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.


Monday, April 20, 2015

Medicare Billing: 837P and Form CMS-1500


What are the 837P and Form CMS-1500?
837P: The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. Review the chart below “ANSI ASC X12N 837P” for more information about this claim format.

Form CMS-1500:The Form CMS-1500 is the standard paper claim form that health care professionals and suppliers use to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.
In order to align the CMS-1500 with some of the changes in the electronic format, the previous 08/05 version was revised to the 02/12 version. Visit the National Uniform Claim Committee (NUCC) website
for information on the revision process. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (02/12) and the form is referred to throughout this fact sheet as the CMS-1500.

In addition to billing Medicare, the 837P and Form CMS-1500 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.

ANSI ASC X12N 837P

The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional)
Version 5010A1 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
P = Professional version of the 837 electronic format Version
5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers.

          Implementation and Companion Guides for Electronic Transactions
Health care professionals or suppliers billing electronic claims must comply with the ASC X12N implementation guide. The “837P Health Care Claim: Professional” implementation guide is available for purchase and provides instructions on the content and format requirements for each of the standards’ requirements. 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. These documents are written for use by all health benefit payers, not specifically for Medicare.

Implementation Guides, including Version 5010 Consolidated Guides, can also be purchased from the
Washington Publishing Company on the Internet. CMS publishes a companion guide to supplement the implementation guide and provide further instruction specific to Medicare. The “5010A1 Part B 837 Companion Guide” is located on the CMS website and provides specific 837P 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.
Please note that the implementation guides and companion guides are technical documents and health care professionals or suppliers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims
Health care professionals and suppliers 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 payment requires 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 involve 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 Paper Form CMS-1500?

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


ASCA Exceptions: Before submitting a hard copy claim on the Form CMS-1500, health care professionals and suppliers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, health care professionals and suppliers that have fewer than 10 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 a health care professional or supplier meets an exception, there is no need to submit a waiver request.

Waiver Requests: 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 a health care professional’s or supplier’s staff prevents use of a computer for electronic submission of claims. Health care professionals and suppliers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their MAC.

Wednesday, March 25, 2015

New Patient Visits by Same Physician or Physician Group: Overpayments



Medicare's Common Working File (CWF) system detects erroneous billings when there are two new patient CPT codes being billed within a three-year period of time by the same physician or physician group.

The Recovery Auditors are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with 'New Patient' Evaluation and Management (E/M) services to have improper payments, because the new patient services have been billed two or more times within a three-year period by the same physician or physician group.

If Medicare discovers that a new patient code has been paid more than one time in a three-year period to the same physician, then Medicare Contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.

Codes that are checked:


•    CPT codes: 99201-99205, 99324-99328, 99341-99345, 99381-99387, 92002, and 92004
•    The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012, and 92014).

New Patient Definition:

The 'Medicare Claims Processing Manual,' Chapter 12, Section 30.6.7 provides that 'Medicare interpret the phrase 'new patient' to mean a patient who has not received any professional services (i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years). For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit).'

Tuesday, March 10, 2015

Medicare coverage on Seasonal Flu Vaccinations



Generally, Medicare Part B covers one flu vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries.
Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers, and patients.
Note: The flu vaccine is not a Part D-covered drug.

This recurring update notification provides the payment allowances for the following seasonal influenza virus vaccines, when payment is based on 95 percent of the Average Wholesale Price (AWP).
CPT 90655 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90656 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90657 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90661 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90685 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90686 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90687 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90688 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2035 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2036 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2037 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2038 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015

Payment for the following CPT or HCPCS codes may be made if your MAC determines its
use is reasonable and necessary for the beneficiary, during the effective dates indicated
below:
CPT 90654 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90662 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90672 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90673 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2039 Flu Vaccine Adult - Not Otherwise Classified payment allowance is to be
determined by the local claims processing contractor with effective dates of 8/1/2014 -
7/31/2015.

Payment allowances for codes for products that have not yet been approved will be provided
when the products have been approved and pricing information becomes available to CMS.
The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP
and are updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug
Pricing Files. The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the AWP as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally
Qualified Health Center (FQHC). Where the vaccine is furnished in the hospital outpatient
department, RHC, or FQHC, payment for the vaccine is based on reasonable cost.

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
Note: MACs will not search their files either to retract payment for claims already paid or to retroactively pay claims prior to the implementation date of CR8890. However, they will adjust claims that you bring to their attention.

Sunday, March 1, 2015

EHR Incentive Program: How to Report Once in 2014 for Medicare Quality Reporting Programs



Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:

•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once
Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:

•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.
•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.
•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.
2014 QRDA III SEVT Testing Available
The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.
Related Posts with Thumbnails