Thursday, June 25, 2015

How to Complete CMS-838 Credit Balance Reports


As your Medicare Administrative Contractor, Novitas Solutions, Inc. is responsible to ensure compliance with the Credit Balance reporting process. The information provided below offers a brief explanation of how the CMS-838 Credit Balance Reports should appear before mailing or faxing to Medicare.

The CMS-838 Credit Balance Report
The CMS-838 Credit Balance Report is comprised of the Certification Page and the Detail Page which is completed when there are credit balances to report. The Certification Page is required with every submission; no matter which of the following blocks are checked on the Certification Page:

Qualify as a Low Utilization Provider
The Credit Balance Report Detail Page is attached
There are no Medicare credit balances to report for this quarter (No Detail Page(s) attached).
Any Credit Balance 838-Certifications that are not accurate and complete will be deemed invalid. Effective for the 03/31/15 reporting quarter, the immediate return of invalid or incomplete CMS-838 Certification Pages will result for the following reasons. Please note that invalid Certification Pages will invalidate your entire submission:

The incorrect version of the CMS-838 Certification Page/Detail Page is received. Please use the correct version of the CMS-838 Credit Balance Report. You can type directly into this version which is strongly encouraged to ensure your report is legible. Once completed in full, the report should be printed for signatures.
Proper 6-digit Provider Transaction Access Number (PTAN) is missing, invalid, or a National Provider Identifier (NPI) is listed. The name of the facility should be indicated.
Multiple PTANS are present. Only one PTAN per Certification Page is acceptable
Incomplete or inaccurate Quarter Ending date. Quarters should be reported as 03/31/XX, 06/30/XX, 09/30/XX or 12/31/XX. Four digit years will also be acceptable.
Signature and date of Administrator is missing
Correct “Check One” block is blank or does not match the contents.
*Although Novitas will not return as invalid reports missing the Contact Person/Phone number, completing this section is necessary if contact to the provider with regard to the report is necessary.
When returning an invalid or incomplete report for the reasons listed above, you will receive a cover sheet detailing the reason for return. Your report should be corrected and mailed or faxed within the acceptable timeframe in order to avoid receiving a Delinquency Warning Letter or having 100% of your Medicare Payments withheld.
Please note that CMS-838 Detail pages are not necessary when there are no Medicare Credit Balances to report for the quarter (the third check block on the 838-Certification page). In addition, documents such as vendor reports verifying no credits, shared system reports, or other validation documents are not necessary when there are no Medicare credit balances to report.
When Medicare Credit Balances Are Identified
When reporting Medicare Credit Balances, a complete CMS-838 Detail Page is required with the submission. Although an 838-Certification Page may pass the initial validation process, the 838-Detail Page may contain inaccurate or incomplete information when reporting Medicare credit balances. Currently, telephone contact results when CMS-838 Detail Pages are incomplete or inaccurate and reports are not accepted as valid until what is requested is corrected and received timely. However, effective for the 06/30/15 reporting quarter, incomplete and/or inaccurate CMS-838 Detail Pages will be immediately returned.

Accurate and complete CMS 838-Detail Pages should include the following:
Column 1- Last name and first name of beneficiary
Column 2- Health Insurance Claim Number (HICN) of beneficiary
Column 3- Internal Control Number (ICN): Please note that this is not always the ICN of the original claim. This should be the ICN of the claim identifying the overpayment.
Column 4- Type of Bill (TOB): This is a required field and is 3-digits
Column 5- Admission Date: From date or start date service began
Column 6- Discharge Date: Through date or date service ended
Column 7- Paid Date: Date claim paid
Column 8- Cost Report: “O” is entered for a cost report period is open or “C” if closed
Column 9- Amount of Medicare Credit Balance: Total Credit Balance owed to Medicare. This is not the billed amount.
Column 10- Amount Credit Balance Repaid: This is the amount repaid with the submission of this report
Column 11- Method of Payment: The choices are “C” when remitting a check to repay the amount owed to Medicare (the check and UB04s must accompany the report), “X” when an adjustment has already been submitted through the shared system, or “A” when Novitas is expected to adjust the claim (UB04 is required)
Column 12- Amount of Medicare Credit Balance Outstanding: Column 10 minus Column 9)
Column 13- Reason for Medicare Credit Balance: The choices are “1” when a Duplicate is identified, “2” when MSP is identified, and “3” for Other.
Column 14- Value Code is required when reporting “2-MSP” in Column 13. Acceptable Value Codes are: 12-Working Aged, 13-End Stage Renal Disease (ESRD), 14-Auto/No Fault, 15-Worker’s Compensation, 16-Other Government Program, 41-Black Lung, 42-Department of Veterans Affairs (VA), 43-Disability, 44-Conditional Payment, and 47-Liability
Column 15- Name and complete billing address and is required when reporting “2-MSP” in Column 13. This column is also used to explain “3-Other” being reported in Column 13.
The following is an example of an acceptable CMS-838 Detail Page when “Duplicate” is the Reason for Medicare Credit Balance (Block 13)

The following is an example of an acceptable CMS-838 Detail Page when “MSP” is the Reason for Medicare Credit Balance (Block 13)



The following is an example of an acceptable CMS-838 Detail Page when “Other” is the Reason for Medicare Credit Balance (Block 13)




Friday, June 19, 2015

Items and Services Furnished Outside the United States (U.S.) - Medicare


Most items and services furnished or delivered outside the U.S. are not covered, including when the beneficiary was within the U.S. when the contract to purchase the item was made or the item was purchased from an American firm. Payment will not be made for a medical service (or a portion thereof) that was subcontracted to another provider or supplier located outside the U.S.Medicare pays for provider professional services that are furnished in the U.S., except for certain limited services as described below under
Exceptions. The Centers for Medicare & Medicaid Services (CMS) recognizes the following as being
within the U.S.:
• The 50 States;
• The District of Columbia;
• The Commonwealth of Puerto Rico;
• The Virgin Islands;
• Guam;
• The Commonwealth of the Northern Mariana Islands;
• American Samoa; and
• Territorial waters adjoining the land areas of the U.S. (for services furnished onboard a ship).
A hospital is considered outside the U.S. if it is not physically located in one of the jurisdictions listed
above, even if it is owned  or operated by the U.S. Government.

Exceptions
The following services are covered:
• Emergency inpatient hospital services furnished at a foreign hospital provided the foreign hospital is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency. One of the following conditions must exist:
◦ The beneficiary was physically present in the U.S. at the time of the emergency that necessitated inpatient services; or
◦ The emergency arose in Canada while the beneficiary was traveling, by the most direct route and without unreasonable delay between Alaska and another State;
• Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the U.S. provided the hospital is closer to, or substantially more accessible from, the beneficiary’s U.S. residence than the nearest participating U.S. hospital that is adequately equipped to deal with and available to treat the illness or injury;
• Physician and ambulance services furnished in connection with a covered foreign hospitalization. Payment will not be made for any other Part B outpatient, medical, and other health services that are furnished outside the U.S.;
• Services furnished onboard a ship in a U.S. port or furnished within 6 hours of when the ship arrived at or departed from a U.S. port. Services that do not meet this requirement are considered furnished outside U.S. territorial waters, even if the ship is of U.S. registry;
• Physician and ambulance services furnished in Canada and covered by the Railroad Retirement Board to a Railroad Retirement beneficiary in connection with covered hospital services; and
• Services for a beneficiary who has elected the religious nonmedical health care benefit; however, the receipt of medical services may revoke the religious nonmedical health care benefit.

B) Items and Services Required as a Result of War
Items and services that are required as a result of war or an act of war and that occur after
the effective date of the beneficiary’s current entitlement are not covered.

C) Personal Comfort Items and Services
Personal comfort items will not be covered because these items do not meaningfully contribute to the treatment of a beneficiary’s illness or injury or the functioning of a malformed body member.
Some examples of personal comfort items are:
• Radios;
• Televisions; and
• Beauty and barber services, except as described below under Exceptions.

When a beneficiary requests a personal comfort item, you should inform him or her that there is a
specified charge for the item. The specified charge may not exceed the customary charge, and
future charges may not be more than the amount specified. You cannot require the beneficiary
to request non-covered items or services as a condition of admission or continued stay.

Exceptions
Certain basic personal services that residents in Skilled Nursing Facilities (SNF) and general
psychiatric hospitals need and cannot perform for themselves are covered. Some examples include:
• Shaves;
• Haircuts;
• Shampoos; and
• Simple hair sets.
These services may be considered ordinary patient care and covered costs are reimbursable under Part A when they are:
• Furnished by a long-stay institution;
• Included in the flat rate charge; and
• Routinely furnished without charge to the beneficiary.

D) Routine Physical Checkups; Certain Eye Examinations, Eyeglasses and Lenses; Hearing Aids and Examinations; and Certain Immunizations
The following routine items and services are not covered:
• Routine or annual physical checkups, except as described in the Exceptions Section under
1) Services and Supplies That Are Not Medically Reasonable and Necessary below
• Physical examinations that are performed without a specific sign, symptom, or beneficiary complaint necessitating the service or that are required by third parties (for example, insurance companies, business establishments, or Government agencies);
• Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses;
• Eye refractions furnished by all practitioners for any purpose;
• Eyeglasses and contact lenses;
• Examinations for hearing aids;
• Hearing aids; and
• Immunizations, except as described in the Exceptions Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary given below.

Exceptions
The following items and services are covered:
• Physician services performed in conjunction with an eye disease (for example, glaucoma and cataracts);
• Services performed incident to physician services in conjunction with an eye disease;
• One pair of eyeglasses or contact lenses after each cataract surgery with insertion of
an intraocular lense;
• Vaccinations directly related to the treatment of an injury or direct exposure to a disease or condition (for example, antirabies treatment and immune globulin);
• Vaccinations that are specifically covered by statute (for example, seasonal influenza virus, pneumococcal, and Hepatitis B);
• A reasonable supply of antigens (not more than a 12-week supply that has been prepared for a particular beneficiary) a doctor of medicine (MD) or a doctor of osteopathy (DO) has prepared after
examining the beneficiary and determining a plan of treatment and dosage regimen. A different physician may administer the antigens; and
• Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve and are indicated only when hearing aids are medically inappropriate or cannot be utilized due to:
◦ Congenital malformations;
◦ Chronic disease;
◦ Severe sensorineural hearing loss; or
◦ Surgery.
These devices, which are payable as prosthetic devices, include:
• Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or the auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays; and
• Osseointegrated implants that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.

Thursday, June 18, 2015

Tention Health Professionals: Information Regarding the 2015 Medicare Physician Fee Schedule

On April 1, 2015, the Medicare Physician Fee Schedule (MPFS) was updated using the Sustainable Growth Rate (SGR) methodology as required by current law. The SGR methodology required a 21% decrease in all MPFS payments beginning April 1, 2015. The Centers for Medicare & Medicaid Services (CMS) took steps to limit the impact on Medicare providers and beneficiaries by holding claims paid under the MPFS with dates of service on and after April 1, 2015. Additionally, Medicare is also holding all therapy claims that would no longer qualify for the therapy cap exceptions (those therapy claims with the ‘KX’ modifier), due to the expiration of the therapy cap exceptions process on April 1, 2015.  In the absence of additional legislation to avert the negative update, CMS must update payment systems to comply with the law, and implement the negative update.

Beginning on April 15th, 2015, CMS will release held MPFS claims, paying at the reduced rate, based on the negative update, on a first-in, first-out basis, while continuing to hold new claims as they are received.  CMS will release one day's worth of held claims, processing and paying at the rate that reflects the negative update. At the same time, CMS will hold the receipts for that day, thus, continuing to hold 10 days' worth of claims in total. This is to provide continuing cash flow to providers, albeit at the rate that reflects the negative update. This “rolling hold” will help minimize the number of claims requiring reprocessing should Congress pass legislation changing the negative update.

Providers should remember that claims for services furnished on or before March 31, 2015 are not affected by the payment cut and will be processed and paid under normal time frames.  We are working to limit any impact to Medicare providers and beneficiaries as much as possible. The MACs will automatically reprocess the claims paid at the reduced rate if Congressional action is taken to avert the negative update.  No action is necessary from providers who have already submitted claims for the impacted dates of service.

Informational Alert
Issued 4/15/2015 at 7:22 AM
Common Working File (CWF) Hosts will be Conducting History Purges
On Saturday, May 2, 2015, the CWF Northeast, Southwest, Southeast, Great Lakes, and Mid-Atlantic Hosts will be conducting a history archive.
On Saturday, May 9, 2015, the CWF South, Pacific, Great Western, and Keystone Hosts will be conducting a history archive.

Due to the anticipated duration of this activity and to ensure the completion of the weekly processing and scheduled data center maintenance, Saturday, May 2, 2015, will be a CWF Dark Day at the Northeast, Southwest, Southeast, Great Lakes, and Mid-Atlantic Hosts only. Saturday, May 9, 2015, will be a CWF Dark Day at the South, Pacific, Great Western, and Keystone Hosts only. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until 12:00 p.m. (Eastern Standard Time) each Saturday.

All files received from satellites for Friday’s cycle (May 1, 2015 and May 8, 2015) will be completed prior to bringing CWF production down.
If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history archive has been completed.

The oldest claim history maintained after the purge process will be as follows:

• Oldest Inpatient Thru Date To Keep On File: 01/01/1966
• Oldest Outpatient Thru Date To Keep On File: 02/01/2013 (27 Months)
• Oldest Part B Thru Date To Keep On File: 05/01/2013 (24 Months)
• Oldest Hospice Thru Date To Keep On File: 01/01/1966
• Oldest Home Health Thru Date To Keep On File: 01/01/1998


• Oldest DMERC Thru Date To Keep On File: 05/01/2013 (24 Months)

Wednesday, June 10, 2015

New Timeframe for Response to Additional Documentation Requests AND Payment for G0101 and Q0091 in RHC


Payment for G0101 and Q0091 in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that Bill Under the All-Inclusive Rate (AIR) System.

Provider Types Affected

This MLN Matters Article is intended for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who are authorized to bill under the All Inclusive Rate (AIR) system and submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 8927 adds Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) to the list of preventive services paid based on the All-Inclusive Rate (AIR) for RHCs and FQHCs. Make sure your billing staffs are aware of this changes.

Background

The Centers for Medicare and Medicaid Services (CMS) has determined that HCPCS codes G0101 and Q0091 are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.

CR8927 instructs MACs to allow HCPCS codes G0101 and Q0091 to be billed as a stand-alone encounter/visit. These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Tyoes of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to G0101 or Q0091. If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.

G0101 or Q0091 are payable annually for women at high risk for developing cervical or vaginal cancer, and women of childbearing age who have had an abnormal Pap test within the past 3 years. It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, G0101 and Q0091 are qualifying visit when billed with FQHC payment HCPCS codes G0466 or G0467.

Your MAC will not search for claims that have been denied with HCPCS code G0101 or Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.


New Timeframe for Response to Additional Documentation Requests

Provider Types Affected

This MLN Matters Article is intended for physician, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.

Background

In certain circumstance, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments or the billing history found in claims processing system (if applicable) or Medicare's Common Working File (CWF).

In those instances, the CMS review contractor will solicit documentation from the provider or supplier by issuing as ADR. The requirements for additional documentation are as follows:

The Social Security Act, Section 1833 (e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.

According to the "Medicare Program Integrity Manual" Chapter 3, Section 3.2.3.2, (Verifying Potential Errors and Tracking Corrective Actions), when requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.

Note: This article was revised on November 18, 2014, to make corrections in the article, especially to clarify ADR requirements related to pre-payment review.


Friday, May 22, 2015

Medicare Billing: 837I and Form CMS-1450


What are the 837I and Form CMS-1450?

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed. In addition to billing Medicare, the 837I and Form CMS 1450 may be suitable for billing various government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).


 ANSI ASC X12N 837I

The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional)
Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
I = Institutional version of the 837 electronic format
Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.

Implementation and Companion Guides for Electronic Transactions

ASC X12N implementation guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards’ requirements. The documents are written for use by all health benefit payers, not specifically for Medicare. Implementation guides, including Version 5010 consolidated guides, can be purchased at the ASC X12 store or from the Washington Publishing Company on the Internet.

CMS publishes a companion guide to supplement the implementation guide to provide further instruction specific to Medicare. The “5010A2 - Part A 837 Companion Guide” is located on the CMS website and provides  specific 837I electronic claim loop and segment references. MACs also publish their own companion documents, which provide additional information specific to that contractor’s business. To locate a MAC’s Companion Guide, visit that contractor’s website. Implementation guides and companion guides are technical documents, and providers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims

Providers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.
In addition to correct claims completion, Medicare coverage and payment is contingent upon a determination that an item or service:
• Meets a benefit category;
• Is not specifically excluded from coverage; and
• Is reasonable and necessary.

In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. It is a crime to defraud the Federal government and its programs. Punishment may include imprisonment, significant fines, or both under a number of laws including the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the Criminal Health Care Fraud Statute.

When Does Medicare Accept a Hard Copy Claim Form?

Initial claims for payment under Medicare must be submitted electronically unless an institutional provider qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Before submitting a hard copy claim, providers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, institutional providers that have fewer than 25 Full-Time Equivalent (FTE) employees and bill a MAC are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If an institutional provider meets an exception, there is no need to submit a waiver request.

There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of an institutional provider’s staff prevents use of a computer for electronic submission of claims. Institutional providers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their MAC.

Monday, May 11, 2015

J3590/C9399 Vimizim™ (elosulfase alfa) and Diagnostic Tests- CMS Requirements


J3590/C9399 Vimizim™ (elosulfase alfa)

Vimizim™ (elosulfase alfa) injection, for intravenous use is a hydrolytic lysosomal glycosaminoglycan (GAG) specific enzyme indicated for patients with Mucopolysaccharidosis type IVA (MPS IVA: Morquio A syndrome). Vimizim™ was approved by the Food and Drug Administration (FDA) on February 14, 2014.
Vimizim™ is supplied as a concentrated solution for infusion in a 5mg/5ml (1mg / mL) single-use vial requiring dilution. As approved by the FDA the recommended dose is 2mg per kg administered intravenously over a minimum range of 3.5 to 4.5 hours, based on infusion volume, once every week. Pre-treatment with antihistamines with or without antipyretics is recommended 30-60 minutes prior to the start of the infusion.

In the absence of a national coverage determination (NCD) or local coverage determination (LCD), Medicare can consider coverage of a drug that is usually not self-administered per the FDA indication when administered incident to a physician service or in the hospital setting. The patient’s medical record must also support the diagnosis of Mucopolysaccharidosis, type IVA (MPS IVA; Morquio A syndrome using the appropriate ICD-9-CM code(s) of 277.5 (Mucopolysaccharidosis) and FDA guidance for use as well as the administration.

Diagnostic Tests- CMS Requirements
The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of diagnostic tests due to missing physician/non-physician practitioner order or intent within the medical record.  This has led to the recoupment of overpayments by Novitas Solutions, Inc totaling over $355.64. More importantly, when CMS and CERT extrapolate these errors to the universe, they will account for approximately $22.1 million in claims payment errors for the November 2012 report.
Medicare defines a Diagnostic Test as including:
"All diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary."

And further defines Clinical Laboratory Services as:

"The biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition."
CMS also gives direction that Clinical Laboratory Services "must be ordered and used promptly by the physician who is treating the beneficiary."

CMS defines an order as:
" A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y)."
An order can be written in the beneficiary's record or can be a telephone order from the physician's office to the testing facility.  If a telephone order, both the treating physician and the testing facility must have documented in the beneficiary's record the telephone call and the extent of the diagnostic tests being ordered.

Although CMS does not require the order to be signed by the physician, the physician must have clearly documented in the beneficiary's record the intent to order the diagnostic test.

Documentation requested by the CERT contractor or Novitas Solutions, Inc to support the order for the diagnostic test (or the physician's intent to order), will be sent to the testing facility, as it is the facility that is billing for the test.   Often the testing facility is unable to provide the physician's order or intent because this information is in the beneficiary's record in the physician's office.   The testing facility has to request this information from the physician in order to be paid for the service.  Without the order for the test, or the intent to order, both the CERT contractor and Novitas Solutions, Inc will deny payment for the diagnostic test or service.

To avoid such denials, testing facilities and physician's offices need to work together.  Testing facilities should attempt at the time the beneficiary is presenting to the facility, to have a diagnostic test performed, to obtain a physician's order.  This can be accomplished by directing the beneficiary to bring a prescription that includes the condition or diagnosis code for which the diagnostic test is ordered as well as the order for the diagnostic test. If the beneficiary presents without a valid order, the testing facility could call the physician's office to obtain a telephone order for the diagnostic test.

Wednesday, April 29, 2015

New Timeframe for Response to Additional Documentation Requests

Provider Types Affected

This MLN Matters Article is intended for physician, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.

Background

In certain circumstance, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments or the billing history found in claims processing system (if applicable) or Medicare's Common Working File (CWF).

In those instances, the CMS review contractor will solicit documentation from the provider or supplier by issuing as ADR. The requirements for additional documentation are as follows:

The Social Security Act, Section 1833 (e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period.

According to the "Medicare Program Integrity Manual" Chapter 3, Section 3.2.3.2, (Verifying Potential Errors and Tracking Corrective Actions), when requesting documentation for pre-payment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.

Note: This article was revised on November 18, 2014, to make corrections in the article, especially to clarify ADR requirements related to pre-payment review.


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