Friday, August 21, 2015

Proposed fiscal year 2016 payment and policy changes for Medicare Skilled Nursing Facilities

On April 15, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1622-P] outlining proposed Fiscal Year (FY) 2016 Medicare payment rates for skilled nursing facilities (SNFs). The FY 2016 proposals and other issues discussed in the proposed rule are summarized below.

The proposed rule proposes policies that continue a commitment to shift Medicare payments from volume to value. The Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. The proposed rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.

Changes to Payment Rates under the SNF Prospective Payment System (PPS)
Based on proposed changes contained within this rule, CMS projects that aggregate payments to SNFs will increase by $500 million, or 1.4 percent, from payments in FY 2015. This estimated increase is attributable to a 2.6 percent market basket increase, reduced by a 0.6 percentage point forecast error adjustment and further reduced by 0.6 percentage point, in accordance with the multifactor productivity adjustment required by law.

SNF Quality Reporting Program
The Improving Medicare Post-Acute Care Transformation Act of 2014 (P.L. 113-185) (IMPACT Act), enacted on October 6, 2014, requires the implementation of a quality reporting program for SNFs.

In addition, the Act requires establishing a SNF quality reporting program. Beginning with FY 2018, the Act requires SNFs that fail to submit required quality data to CMS under the SNF Quality Reporting Program will have their annual updates reduced by two percentage points.

For the FY 2018 SNF QRP and subsequent years, CMS is proposing to adopt three measures addressing three quality domains identified in the IMPACT Act: (1) skin integrity and changes in skin integrity; (2) incidence of major falls; and (3) functional status, cognitive function, and changes in function and cognitive function. The proposed measures satisfy the IMPACT Act requirement of standardized data reporting across four post-acute care settings, including home health agencies, inpatient rehabilitation facilities, skilled nursing facilities and long term care hospitals.  The proposed measures are identified below in the Summary Table of Domains and Proposed Measures for the SNF QRP.  CMS intends to propose additional quality measures and resource use measures in future rulemaking.

Summary Table of Domains and Proposed Measures for the SNF Quality Reporting Program

DomainProposed Measures
Skin Integrity and Changes in Skin IntegrityOutcome Measure: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) (NQF #0678; Measure Steward: CMS)
Incidence of Major FallsOutcome Measure: Application of Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674; Measure Steward: CMS)
Functional Status, Cognitive Function, and Changes in Function and Cognitive FunctionProcess Measure: Application of Percent of Patients or Residents With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF#2631) (Under NQF review Measure Steward: CMS)

SNF VBP Program

Section 215 of the Protecting Access to Medicare Act of 2014 (PAMA) added new subsections (g) and (h) to section 1888 to the Social Security Act (Act) New Subsection 1888(h) authorizes establishing a Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program beginning with FY 2019 under which value-based incentive payments are made to SNFs in a fiscal year based on performance.

The rule proposes to adopt the Skilled Nursing Facility 30-Day All-Cause Readmission Measure, (SNFRM) (NQF #2510), as the all-cause, all-condition readmission measure that will be used in of the SNF VBP Program. The Skilled Nursing Facility 30-Day All-Cause Readmission Measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for SNF Medicare beneficiaries within 30 days of their prior proximal short-stay acute hospital discharge.

The Act also requires CMS to replace this measure with an all-condition, risk-adjusted potentially preventable hospital readmission rate. CMS intends to address this topic in future rulemaking.

Future Policy Considerations

In the proposed rule, CMS is seeking public comments on numerous issues related to the SNF VBP Program’s policies.  CMS intends to propose additional details of the SNF VBP in the FY 2017 SNF PPS proposed and final rules, and is currently seeking comments on:
Performance standards
Measuring improvement
Appropriate baseline and performance periods
Performance scoring methodology
Public reporting of performance information

Feedback reports

Wednesday, August 12, 2015

New field qualifiers on 17

CMS 1500 Claim Form Instructions: Revised for Form Version 02/12

Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with
claims received on and after April 1, 2014:
• Medicare will begin accepting claims on the revised form, 02/12, on January 6,2014;
• Medicare will continue to accept claims on the old form, 08/05, through March 31,2014;
• On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500claim form, 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS1500 claim form, 08/05.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to  ifferentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain  roviders are being identified as having performed an ordering, referring, or supervising role in the furnishing f the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and
expands the number of possible diagnosis codes on a claim to 12.

The qualifiers that are appropriate for identifying an ordering, referring, or supervising role
are as follows:
• DN - Referring Provider
• DK - Ordering Provider
• DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that the paper format for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore supports the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception.

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)

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