Monday, July 27, 2015

Important News - Attention Health Professionals: Information Regarding the Medicare Access and CHIP Reauthorization Act of 2015

On April 14 , 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015; the President is expected to sign it shortly. This law eliminates the negative update of 21% scheduled to take effect as of April 1, 2015, for the Medicare Physician Fee Schedule. In addition, provisions allowing for exceptions to the therapy cap, add-on payments for ambulance services, payments for low volume hospitals, and payments for Medicare dependent hospitals that expired on April 1 have been extended. CMS will immediately begin work to implement these provisions.

In an effort to minimize financial effects on providers, CMS previously instituted a 10-business day processing hold for all impacted claims with dates of service April 1, 2015, and later. While the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate. No action is necessary from providers who have already submitted claims for the impacted dates of service.

CMS Announces Opportunity to Apply for Navigator Grants in Federally-facilitated and State Partnership Marketplaces Navigator awards extend to three years to provide stability and assistance to consumers as they enroll in coverage

The Centers for Medicare & Medicaid Services (CMS) announced today the availability of funding to support Navigators in Federally-facilitated Marketplaces (FFM), including State Partnership Marketplaces. The Affordable Care Act is working for millions of Americans who are able to access quality health coverage at a price they can afford, in part because of the efforts of in-person assisters in local communities across the nation.  People shopping for and enrolling in coverage through the Health Insurance Marketplaces can get local help in a number of ways, including through Navigators. Navigators provide objective information about health coverage to consumers to help them make the best possible choice. They are knowledgeable about qualified health plans in the Marketplaces, and public programs including Medicaid and the Children’s Health Insurance Program. Grantees will be selected for a three year project period, and a total of up to $67 million is available for the first year of the award.

“Navigators play a vital role in helping Americans enroll in coverage through the Marketplaces and assessing if they qualify for any insurance affordability programs. Navigators have been an important resource for the millions of Americans who enrolled in coverage over the past two years. This funding announcement ensures this important work will continue over the next three years in states with a FFM, including during Marketplace open enrollment periods,” said CMS Acting Administrator Andy Slavitt. The funding opportunity announcement is open to eligible individuals, as well as private and public entities, applying to serve as Navigators in states with a FFM. It is open to new and returning HHS Navigator grant applicants, and applications are due by June 15, 2015.



The 2015 Funding Opportunity Announcement expands the project period from 12 months to 36 months. The multi-year grant award will be funded in 12-month increments and continued funding will be contingent on the grantee continuing to meet all Navigator program requirements and on funding availability. This change is designed to provide greater consistency for Navigator grantee organizations and their staff from year to year, reducing yearly start up time and providing for a more efficient use of grant funds. Navigator grant applicants should describe how they intend to assist consumers who are uninsured or underinsured and consumers who are likely to be eligible for or enrolled in coverage through a Marketplace. Applicants should also describe how they plan to assist persons seeking to re-enroll in coverage through a Marketplace and provide post-enrollment assistance.

Sunday, July 19, 2015

Rehabilitation Therapy Billing Guidelines , calculation of units



Practitioner billing for Part B rehab therapy services on a 1500 claim form or electronic equivalent:
Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that best describe the therapy services rendered

Functional Therapy Reporting ‘G’ codes *

HCPCS/CPT therapy modifiers
GN, services delivered under a SLP plan of care
GO, services delivered under an OT plan of care
GP, services delivered under a PT plan of care
Severity/Complexity Modifiers
CH, 0% impaired, limited or restricted
CI, 1% but less than 20% impaired or restricted
CJ, 20% but less than 40% impaired or restricted
CK, 40% but less than 60% impaired or restricted
CL, 60% but less than 80% impaired or restricted
CM, 80% but less than 100% impaired or restricted
CN, 100% impaired or restricted

Units - Number of times the service/procedure reported according to the HCPCS/CPT code definition
Untimed, bill as 1 unit
Timed, definition includes time; e.g., 15 minutes
Bill as 1 or more units depending on time spent in direct one-on-one contact with the patient
Units are constrained by the total treatment time
Do not bill for less than 8 minutes
Time must be documented in the medical record as either:
total number of timed minutes or;
beginning and ending time
Pre- and post-delivery services are not to be counted towards treatment time
Counting Minutes for Timed Codes

Billable Units Number of Minutes
1 ≥ 8 minutes through 22 minutes
2 ≥ 23 minutes through 37 minutes
3 ≥ 38 minutes through 52 minutes
4 ≥ 53 minutes through 67 minutes
6 ≥ 68 minutes through 82 minutes
7 ≥ 83 minutes through 97 minutes
8 ≥ 98 minutes through 112 minutes
9 ≥ 113 minutes through 127 minutes

Billing Units example
Documentation shows:
7 minutes of neuromuscular reeducation (97112)
7 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
21 Total timed minutes
Billable codes/units (21 minutes = 1 billable unit)
Select one of the codes to bill
Although only one code is billed, documentation should include all services rendered.

Definition of Emergency Care Services and Appeals of Opt Out Determinations

This Article is intended for physicians and practitioners who opt-out of Medicare, and beneficiaries that receive services from opt out physicians and practitioners.

Note: The private contracting regulation at 42 CFR 405.450 describes certain opt-out determinations made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to appeal those determinations. The cross references to the processes used to appeal the determinations described in Section 405.450 were updated in the November 13, 2014 Federal Register (Volume 79, Number 219). The definition of Emergency care services at 42 CFR 405.400 was also corrected in that November 13, 2014
Federal Register.

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and because of the danger to life or health, which require use of the most accessible hospital available that is equipped to furnish those services. Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an ear infection with significant pain, the Centers for Medicare & Medicaid Services (CMS) would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.



What You Need to Know- Be aware that a physician or practitioner who is dissatisfied with a Medicare determination under Section 405.450(a) may utilize the enrollment appeals process currently available for providers and suppliers in Part 498. Be aware that a determination described in Section 405.450(b) (that payment cannot be made to a beneficiary for services furnished by a physician or practitioner who has opted out) is an initial determination for the purposes of Section 405.924 and may be challenged through the existing claims appeals procedures in Part 405 subpart I. Be aware that emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

Tuesday, July 7, 2015

Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services


The Centers for Medicare & Medicaid Services (CMS) finalized clarifications and revisions to policies regarding physician certification and recertification of patient eligibility for Medicare home health services in the CY 2015 HH PPS final rule which was published on November 6, 2014. In the final rule, CMS also finalized revisions to the timeframe required for therapy functional reassessments.

Face-to-Face Encounter Requirements
The Affordable Care Act requires that the certifying physician or allowed NPP must have a
face-to-face encounter with the beneficiary before they certify the beneficiary’s eligibility for the home health benefit. CMS is implementing the following three changes to the face-to-face encounter requirements for episodes beginning on or after January 1, 2015. These changes will reduce administrative burden and provide HHAs with additional flexibilities in developing individual agency procedures for obtaining documentation supporting patient eligibility for Medicare home health care.

• CMS is eliminating the narrative requirement. The certifying physician is still required to certify (attest) that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility. For medical review purposes, Medicare requires documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of patient eligibility.
•If a HHA claim is denied, the corresponding physician claim for certifying/re-certifying patient eligibility for Medicare-covered home health services is considered non-covered as well because there is no longer a corresponding claim for Medicare-covered home health services.
•CMS is clarifying that a face-to-face encounter is required for certifications, rather than initial episodes; and that a certification (versus a re-certification) is generally considered to be any time a new start of care assessment is completed to initiate care.

Therapy Reassessments
CMS has eliminated the 13th and 19th visit therapy reassessment requirements. Forepisodes beginning on or after January 1, 2015; at least every 30 calendar days a qualified therapist


(instead of an assistant) must provide the needed therapy service and functionally reassess the patient. This policy change will lessen HHAs’ burden of counting visits. This change will reduce the risk of non-covered visits so that therapists can focus more on providing quality care for their patients, while still promoting therapist involvement and quality treatment for all beneficiaries regardless of the level of therapy provided.

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)
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