes)
5 Minutes
10 Minutes
15 Minutes
25 Minutes
40 Minutes
Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved.
Consultation Codes
• No longer recognized by Medicare
• Use codes which represent where the visit
occurs and identify the complexity of the
visit performed
• Consultations in the office or outpatient
setting, use codes 99201-99215
• New and established patient rules apply
Current Procedural Terminology (CPT) only copyright 2012 American Medical Association. All rights reserved.
Multiple Visits on Same
Day
• Cannot be paid for same patient on the
same day by physician or physician of
same specialty from the same group
practice
• Exception when documentation reveals
visits were for:
Unrelated problems; and
o Could not be provided during the same
encounter
o
Documentation Tips for the Key
Components of an Evaluation and
Management Service
Documentation TipsChief Complaint
• The medical record should clearly reflect
the chief complaint
Follow-up for hypertension
o Complaining of back pain
o
• Chief complaint easily inferred
o
Patient complaining of “productive cough,
nasal drainage, and headache”
Documentation Tips“Double Dipping”
• Review of Systems (ROS) are questions
concerning the system(s) directly related
to the problem(s) identified in the History
of Present Illness (HPI).
• Not considered “double dipping” to use the
system(s) addressed in the HPI for credit
in the ROS
Documentation Tips Non-Contributory
• The term "non-contributory" may be
appropriate documentation when referring
to a patient's family history during an
Evaluation and Management visit, if the
family history is not pertinent to the
presenting problem.
Documentation TipsHistory
• Not required to re-record Review of Systems
(ROS) and Past Family Social History (PFSH)
from a previous encounter. Must show evidence
of physician review and update
• Ancillary staff may record ROS and/or PFSH
o
Physician must review and supplement or notate
confirmation of information recorded
• Unable to obtain history, physician must indicate
why and the attempts made
Documentation Tips Exam
• Physician’s “hands on”
• Type of content of the exam is based on clinical
judgment and nature of the presenting problem
• 1995 guidelines- eight or more body areas or
organ systems
o
Cannot combine body areas and organ systems to
determine the level of the exam
• 1997 guidelines provide specialty exams
• Documentation of “normal” sufficient
• Documentation of “abnormal” requires elaboration
“4 X 4”
• Four or more items in Four or more body areas or organ
systems = DETAILED exam
• Example:
o
o
o
o
Constitutional- 1) BP 2) Temp 3) Pulse 4) Respiration
Respiratory- 1) Chest clear to auscultation 2) Non-labored
breathing 3) No rhonchi 4) No rales
Cardiovascular- 1) Regular Rate 2) and Rhythm 3) Normal S1 4)
and S2
Gastrointestinal - 1) Abdomen soft 2) Normal bowel sounds 3)
No hernia 4) Abdomen flat
• Clinical inference overrides “4 X 4” tool
• 1997 single organ system exams may be more beneficial in
scoring
Documentation TipsMedical Decision Making
• Number of Diagnosis or Treatment Options
o
Additional workup- anything that is being done
beyond that encounter
• Amount and/or Complexity of Data Reviewed
o
Two points may be given for independent
visualization if indicated in the documentation
• Risk of Complications and/or Morbidity or
Mortality
o
The level of risk is based on the content of the
entire note for the encounter
Time Documentation
References
• Novitas Solutions Evaluation and Management Center
o
http://www.novitassolutions.com/webcenter/spaces/EvaluationandManagement_JL
• Evaluation and Management Service Guide
o
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads//eval_mgmt_serv_guideICN006764.pdf
• Frequently Asked Questions
o
http://www.novitas-solutions.com/webcenter/spaces/FAQs_JL
• Centers for Medicare and Medicaid Services Internet Only Manual,
Publication 100-4; Chapter 12, Section 30.6.7, Payment for Office
and Other Outpatient Evaluation and Management Visits
o
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c12.pdf
Contractor Initiatives
68
Website Improvements
• Novitas Solutions Web site improvements were
implemented September 29, 2013
• New features include:
Separate Website for Jurisdiction H (JH) and Jurisdiction L
(JL)
o Improved Search Functionality
o Navigation Enhancements
o
• Webinars are scheduled in January - register now at:
o
JL
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?co
ntentId=00008049
69
Novitas Home Page
70
JL Navigation
71
Navigation Help
72
Tips for Searching
•
•
•
•
Use Search Filters
Use commas to separate the words
Adding OR between words
Placing two periods between two numbers
returns all results
o
1..4 returns all documents with 1,2,3, or 4
73
JL Local Coverage
Determinations (LCDs)
•
The following MAC Local Coverage Determinations (LCDs) are now
effective:
o
o
o
o
o
o
o
•
Bariatric Surgical Management of Morbid Obesity (L34495)
Biomarkers Overview (L33640)
Hemophilia Factor Products (L33658)
Molecular Diagnostics: Genitourinary Infectious Disease Testing (L32567)
Oral Maxillofacial Prosthesis (L33654)
Prostate Mapping Biopsy (L33656)
Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (L33652)
The following MAC Local Coverage Determinations (LCDs) have been
revised:
o
o
o
Scanning Computerized Ophthalmic Diagnostic Imaging (L27529)
Transcranial Magnetic Stimulation (TMS) for the Treatment of Depression (L32055)
Trigger Point Injections (L27540)
74
Retired Local Coverage
Determinations (LCDs)
• Novitas began directing customers to the
Medicare Coverage Database (MCD) for retired
LCDs and previous versions for currently active
LCDs
• Medical Policy page has been updated with a link
to the MCD
o
http://www.cms.gov/medicare-coverage-database/
• Active and Draft policies can be found on our
website
o
http://www.novitassolutions.com/webcenter/spaces/MedicalPolicy_JL
75
Jurisdiction L Customer
Contact Information
•
Provider
o
o
1-877-235-8073
Hours of Operation, Eastern Time (ET)
 Monday - Thursday: 8:00 am – 4:00 pm ET
 Friday: 8:00 am – 2:00 pm ET
•
Interactive Voice Response (IVR)
o
Hours of Operation
 Eligibility and General Information
–
24 Hours a day 7 Days a week
 Full IVR Options
–
–
Mon- Fri 6:00am – 9:00pm ET
Saturday 6:00am - 4:00pm ET
 Step-by-Step Guide
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004403
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004415
76
Beneficiary Contact
Information
• Patient / Medicare Beneficiary
o
1-800-MEDICARE (1-800-633-4227)
 http://www.medicare.gov/index.html
77
Fax to Image
•
Were you aware records for an Additional Development Request (ADR) can be faxed
directly to Novitas Solutions?
•
The fax to image option allows for documentation to be submitted directly to Novitas
Solutions.
o
o
Available 24 hours a day, 7 days a week
Fax ADR response to 1-877-439-5479
•
Faxes should not exceed 200 pages
•
The original ADR request must be submitted as the cover sheet to the records
•
Supporting documentation, or requested medical records, should follow the ADR letter
•
Each ADR request must be faxed separately
•
Additional Tips
o
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00007732
78
Part B Redetermination
Request
• Correct clerical errors or omission by calling the
Claims Correction line
o
o
JL Providers 1-877-235-8073
JH Providers 1-855-252-8782
• Part B Redetermination Requests may be faxed
o
o
Available 24 hours a day, 7 days a week
1-888-541-3829
• Appeals Status Inquiry Tool now available
o
JL
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid
?contentId=00002677
79
Overpayments
• Novitas identifies overpayment and sends
demand letter
o
o
Copy of demand letter sent with check
No form involved with demanded debt
• Provider identifies overpayment
o
o
Voluntarily sends unsolicited check
Use return of monies form
• http://www.novitassolutions.com/webcenter/content/conn/UCM_
Repository/uuid/dDocName:00008243
80
Provider Enrollment
• Provider Enrollment Status Inquiry Tool
o
JL
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?co
ntentId=00004864
• Release of Information
o
o
Individual Physician or Practitioner
Authorized Delegated Official
• Upcoming Revalidation Mailings
o
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.htm
l
81
Stay Up-to-Date
• Weekly Podcast
o
o
Weekly podcast of the latest Medicare Updates
and other informative topics
Subscribe http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag
ebyid?contentId=00008119
• Web Updates
o
Daily E-mail of the latest Medicare Updates
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag
ebyid?contentId=00007968
82
Calendar of Events
• Our Training and Events Center offers a wide
variety of education
• Join us for Workshops, Teleconferences, and
Webinars
• To view the most current calendar of events, visit:
JL
 http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid
?contentId=00008204
83
Novitasphere
•
•
•
•
Coming Soon
Part B Provider Portal
Connect via internet to Novitas
Available options include:
Claim submission;
o Claim status; and
o Eligibility
o
84
Centers for Medicare &
Medicaid Services (CMS)
• The CMS website offers valuable resources such as:
o
o
o
o
CMS Internet Only Manuals (IOMs)
Medicare Learning Network (MLN) Matters Articles
Open Door Forum
MLN Connects
 http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2013-0627Enews.pdf
• For additional resources visit:
o
http://www.cms.gov/
85
Thank You
Janice Mumma, CPC, CPC-H
Supervisor, Provider Outreach and Education
717-526-3645
[email protected]
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