Thursday, February 4, 2016

Federal sequestration payment reductions FAQs

Q: Does the 2 percent payment reduction under sequestration apply to the payment rates reflected in Medicare fee-for-service fee schedules or does it only apply to the final payment amounts?

A: Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare secondary payment adjustments. All fee schedules, Pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced.


Q: How is the 2 percent payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?
A: Claim adjustment reason code (CARC) 253 is used to report the sequestration reduction on the ERA and SPR.



Q: What is the verbiage for CARC 253?
A: “Sequestration - reduction in federal payment.”


Q: Will the 2 percent reduction be reported on the remittance advice in a separate field?
A: For institutional Part A claims, the adjustment is reported on the remittance advice at the claim level. For Part B physician/practitioner, supplier, and institutional provider outpatient claims, the adjustment is reported at the line level.


Q: How will the payments be calculated on the claims?
A: The reduction is taken from the calculated payment amount, after the approved amount is determined and the deductible and coinsurance are applied.
Example: A provider bills a service with an approved amount of $100.00, and $50.00 is applied to the deductible. A balance of $50.00 remains. We normally would pay 80 percent of the approved amount after the deductible is met, which is $40.00 ($50.00 x 80 percent = $40.00).
The patient is responsible for the remaining 20 percent coinsurance amount of $10.00 ($50.00 - $40.00 = $10.00). However, due to the sequestration reduction, 2 percent of the $40.00 calculated payment amount is not paid, resulting in a payment of $39.20 instead of $40.00 ($40.00 x 2 percent = $0.80).


Q: How are unassigned claims affected by the 2 percent reduction under sequestration?
A: Though beneficiary payments toward deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The non-participating physician who bills on an unassigned basis collects his/her full payment from the beneficiary, and Medicare reimburses the beneficiary the Medicare portion (e.g., 80 percent of the reduced fee schedule amount.

Note: The “reduced fee schedule” refers to the fact that Medicare’s approved amount for claims from non-participating physicians/practitioners is 95 percent of the full fee schedule amount). This reimbursed amount to the beneficiary would be subject to the 2 percent sequester reduction just like payments to physicians on assigned claims. Both are claims payments, but to different parties. If the limiting charge applies to the service rendered, providers cannot collect more than the limiting charge amount from the beneficiary.

Example: A non-participating provider bills an unassigned claim for a service with a limiting charge of $109.25. The beneficiary remains responsible to the provider for this full amount. However, sequestration affects how much Medicare reimburses the beneficiary. The non-participating fee schedule approved amount is $95.00, and $50.00 is applied to the deductible. A balance of $45.00 remains. Medicare normally would reimburse the beneficiary for 80 percent of the approved amount after the deductible is met, which is $36.00 ($45.00 x 80 percent = $36.00). However, due to the sequestration reduction, 2 percent of the $36.00 calculated payment amount is not paid to the beneficiary, resulting in a payment of $35.28 instead of $36.00 ($36.00 x 2 percent = $0.72).

We encourage physicians, practitioners, and suppliers who bill unassigned claims to discuss with their Medicare patients the impact of the sequestration reductions to Medicare payments.


Q: Is this reduction based on the date of service or date of receipt?

A: In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME competitive bidding program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.


Q: If a durable medical equipment capped rental period started before April 1, 2013, are the rental payments for months after April 1, 2013, subject to the 2 percent reduction?

A: Any claims for rental payments with a “FROM” date of service on or after April 1, 2013, will be subject to the 2 percent reduction, regardless of when the rental period began. For example, if a capped rental wheelchair was provided in February 2013, the monthly rental payment for May 2013 would be subject to the 2 percent sequestration reduction. The initial and subsequent monthly rental payments billed with a “FROM” date of service beginning on or prior to March 31, 2013 would not be affected by the 2 percent reduction.


Q: How long is the 2 percent reduction to Medicare fee-for-service claim payments in effect?
A: The sequestration order covers all payments for services with dates of service or dates of discharge (or a start date for rental equipment or multi-day supplies) April 1, 2013, through March 31, 2016.


Q: Are drugs excluded from the 2 percent reduction?


A: No. All fee-for-service Medicare claim payments are subject to the 2 percent reduction. There are no exemptions provided in the law for drugs or any other health care item or service provided under the fee-for-service program.

Thursday, January 28, 2016

Examples for the limiting charge after applying the EHR and PQRS negative adjustments



Non-Par Non-Assigned Claim No EHR/PQRS Adjustment:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
Adjustment Total $5.00
MPFS Allowed Amount $100-$5.00= $95.00
Limiting Charge Allowed= $95.00 x 115%= $109.25

Non-Par Non-Assigned Claim with EHR Adjustment:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1% EHR negative adjustment $.95 (95 x.01)
Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
Limiting Charge Allowed= $94.05 x 115%= $108.16

Non-Par Non-Assigned Claim with PQRS Adjustment:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1.5% PQRS negative adjustment $1.43 (95 x.015)
Adjustment Total $ 6.43
MPFS Allowed Amount $100-$6.43= $93.57
Limiting Charge Allowed= $93.57 x 115%= $107.61

Non-Par Non-Assigned Claim with EHR + e-prescribing:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x.02)
Adjustment Total $ 6.90
MPFS Allowed Amount $100-$6.90= $93.10
Limiting Charge Allowed= $93.10 x 115%= $107.07

Non-Par Non-Assigned Claim with EHR without 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1% EHR negative adjustment $.95 (95 x .01)
EHR Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
1.5% PQRS negative adjustment $1.41 ($94.05 x .015)
PQRS Adjustment Total $94.05-$1.41=$92.64
MPFS Allowed Amount $92.64
Limiting Charge Allowed= $92.64 x 115%= $106.54

Non-Par Non-Assigned Claim with EHR with 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x .02)
EHR Adjustment Total $6.90
MPFS Allowed Amount $100-$6.90= $93.10
1.5% PQRS negative adjustment $1.40 (93.10 x .015)
PQRS Adjustment Total $93.10-$1.40=$91.70
MPFS Allowed Amount $91.70


Limiting Charge Allowed= $91.70 x 115%= $105.46

Thursday, January 21, 2016

Hospital billing rejection on Maternity room and NDC number

Maternity Room and Board Revenue Codes;


Molina is finding that some maternity claims have either denied or paid zero. Upon researching the claims, Molina discovered that the claims in question were billed without maternity room and board revenue codes. Please keep in mind that although there may be some circumstances when you do not need a maternity revenue code, the claims will process more efficiently if you are billing the appropriate maternity room and board revenue code when applicable.


 NDC Billing Instructions

Molina EDI Help Desk is reporting claims are being rejected because more than one NDC code is being billed on one service line. Below you will find instructions on billing multiple NDC codes for the same drug on a claim. For more detailed information on billing NDC codes, please see the
BMS website at www.wvdhhr.org/bms. On this site, you will find a listing of drug codes and whether or not they require a NDC, Frequently Asked Questions, a provider notice and a list of manufacturers that participate in the rebate program.


Multiple NDCs

At times, it may be necessary for providers to report multiple NDCs for a single procedure code. For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code, NDC qualifier, NDC, NDC unit qualifier and NDC units. The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line. The second line item with the same procedure
code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.
 
Split Billing

Reminder: Molina updates the hospital contracts every July 1st and October 1st. If you are billing an outpatient claim that extends from June to July or September to October, it is important for you to split the claim into two claims, one date ending on June 30th or September 30th, and the next claim beginning on July 1st or October 1st.

Please Note: Inpatient acute care claims cannot be split billed; must be billed upon discharge only.

Thursday, January 7, 2016

UB 04 Medicare Discharge status code

DISCHARGE STATUS

This field identifies the discharge status of the patient at the statement through date. This is a two-position alphanumeric field. The valid values are:

Value Description

01 Discharged to home or self-care (routine discharge)
02 Discharged/transferred to another short-term general hospital
03 Discharged/transferred to SNF
04 Discharged/transferred to an ICF
05 Discharged/transferred to another type of institution
06 Discharged/transferred to home under care of organized home health service organization
07 Left against medical advice
08 Discharged from outpatient care to be admitted to the same hospital from which the patient received outpatient services
09 Discharged from outpatient care to be admitted to the same hospital from which the patient received outpatient services
20 Expired (Or did not recover – Christian Science Patient)
30 Still a patient
40 Expired at home. For use only on Medicare hospice care claims.
41 Expired in a medical facility, i.e., hospital, SNF, ICF or freestanding hospice
42 Expired – place unknown. For use only on Medicare hospice care claims
50 Hospice – home
51 Hospice – medical facility
61 Discharged/transferred to a hospital based Medicare approved swing bed
62 Discharged/transferred to inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital.
63 Discharged/transferred to a Medicare certified long term care hospital (LTCH).
64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare.
64 Discharged/transferred to a psychiatric hospital or psychiatric distinct part of a hospital (effective for discharges on or after April 1, 2004).

Friday, December 25, 2015

Clinical Indications - When Gender Reassignment Surgery is covered


GRS may be considered medically reasonable and necessary when all the following candidate criteria are met and supporting provider documentation is submitted.

Candidate Criteria:
The candidate is at least 18 years of age; and
Has been diagnosed with GID, including meeting all of the following indications:

o The desire to live and be accepted as a member of the opposite sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment; and
o The desire for alternate gender identity has been present for at least 5 years; and
o The GID is not a symptom of another mental disorder, hormonal aberration or chromosomal variation; and
o The GID causes clinical distress or impairment in social, occupational, or other important areas of functioning.

For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is:

o Recommended by a mental health professional and
o Provided under the supervision of a physician; and
o the supervising physician indicates that the patient has taken the hormones as directed.

When the initial requested surgery is solely a mastectomy for candidates requesting female to male surgery, the treating physician may indicate that no hormonal treatment (as described above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy are met.
The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to the original gender. This requirement must be demonstrated by living in their new gender while:

o Maintaining part- or full-time employment; or
o Functioning as a student in an academic setting; or
o Functioning in a community-based volunteer activity as applicable.

If the candidate does not meet the 12 month time frame criteria as noted above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria.
Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) are required.
The individual contemplating or undergoing GRS shall have documentation of regular therapy sessions with a qualified mental health professional for two (2) years prior and expectantly, two (2) years following GRS or therapy made available to the Medicare carrier upon request.

If the individual has significant medical or mental health issues present, they must be well controlled. If the individual is diagnosed with severe psychiatric disorders with impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder, paranoid state or equivalent debilitative disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.

Failure to control and maintain a lifestyle devoid of psychotic behavior and ideations for a period of 24 months prior to planned surgical intervention renders the individual ineligible for surgical gender reassignment under the Medicare program due to the unacceptably high suicide risk and disastrous sequella seen in individuals psychologically unsuitable for this therapy.

* At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D, D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

Primary Gender Reassignment Surgery (GRS-1) may consist of any combination of hysterectomy, salpingo-oophorectomy, mastectomy or orchiectomy, considered medically necessary when all of the above criteria are met.



Individuals having undergone (or in concert with) any combination of the above primary gender reassignment surgical procedures (GRS-1), may elect to pursue secondary genital reconstructive surgery (GRS-2) consisting of any combination of metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, reduction mammoplasty or mastectomy, or placement of testicular prostheses, Medical Necessity is established only when all criteria for Gender Reassignment Surgery are met.

Friday, December 18, 2015

UB 04 - FL 67 - POA indicator missing Denial

What steps can we take to avoid return to provider (RTP) reason code 34931?

A: One or more present on admission (POA) indicator(s) is/are missing, invalid or incorrectly submitted with the reported diagnosis code(s). It is recommended that you review each diagnosis code and POA indicator to ensure they are correct, prior to submitting your claim.

• POA is defined as being present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department and/or observation services, or outpatient surgery, are considered POA.

• Claims for inpatient admission to acute care inpatient prospective payment system (IPPS) hospitals must include the appropriate POA indicator for the principal and all secondary diagnoses, unless the code is exempt.

• It is important to review the POA exempt list to ensure you are submitting your claims correctly. Refer to downloads on the CMS website, at Hospital Acquired Conditions (Present on Admission) - Coding external link.

Note: The 2015 ICD-9-CM and ICD-10-CM POA exempt lists are identical to the 2014 ICD-9-CM and ICD-10-CM POA exempt lists. There were no changes.

• The CMS Hospital-acquired conditions (HAC) and present on admission (POA) indicator reporting provision external pdf file fact sheet provides background information, additional resources and general reporting requirements.
The following hospitals are exempt from this provision:
• Critical access hospitals
• Long term care hospitals
• Cancer hospitals
• Children’s inpatient facilities
• Religious non-medical health care institutions
• Inpatient psychiatric hospitals
• Inpatient rehabilitation facilities
• Veteran’s administration/department of defense hospitals

Valid values for POA indicators are:

Code Reason for code

Y Diagnosis was present at time of inpatient admission.
N Diagnosis was not present at time inpatient admission.
U Documentation insufficient to determine if the condition was present at the time of inpatient admission.
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

‘Blank’ Unreported/not used. Exempt for POA reporting.


Note: Blank is used on UB-04 claim form and the equivalent 5010 electronic claim version.





Gender Reassignment Surgery



Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY
Gender Reassignment Surgery

Gender Identity Disorder (GID) is the formal diagnosis used to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender). Although it is a psychiatric classification, GID is not medically classified as a mental illness.

In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) are met. The criteria are:
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or sex characteristics; OR
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender; OR
3. A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
4. A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR
5. A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR
6. A strong conviction that one has the typical feelings and reactions of the other gender or some alternative gender different from one’s assigned gender; AND

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender reassignment surgery (GRS) is one treatment option for extreme cases of gender dysphoria or GID, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in his or her own gender. People with gender dysphoria often report a feeling of being born the wrong sex. GRS is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful psychological, behavioral, functional and medical outcomes. Before undertaking gender reassignment surgery, candidates need to undergo important medical and psychological evaluations, begin medical therapies and behavioral trials to confirm that surgery is the appropriate treatment choice.

Prior to March 27, 2014, GRS was specifically excluded from coverage and reimbursement by The Center for Medicare and Medicaid Services. After May 30, 2014 procedures for GRS may be covered and reimbursable by Medicare when specific criteria outlined below are present and documented in the patient record.