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Billing for Denial –The Right Way

Cynde Derryberryy y y

Vice President, Reimbursement Advisory Services

MCG Resources

Top 5 Things to Know for CE: Make sure your BADGE IS SCANNED each time you enter a session, to record your attendance. Carry the Evaluation Packet you received on registration with you to EVERY session. If you’re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable. Pharmacists, Pharmacy Technicians and Nurses need to track their hours on ythe Statement of Continuing Education Certificate form as they go. FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Certificate form.

Keep the PINK copies for your records. Place the YELLOW and WHITE copies in your Evaluation packet. Make sure an evaluation form from each session you attended is completed and in your Evaluation packet (forgot to pick up an evaluation form at a session? (Extras are available in an accordion file near the registration desk.) Put your name and unique member ID number (six digit number on the bottom of your badge) on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center.

Disclosures

Cynde Derryberry is Vice President of Vice President, Reimbursement Advisory Services at MCG Resources. The conflict of interest wasMCG Resources. The conflict of interest was resolved by peer review of slide content.

Clinical trials and off-label uses will not be discussed during this presentation.

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Medicare Benefit Categories Medicare Denial Categories Codes and Modifiers Claiming ABNs Challenges Tools and Tips

DMEPOS ◦ Durable Medical

Equipment Prosthetics, Orthotics & Supplies

DME Prosthetic devices Orthotics Surgical dressings Immunosuppressive drugs

DME MACs ◦ 4 Regions◦ Process DMEPOS claims

Covered services fall into one of the BENEFIT CATEGORIES listed ◦ (Social Security Act 1861s)

Therapeutic shoes diabetics Oral anticancer drugs Oral antiemetic drugs◦ Replacement for IV antiemetics

IVIG

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DME◦ Can withstand repeated use, is primarily used to serve a medical

purpose, is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home

Prosthetic Devices ◦ Replace all or part of an internal body organ or the function of aReplace all or part of an internal body organ or the function of a

permanently inoperative or malfunctioning internal body organ

IVIG ◦ For treatment in the home of a patient with a diagnosed primary

immune deficiency disease, but not including items/services related to the administration

**Note that the list above is not all inclusive**Section 1861(s) of the Social Security Act (SSA) lists covered services

Items/services that are not reasonable & necessaryfor the diagnosis or treatment of an illness/injury orto improve the functioning of a malformed body member

DME and related supplies/accessories provided to patients in skilled nursing facilitiesp g

Experimental/Investigative items Preventative Services Personal Comfort Items

**Note that the list above is not all inclusive**

Section 1862(1)(a) of the SSA lists Excluded Services/Items

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• Reduction to Least Costly (2.4.11 change)

• Fragmented Coding• Non-Covered (technical)• Other

Easily Defined

• Excluded Services

• Not Medically Necessary

Not so Easily

Defined

Statutorily Excluded DME & related supplies in a Skilled Nursing Facility Experimental/Investigational Preventative services

D fi iti f M di B fit N t M t Definition of a Medicare Benefit Not Met Oral Enteral TPN/ENT used to treat a temporary condition Infusion drugs not administered via a external

infusion pump Most oral drugs

ABN is NOT required

◦ Not ordered by a physician, nurse practitioner, clinical nurse specialist or P.A.

◦ Same or similar items

◦ Items which do not meet medical necessity coverage criteria, or frequency guidelines specified in policy

ABN IS Required

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CODESMODIFIERSCLAIMING

Description

A4221 Supplies for maintenance of drug infusion catheter, Per Week (List drugs separately)

A4222 Infusion supplies for External Drug Infusion Pump, Per Cassette or Bag (List drugs separately)

A4223 Infusion Supplies not used with External Infusion Pump, Per Cassette or Bag (List drugs separately)

J Codes If a specific J Code exists for a drug it must be used

A9270 Non-Covered Item or Service – this code should rarely be used. Check first to see if a specific HCPC or CPT code applies to your item or service

Description

GA WAIVER OF LIABILITY STATEMENT ON FILE

GZITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE OR NECESSARY

GYITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT

GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY

KE FOR USE WITH NON-COMPETITIVE BID BASE EQUIPMENT

KH DMEPOS ITEM, INITIAL CLAIM, FIRST MONTH RENTAL

KI DMEPOS ITEM, SECOND OR THIRD MONTH RENTAL

KJDMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, MONTHS 4-15

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If the drug is administered via an external infusion pump, then it meets the definition of the Medicare benefit

If the beneficiary does not meet the coverage criteriaor if the drug being administered is not listed in theor if the drug being administered is not listed in the external infusion pump policy, a denial of not medically necessary will be given for the pump, drug, and supplies

An ABN is Required!

Before billing Medicare for denial you will need:◦ Dispensing Order◦ Written Order – Signed & Dated◦ DIF ◦ ABN◦ Proof of Delivery

Bill using Medicare A, E, J CodesA few “what not to dos”…S Codes should NEVER be billed to MedicareA4223 not to be used with an External Infusion PumpGA and GY should not be combined on your claim line

Example assumes ABN was obtained

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The Medicare ERN must have a “PR” Patient Responsibility denial on all claim lines

Codes will not match one for one if the Secondary payor uses S Codes

Most payors require at minimum the date of service and dollar amount match the Medicare remit◦ Note that some may also require the unit to match

Use the narrative field or a cover sheet to explain A4221, A4222, and E0781 are equal to the S Code you are billing ◦ The combined charges for these 3 codes (and pole if used) should

match the S Code charge

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The definition of a Medicare Benefit is no longer met – therefore the service is non-covered

An ABN is not Required!

Written Order no longer required DIF not required** ABN not required A4223 should be used for supplies/per diem A4221 may still be used (with a GY modifier) A4222 should never be used with A4223 GY Modifier should be attached to drugs A Secondary payor may still require a SMN/LMN

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If administered via an External Infusion Pump (EIP) and the patient has a covered diagnosis:◦ Verbal Order◦ Written Order – Signed & Dated◦ DIF ◦ ABN for the pump and supplies◦ ABN for the pump and supplies

IVIG not meeting criteria (diagnosis) will be denied as non-covered, therefore no ABN is required

IVIG administered w/o an EIP but with a covered diagnosis - patient is considered to have met coverage criteria

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A written notice that advises a beneficiary before items are furnished that Medicare is likely to deny payment ◦ Hand Delivery, Secure Fax or Secure Email◦ Delivery methods require adherence to all HIPAA privacy requirements ◦ When delivery is not in person, contact must be documented To be considered effective, the beneficiary cannot dispute such contact

Allows beneficiaries to make informed consumer decisions about items or services for which they may have to pay out of pocket

Required Form is CMS R-131

General Information and/or “must haves”: Clearly lists the items/services States the reason you believe Medicare may deny Includes estimated costs Must be easy to read – 12 pt font size ABN form must not exceed one page Must be signed/dated by the patient or authorized rep Must keep original on file (copy to patient) Valid for ONE year

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Reason Why Medicare Won’t Pay Medicare does not pay for this ______for your diagnosis

Test of permanence not met – length of need is less than 90 days Medicare coverage criteria is not met90 days. Medicare coverage criteria is not met, therefore Medicare is likely to deny these items/services as not reasonable and necessary

Medicare coverage criteria for this item/service has not been met, therefore Medicare is likely to deny these items/services as not reasonable and necessary

Estimated costs should be within $100 or 25%

Multiple items/services that are routinely grouped can be bundled into a single cost estimate

Average daily cost estimates are permissible

Estimates that substantially exceeds the actual cost would generally still be acceptable◦ Estimate can not be LESS than what the patient would owe

Must be completed by the beneficiary Only one option can be chosen If some but not all items are accepted either cross out the

item, reason and estimated cost, or complete a new ABN

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Option 1: ◦ Allows the beneficiary to receive the items/services ◦ Used for beneficiaries who need to obtain an official Medicare

decision in order to file a claim with a secondary insurance ◦ May collect payment upon delivery◦ A claim must be submitted to Medicare◦ Payment decision can be appealed

Option 2: Option 2: ◦ Allows the beneficiary to receive the noncovered items/services ◦ May collect payment upon delivery◦ No claim will be filed - no appeal rights ◦ Use for a Voluntary notice

Option 3: ◦ The beneficiary does not want the item/services ◦ There are no appeal rights associated with this option◦ Cannot bill Medicare “just to see” if they would pay

H: Used to provide additional information I: Beneficiary or authorized representative must sign

Representative is an individual who may make health care and financial decisions on a beneficiary’s behalf

(Representative) should be in parenthesis after his/her signature

J: Beneficiary/representative must enter the date signed

ABNs are not required for care that is either statutorily excluded from coverage under Medicare or fails to meet a technical benefit requirement

ABNs can be issued voluntarily for care that is never ABNs can be issued voluntarily for care that is never covered such as: ◦ Care that fails to meet the definition of a Medicare benefit as

defined in §1861 of the Social Security Act◦ Care that is explicitly excluded from coverage under §1862

of the Social Security Act

Medicare Claims Processing Manual Chap.30 (50. 3.2)

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Items/services provided under the Medicare Advantage (MA) Program

Prescription drugs provided under the Medicare Prescription Drug Program (Part D)Prescription Drug Program (Part D)

Medicare Claims Processing Manual Chap.30 (50.1)

Unable to Obtain an ABN ◦ Inability to give notice does not allow financial liability to be shifted to the

patient, unless all attempts to issue the notice have been exhausted ◦ All attempts must be clearly documented in the patient’s record & must

be undisputed by the beneficiary

Patient Refuses to Sign or to Choose an Option g p◦ Consider not furnishing the item/service unless the consequences

(health and safety) are such that this is not an option◦ Limitation of Liability provision If the patient demands the service - annotate the ABN, with the signature

of a witness, that the beneficiary received notice but refused to sign the form - submit the claim with an indication that an ABN was given

◦ Provide a copy of the annotated ABN to the beneficiary, keep the original version of the annotated notice in the patient’s file

Medicare Claims Processing Manual

Switching from a MA plan to Medicare FFS

Do I bill at Contract Rate or at List?

Drugs that have “S” Codes

Crossovers

COBRA

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Cover Letters for Secondary Claims

Write the Member ID on your Medicare ERN

Print/write “Medicare ERN attached”If ll d b thIf allowed by the payorDo not use highlighter

GY: Add a narrative –Not administered via an External Infusion PumpUsed to treat a temporary condition

System Capabilities – use them!

Demand EOB/ERNs

NHIA “Medicare Billing for Denial Tool”

Webinars

Listservs

ABN Instructions http://www.cms.gov/BNI/Downloads/RevABNManualInst

ructions.pdf CMS Manuals (Benefit, Program Integrity, etc) http://www cms gov/Manuals/IOM/list asp http://www.cms.gov/Manuals/IOM/list.asp Medicare National Coverage Determinations Manual http://cms.gov/manuals/downloads/ncd103c1_Part4.pdf Pricing, Data, Analysis, and Coding (PDAC) https://www.dmepdac.com/dmecs/index.html

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Thank you!