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Arkansas Healthcare Financial

Management Association

2018 Spring Annual Conference:

Medicare Updates

April 19, 2018

Disclaimer

All Current Procedural Terminology (CPT) only are copyright 2017 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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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Acronym List

Acronym Definition

CERT Comprehensive Error Rate Testing

CMS Centers for Medicare & Medicaid Services

COLA Cost of Living Adjustment

CPT Current Procedural Terminology

CR Change Request

CWF Common Working Files

DCN Document Control Number

EDI Electronic Data Interchange

ESRD PPS End Stage Renal Disease Prospective Payment System

HCPCS Healthcare Common Procedure Coding System

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Acronym List 2

Acronym Definition

HICN Health Insurance Claim Number

ICD International Statistical Classification of Diseases

IPF Inpatient Psychiatric Facilities

IVR Interactive Voice Response

LCD Local Coverage Determination

LTCH Long-Term Care Hospital

MAC Medicare Administrative Contractor

MBI Medicare Beneficiary Identifier

MLN Medicare Learning Network

NCD National Coverage Determination

Acronym List 3

Acronym Definition

NPI National Provider Identifier

OPPS Outpatient Prospective Payment System

PHI Personal Health Information

PII Personally Identifiable Information

PTAN Provider Transaction Access Number

SNF Skilled Nursing Facility

TBD To Be Determined

TC Technical Component

TIN Tax Identification Number

TOB Type of Bill

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Today’s Presentation

Agenda:

• Medicare Updates

• New Medicare Card Updates and Reminders

• Novitasphere Part A Overview

• Medicare Credit Balance Report Common Errors

• Website Features

• Comprehensive Error Rate Testing (CERT)

Objectives:

• Provide the latest news, updates and reminders for Medicare Part A

• Review the New Medicare Card Updates

• Explore Novitasphere’s features, benefits and enrollment steps

• Discuss Medicare Credit Balance Report common errors

• Understand how to avoid common documentation errors based on the Comprehensive Error Rate Testing program findings

Objectives

Identify and understand the current Medicare changes

Learn how to apply the new guidelines

Identify and utilize the educational resources and information

Review important Medicare updates and reminders

Review the various self-service options available to the provider community

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Medicare Updates

April 2018 Update of the Hospital

Outpatient Prospective

Payment System (OPPS)

MM10515;• Effective: April 1, 2018• Implementation Date: April 2, 2018

Key Points:• Describes changes to and billing instructions for various payment policies

implemented in the April 2018 OPPS update: New separately payable procedure code Mulitanalyte assay with algorithmic analyses (MAAA) and proprietary laboratory

analyses (PLA) CPT coding changes effective January 1, 2018 Reassignment of skin substitute product from the low cost group to the high cost

group Drugs and biologicals:

Payments based on average sales price (ASP) OPPS pass through status Restated payment rates based on ASP methodology Changes to biosimilar product HCPCS codes and modifiers

Use of modifier FY: Clarification the payment adjustment applies to an imaging service that is an X-ray

taken using computed radiography technology where the X-ray taken using computed radiography technology is not combined with digital radiography in the same imaging service

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Outpatient Therapy Cap Exception

Section 50202 of the Bipartisan Budget Act of 2018 repeals Medicare provisions affecting the outpatient therapy caps:

• Once the $2010 therapy cap is met, the provider will need to attest that the services meet the requirements for an exception by appending the KX modifier:

Following claims no longer subject to the therapy cap:

Outpatient therapy hospital

Critical Access Hospital (CAH) therapy

• Claims for therapy services above certain threshold levels of incurred expenses will be subject to targeted medical review:

Medical review threshold for therapy services in 2018 is $3,000

Reference:

• Medicare Expired Legislative Provisions Extended and Other Bipartisan Budget Act of 2018 Provisions

Correction to Prevent Payment on Inpatient

Information Only Claims for Beneficiaries

Enrolled in Medicare Advantage Plans

MM10238:

• Effective Date: April 1, 2015

• Implementation Date: April 2, 2018

Key Points:

• Informational only bills are submitted when a patient is an inpatient in a facility and is enrolled in a Medicare Advantage (MA) plan that would be responsible for payment for the services rendered to the beneficiary

• Inpatient hospital (11X) claims with Value Code D4 for Investigational Device Exemption (IDE) studies or Clinical Studies Approved Under Coverage with Evidence Development (CED) billed for beneficiaries enrolled in a MA billed with Condition Code 04 and Condition Code 30 were incorrectly receiving payment

• MACs will reprocess these inpatient information only claims with a payment greater than $0 within 90 days of April 2, 2018

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2018 MAC Satisfaction Indicator

(MSI) Survey

This survey measures your satisfaction with our processes and service delivery so we can gain valuable insights and determine process improvements:

• CFI Group is conducting the survey on behalf of CMS:

Evaluate our services in 10 minutes

Responses are kept confidential

Provide your name, telephone number and email address if you would like to be contacted about your survey responses

Improvements based on 2017 MSI feedback:

• Added a "Was this page helpful?" interaction to all content pages

• Designed and debuted new information centers for Enrollment, Appeals and Claims

• Enhanced and expanded data provided by many of our self-service lookup tools

JH Provider MSI Survey

Reinstating the QMB Indicator in the Medicare

Fee-For-Service Claims Processing System

from CR9911

MM10433:

• Effective: July 1, 2018

• Implementation: For claims processed on or after July 2, 2018

Key Points:

• Reintroduce QMB information in the RA without impeding claims processing by secondary payers:

Retain the display of patient liability amounts needed by secondary payers to process QMB cost-sharing claims:

Claim Adjustment Group Code “PR” along with CARCs 1, 2, 66, 247, and 248, as applicable, with monetary values on Medicare 835 ERAs and SPRs, as applicable

Revised alert RARCs N781 and N782

• Changes to the MSN by including QMB messages and reflecting $0 cost-sharing liability for the period beneficiaries are enrolled in QMB

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RA Messages for QMB

RARC Codes:

• N781 - Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer.

• N782 – Alert: Patient is a Medicaid/ Qualified Medicare Beneficiary. Review your records for any wrongfully collected coinsurance. This amount may be billed to a subsequent payer.

Adjustments to QMB Claims

Processed Under CR 9911

MM10494:

• Effective Date: September 20, 2018, for Part A and DME MAC claims; December 20, 2018, for Part B MAC claims

• Implementation Date: September 20, 2018, for Part A and DME MAC claims; December 20, 2018, for Part B MAC claims

Key Points:

• Directs MACs to initiate non-monetary mass adjustments for claims impacted by the CR 9911 QMB RA changes

• Enables MACs to generate "replacement" RAs without the CR 9911 changes in order to facilitate re-processing of QMB cost-sharing claims by secondary payers:

Although mass-adjusted claims may not cross over, this solution targets affected providers

Goal is to produce “replacement” Medicare RAs that providers can submit to supplemental payers to coordinate benefits as necessary

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Prohibition Billing Dually Eligible

Individuals Enrolled in the QMB

Program

SE1128

Key Points:• Reminds all Medicare providers and suppliers, including pharmacies,

that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing

• Promoting compliance with QMB billing rules: Identify the QMB status of your patient prior to billing claim:

Use the HETS system to verify QMB status and exemption form cost-sharing charges (Novitas has added a QMB eligibility tab in Novitasphere)

In July 2018, QMB information will be reintroduced on the RA

MA providers should contact MA plan on how to identify QMB status of members before and after claim submission

Verify patient’s QMB status through State online Medicaid eligibility systems or asking patient for other proof

Determine billing processes that apply to seeking payment for Medicare cost-sharing from the States in which you operate:

Generally Novitas will automatically cross your claim over to Medicaid

New Medicare Card Updates and

Reminders

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MBI New Design

New Medicare card:

• Health and Human Services (HHS) logo

• Gender and signature line removed

Railroad Retirement MBI card:

• Railroad Retirement Board logo will be the key identifier

• Mailing will begin June 2018

New Medicare Card Characteristics

Same number of characters as the former Medicare number (11)

Contains uppercase alphabetic and numeric characters

Occupy the same field as the Medicare number on transactions

Be unique to each beneficiary (e.g. husband and wife will have their own MBI)

Be easy to read:

• Alphabetic characters upper case only and will exclude S, L, O, I, B, Z

Not contain any embedded intelligence or special characters

Not contain inappropriate combinations of numbers or strings that may be offensive

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Inform Medicare Patients

CMS began mailing the new MBI cards in April 2018

Deadline for replacing all existing Medicare cards is April 2019

Beneficiaries should destroy the traditional Medicare card

Keep the new MBI confidential

Issuance of the new number will not change Medicare benefits

2018 Medicare & You Handbook includes information on new card

Be Prepared

Participate in CMS New Medicare card Open Door Forums

Sign up for weekly MLN Connects® newsletter

Obtain technical information from your regular communication channels

Test your systems

Work with your billing office staff to be sure you are ready for the new MBI format

Check CMS’ New Medicare card website for updated information

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Transition Period

Transition period April 2018 through December 31, 2019

• Submit either Medicare number or MBI

Beginning October 2018 through transition period:

• When submitting claim using the Medicare number:

Both Medicare number and MBI will be returned on remittance advice

• MBI will be in same place you currently get the changed Medicare number:

835 Loop 2100, Segment NM1 (corrected Patient/Insured Name)

Field NM109 (Identification Code)

• Message field on eligibility transaction responses will indicate when new Medicare card has been mailed to each person

• Medicare number and MBI for the same patient in same batch of claims:

• During the transition period:

• All claims with either Medicare number and MBI can be in the same batch

New Medicare Card

Mailing Waves

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After Transition Period

January 1, 2020 use MBIs on your claims

Exceptions for Fee-for-Service claims:

• For appeals:

Either the current Medicare Number or MBI for appeals and related forms

• For claim status query:

Either the current Medicare Number or MBI if the earliest date of service is before January 1, 2020

Status of dates of service after January 1, 2020 you have to use the MBI

Novitasphere MBI Lookup Coming

June 2018

New MBI crosswalk tool in Novitasphere June 2018

Enroll now!:

• Part B:

Claim corrections, eligibility, claim status, electronic claim submission, electronic remittance advice, comparative billing reports, medical review record submission, and more

• Part A:

Eligibility, electronic claim submission, electronic remittance advice, medical review record submission, cost report submission, and more

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Medicaid and Supplemental

Insurers

CMS will provide State Medicaid Agencies and supplemental insurers MBIs for Medicaid eligible people who also have Medicare

Crossover claims:

• During transition period either Medicare number or MBI is accepted

Supplemental insurer:

• During transition period:

Continue using your unique numbers

• After transition period:

Use MBI where the Medicare number would have been used

Novitasphere Part A Overview

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Novitasphere Portal

Free, secure web-based portal

Part A – Access to Eligibility, Claim Submission with File Status, Electronic Remittance Advice (ERA), Medical Review Record Submission, and Audit and Reimbursement Cost Reports Submission

Live Chat feature

Dedicated Help Desk- 1-855-880-8424

Novitasphere Home page (JH)

Novitasphere Portal Center

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New for Novitasphere in 2018

We will be adding a number of new features for Part A users including:

• ADR information

• Credit balance submission (Part A)

• Immediate recoupment submission

• Medicare Beneficiary Identifier (MBI) lookup tool

• Medical review status

• Overpayment letters

• Redetermination notices

• Redetermination requests

Not a current user, enroll for Novitasphere today (JH)

Novitasphere Enrollment - Three

Basic Steps

1. Complete the Novitasphere Portal Enrollment form

2. Register for Enterprise Identity Management (EIDM) User ID and password

3. Register Novitasphere role in EIDM:

• Register a Multi-Factor Authentication (MFA) Device

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Novitasphere References

Novitasphere Provider Portal Enrollment:

• Training Module

EIDM Registration Instructions (JH)

Novitasphere Portal Enrollment Forms:

• JH Providers - 8292PJH

• JH Third Party - 9281PJH

Novitasphere New User Checklist

Medicare Credit Balance Common

Errors

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Important Medicare Credit Balance

Report Dates

Due each quarter ending

Medicare Credit Balance Report must be submitted within 30 days after the close of each calendar quarter

Quarter End Medicare Credit Balance Report Due

Warning Letter Mailed

Placed on 100%Payment Withhold

March 31 April 30 May 15 June 03

June 30 July 30 August 15 September 03

September 30 October 30 November 15 December 03

December 31 January 30 February 15 March 03

Error Specific to Wrong Form

Only the 10/03 version is official CMS 838 form acceptable:

Older version of the CMS-838 will be rejected

Correct form number is 0938-0600

Available on Credit Balance Reporting page

Medicare Credit Balance Form

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Errors Specific to Quarter End Date

Quarter ending dates are:

• 03/31/18, 06/30/18, 09/30/18 or 12/31/18:

Automated process allows the report to pass straight through the automation process without intervention

Errors with the quarter end date:

• Invalid date:

Report quarters as 03/31/xx, 6/30/xx, 09/30/xx or 12/31/xx

Four digit year is also acceptable

• Blank/missing date

Errors Specific to PTAN

Invalid PTAN:

• PTANs belong to other MACS

• NPIs reported instead of PTAN

• PTANS that are straight Part B only

Multiple PTANs:

• Only one PTAN allowed per certification page

Missing PTAN:

• PTAN blank

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Errors Specific to Check Boxes

No box checked:

• All three boxes blank

Wrong box checked:

• Box 2 checked (credits reported), but no detail page included

• Box 1 checked (no credits reported), no detail page required

Multiple boxes checked:

• Only one box should be checked

Error Specific to Signature

Signature field is blank:

• Required

• Must sign and date

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Detail Page Errors

Missing Cert page

Missing detail page

Value code missing/invalid:

• Block 14, value code only required when reporting 2 as reason for credit balance

Value code reported for non-MSP reason:

• Only required when reporting “2” (MSP) in block 13

• Do not report value code when using “3” (Other)

Page(s) cut off:

• Portion of the fax page(s) cut off/missing

• Ensure entire page is faxed

Detail Page Errors #2

No primary payer information:• MSP is reported in block 13, but missing primary payer information in block

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Unmatched PTANs:• PTAN on CERT page does not match detail page• NPIs should not be used on detail pages• Certification and detail page PTAN must match

Reason for credit balance missing/invalid:• Block 13 must be numeric:

1- Duplicate 2- MSP 3- Other

Not legible:• Detail page data is not legible:

Typed details help ensure legibility

Method of payment missing/invalid:• Block 11 must be “X”, “A”, or “C” only

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Detail Page Errors #3

Blank detail page

Amount of credit balance:

• "0.00" can not be reported in this field

• Block 9 is required dollar amount

Missing/invalid type of bill:

• Block 4, must be 3-digit numeric

Missing dates must be completed:

• Admission

• Discharge

• Paid dates

Pages not attached:

• Missing/incomplete reports

• Fax pages out of order/missing/mismatched

Fax Reminder

Unless you need to send a check, ALL providers must submit Credit Balance Reports and certification pages via fax to 1-410-891-5230

• Only when you are repaying credit balance by check, the check and supporting documentation should be mailed to:

Novitas Solutions, Inc.Attn: Cashier2020 Technology Pkwy, Suite 100Mechanicsburg, PA 17050

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Contact Person

Contact person should be a person who has knowledge of Credit Balance Report and should also know how to process claims

Ensure the telephone number is correct

Only one attempt will be made to contact the provider regarding questions on the submitted report:

• If the provider does not return the telephone call then Novitas will offset the amount reported on the credit balance report

• The claim will not show an adjustment in FISS

Avoid Credit Balance Reporting

Errors

Do not:

• Include claims you have indicated on a prior quarter

• Report your overpayments on your quarterly Credit Balance Report and submit a voluntary refund

• Use staples

• Forget to include your UB-04 with your report

• Mail hard copy once a certification has been faxed

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Website Features

Website Satisfaction Surveys

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Comprehensive Error Rate Testing

(CERT) Program

Comprehensive Error Rate Testing

(CERT)

Program developed by Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claims processing

Designed to protect the Medicare trust fund and determine error rates nationally and regionally

Random audits conducted on a monthly basis

AdvanceMed request medical records for claims selected as part of the monthly random sample

Medical record documentation supporting claim must be returned in designated time frame

JH CERT page

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CERT Program New Processes

Documentation Requests:

• All FIRST Additional Documentation Request (ADR) letters for CERT are sent to the address on file with the National Supplier Clearinghouse (NSC) for the Medicare Administrative Contractor (MAC) for the provider/supplier that billed/submit the claim

• All SUBSEQUENT ADR letters can be sent to a specific correspondence address:

This can be provided to the CERT Customer Service Representative (CSR) by calling 888-779-7477

CERT Identification Online Tool

Provides status information for sampled claims using the Claim Identification Number (CID) where a decision has been made by the CERT contractor:

• Claim in Error- CERT error was assessed or not

• Status Date- last date that CERT updated/reviewed the case

• Status Decision- where the claim is with the CERT Review Contractor

• Appealed- if an appeal was initiated and the appeal status

• Error Code- errors assessed

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Part A - Key Points

Major Part A error drivers continue to be Inpatient Rehab Facility (IRF) and Skilled Nursing Facility (SNF) claims

Specifically, documentation missing from the full complement of required elements as outlined in the regulations

• Missing documentation of prognosis on the plan of care

• Missing progress notes

• Missing or delayed certifications

• Missing required MD signatures

Hospital Outpatient claims have emerged as a high Improper Payment category with a large percentage of overall error for Insufficient Documentation of services

Complete and proper documentation is the key to supporting these services.

CERT Appeals vs. Claim

Adjustments

Part A providers may not cancel or adjust claims selected in the CERT review process

Notify CERT if an error has been made on a claim, do not cancel or adjust claims

Novitas initiates adjustments for necessary denials

CERT adjustments in FISS appear as XXH bill type

Appeal denials on XXH bill type as a means of submitting corrections to claims using the Medicare Part A Redetermination Request form

CERT Appeals vs. Claim Adjustments

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Medical Record Signature

Reminders

Categorized as “Insufficient Documentation” errors:

• Missing signatures

• Illegible handwritten signatures

• Electronic signatures not dated

• Attestation statements do not match the date of service

Records must be signed and dated

Include signature logs to determine handwritten signatures

Complete attestation statements when records are not signed

Do not add late signatures

CMS Complying with Medicare Signature Requirements

Summary

Provided the latest news, updates and reminders for Medicare Part A

Reviewed the New Medicare Card Updates

Explored Novitasphere’s features, benefits and enrollment steps

Discussed Medicare Credit Balance Report common errors

Understand how to avoid common documentation errors based on the Comprehensive Error Rate Testing program findings

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Thank You

Janice Mumma

Supervisor, Provider Outreach and Education

janice.mumma@novitas-solutions.com

717-526-6406

Stephanie Portzline

Manager, Provider Engagement

Stephanie.Portzline@novitas-solutions.com

717-526-6317