Thursday, November 24, 2016

Billing for Allogeneic Stem Cell Transplants - Revenue code 0819

1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants

Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services:

• National Marrow Donor Program fees, if applicable, for stem cells from an unrelated donor;

• Tissue typing of donor and recipient;

• Donor evaluation;

• Physician pre-procedure donor evaluation services;

• Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services,etc.);

• Post-operative/post-procedure evaluation of donor; and

• Preparation and processing of stem cells.

Payment for these acquisition services is included in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the hospital outpatient setting, and in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment. Recurring update notifications describing changes to and billing instructions for various payment policies implemented in the OPPS are issues annually.

Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor (other than the recipient himself or herself). Acquisition charges do not apply to autologous transplants (transplanted stem cells are obtained from the recipient himself or herself), because autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the hospital may bill and receive payment (see Pub. 100-04, chapter 3, §90.3.1 and §231.10 of this chapter for information regarding billing for autologous stem cell transplants).

2. Billing for Acquisition Services

The hospital bills and shows acquisition charges for allogeneic stem cell transplants based on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished. See Pub. 100-04, chapter 3, §90.3.1 for instructions regarding billing for acquisition services for allogeneic stem cell transplants that are performed in the inpatient setting.

When the allogeneic stem cell transplant occurs in the outpatient setting, the hospital identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants separately in FL 42 of Form CMS-1450 (or electronic equivalent) by using revenue code 0819 (Other Organ Acquisition). Revenue code 0819 charges should include all services required to acquire stem cells from a donor, as defined above, and should be reported on the same date of service as the transplant procedure in order to be appropriately packaged for paymentpurposes.

The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient. These charges will be reflected in the transplant hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell acquisition services in cases that do not result in transplant, due to death of the intended recipient or other causes, hospitals include the costs associated with the acquisition services on the Medicare cost report.

In the case of an allogeneic transplant in the hospital outpatient setting, the hospital reports the transplant itself with the appropriate Procedure  code, and a charge under revenue center code 0362 or another appropriate cost center. Selection of the cost center is up to the hospital.

Friday, November 18, 2016

Must required Date elements EMC 837

Required Data Element Requirements

The following Medicare-specific, return as unprocessable requirements in this section and the following two sections are in addition to requirements established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Regulations implementing HIPAA require the use of National Provider Identifiers (NPIs) by covered health care providers and health plans. Although not required by HIPAA, CMS is extending the requirement to include the NPI on electronic claims to paper claims submitted on the Form CMS-1500 (8/05). Carriers are referred to the Health Care Claims Professional 837 Implementation guide for requirements for professional claims subject to HIPAA, including the NPI reporting requirements.

Carriers must return a claim as unprocessable to a provider of service or supplier and use the indicated remark code, or select and use another appropriate remark code, if the claim is returned through the remittance advice or notice process. In most cases, reason code 16, "Claim/service lacks information that is needed for adjudication", will be used in tandem with the appropriate remark code that specifies the missing information.

Carriers shall return a claim as unprocessable:

1. If a claim lacks a valid Medicare Health Insurance Claim Number (HICN) in item 1a. or contains an invalid HICN in item 1a. (Remark code MA61.)

2. If a claim lacks a valid patient’s last and first name as seen on the patient’s Medicare card or contains an invalid patient’s last and first name as seen on the patient’s Medicare card. (Remark code MA36.)

3. If a claim does not indicate in item 11 whether or not a primary insurer to Medicare exists. (Remark code MA83 or MA92.)

4. If a claim lacks a valid patient or authorized person’s signature in item 12 or contains an invalid patient or authorized person’s signature in item 12. (See “Exceptions,” bullet number one. Remark code MA75.)

5. If a claim lacks a valid “from” date of service in item 24A or contains an invalid “from” date of service in item 24A. (Remark code M52.)
6. If a claim lacks a valid place of service (POS) code in item 24B or contains an invalid POS code in item 24B, return the claim as unprocessable to the provider or supplier. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, if a claim contains more than one POS (other than Home – 12), for services paid under the MPFS and anesthesia services.

Effective January 1, 2011, for claims processed on or after January 1, 2011 on the Form CMS-1500, if a claim contains more than one POS, including Home – 12, (or any POS contractors consider to be Home), for services paid under the MPFS and anesthesia services.

(Remark code M77.)

7. If a claim lacks a valid procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D or contains an invalid or obsolete procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D. (Remark code M20 or M51.)

NOTE: Level 3 HCPCS are not valid under HIPAA after Dec 31, 2003.

8. If a claim lacks a charge for each listed service. (Remark code M79.)

9. If a claim does not indicate at least 1 day or unit in item 24G (Remark Code M53.) (Note: To avoid returning the claim as “unprocessable” when the information in this item is missing, the carrier must program the system to automatically default to “1” unit).

10. If a claim lacks a signature from a provider of service or supplier, or their representative. (See “Exceptions,” bullet number one; Remark code MA70 for a missing provider representative signature, or code MA81 for a missing physician/supplier/practitioner signature.)

11. If a claim does not contain in item 33:

a. A billing name, address, ZIP Code, and telephone number of a provider of service or supplier. (Remark code N256 or N258.)


b. A valid PIN number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05) when the NPI is required) for the performing provider of service or supplier who is not a member of a group practice. (Remark code N257)


c. A valid group PIN (or NPI when required) number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05), when the NPI is required) for performing providers of service or suppliers who are members of a group practice. (Remark code N257)

12. If a claim does not contain in Item 33a., Form CMS 1500 (08-05), the NPI, when required, of the billing provider, supplier, or group. (Remark Code N257 or MA112.)

13. Effective May 23, 2008, if a claim contains a legacy provider identifier, e.g., PIN, UPIN, or National Supplier Clearinghouse number. (Remark Code N 257)

NOTE: Claims are not to be returned as unprocessable in situations where an NPI is not required (e.g., foreign claims, deceased provider claims, other situations as allowed by CMS in the future) and legacy numbers are reported on the claim. Such claims are to be processed in accordance with the established procedures for these claims.

Monday, November 14, 2016

Effective date of provider termination

 Voluntary Termination

According to 42 CFR 489.52, a provider that wishes to terminate its agreement to participate in the Medicare program may do so by: (1) filing with CMS a written notice stating its intention to terminate its agreement; and (2) informing CMS of the date upon which it wishes the termination to take effect. The CMS may approve the date proposed by the provider or set a different date no later than six months after the date of the provider’s notice.

The effective date of termination may be less than six months following CMS’ receipt of the provider’s notice of its intention to terminate if CMS determines that termination on that date would not:

• Unduly disrupt the furnishing of services to the community; or

• Otherwise interfere with the effective and efficient administration of the Medicare program.

If a provider sends the FI a written notice of its intention to terminate its agreement, the FI should forward the notice to the CMS RO. The date of receipt of the notice by the FI will be considered the date of filing in determining the date of termination.

The RO promptly notifies the FI when it learns from other sources that a provider wishes to terminate its participation in the program, and keeps the FI informed of the status of the provider’s request. It is the responsibility of the FI, as necessary, to make preliminary arrangements for filing of the cost report, and to adjust any interim payments, accelerated payments, of current financing payments to avoid overpayments. Final notice of termination of the provider’s agreement is formally given to the FI by the RO via Form CMS-2007.

As soon as the termination date is established, the RO instructs the provider to notify the public that it is voluntarily terminating its provider agreement. The public notice should be published in the local newspapers with the largest circulation, as soon as possible, but not less than l5 days before the effective termination date. A provider that wishes to terminate its provider agreement should also file a Form CMS-855A with the FI requesting a voluntary termination of its Medicare billing number.

Thursday, November 10, 2016

Meaning of Accept Assignment ?

1. Meaning of Assignment - For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment, the approved charge, determined by the MAC/carrier, shall be the full charge for the service covered under Part B. The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.

2. Effective Date - If the participant files the agreement with any MAC/carrier during the enrollment period, the agreement becomes effective _____________________.

3. Term and Termination of Agreement - This agreement shall continue in effect through December 31 following the date the agreement becomes effective and shall be renewed automatically for each 12-month period January 1 through December 31 thereafter unless one of the following occurs:

a. During the enrollment period provided near the end of any calendar year, the participant notifies in writing every MAC/carrier with whom the participant has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the end of the current term. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calendar year, the agreement shall end on December 31 of that year.

b. The Centers for Medicare & Medicaid Services may find, after notice to and opportunity for a hearing for the participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is made, the Centers for Medicare & Medicaid Services will notify the participant in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement.

Present On Admission (POA) Indicators

Provider Types Affected

** Hospitals who submit claims to fiscal intermediaries (FI) or Medicare Part A/B Administrative Contractors (A/B MACs) for Medicare beneficiary inpatient services.

** Tufts Health Plan recommends that your billing staff is aware of this requirement, and that your physicians and other practitioners and coders are collaborating to ensure complete and accurate documentation, code assignment and reporting of diagnoses and procedures.

Reporting Options and Definitions

N (No) Not present at the time of inpatient admission

U (Unknown) Documentation is insufficient to determine if condition is present at time of inpatient admission

W Not Applicable

Y (Yes) Present at the time of inpatient admission

** The POA data element on your electronic claims has been moved from the K3 segment (version 4010A1) to the HI - PRINCIPAL  DIAGNOSIS and HI - OTHER DIAGNOSIS INFORMATION segments.

NOTE: The value of “1” has been removed in 5010.

Example: Below is an example of acceptable coding on an electronic claim: HI*BF:4821:::::::N*HI*BF:25000:::::::Y

Friday, November 4, 2016

Carrier Receipted Bill - Definition

A receipted bill is a written acknowledgment by a person or organization furnishing specified covered services, which states that payment has been made for all services on the bill.

Where a receipted bill is submitted, benefits for the services shown on the bill should not be paid to the physician (or his/her supplier) since there can be no assignment.

The bill itself bearing the words “received payment,” “paid in full,” “paid,” or a phrase with the same meaning, is the best evidence of payment if it is signed or initialed by the physician (or his/her employee, etc.) or by the person or organization furnishing supplies or services. There will, however, be other evidence of payment that will be acceptable, such as machine-produced bills that clearly show the amount paid for each service. A rubber-stamp imprint on the bill which includes the name of the physician or other supplier is acceptable, absent a reason to question it. It is also reasonable to accept, as evidence of payment, a cancelled check that is related in time and amount to a doctor’s, or other Part B supplier’s bill.

A bill paid by promissory note is treated as a “receipted bill” unless the bill shows on its face that the note is not given and accepted unconditionally as payment of the bill. For example, a bill marked “paid by promissory note” or “$25 paid in cash, balance paid by promissory note” is treated as a receipted bill. On the other hand, a bill marked “paid subject to payment on promissory note,” or which otherwise clearly indicates that the promissory note was not unconditionally accepted in payment of it, is not a receipted bill.

Sunday, October 30, 2016

What is Healthcare Fraud and abuse ?

 What Is Healthcare Fraud?

The 1199SEIU Benefit Funds define healthcare fraud as an intentional deception or misrepresentation that an individual knows to be false, or that could knowingly result in some unauthorized benefit to that individual or another person.

The most common kind of fraud involves a false statement or misrepresentation made in order to take advantage of 1199SEIU Benefit Funds’ benefits. The violator may be a healthcare provider, an employee of a medical provider, a beneficiary or some other person or business entity.

Examples of fraud include:

• Billing for services and supplies that were not provided;

• Misrepresenting the diagnosis for a patient to justify the services or equipment furnished;

• Altering claim forms to obtain a higher payment amount;

• Unbundling (exploding) charges or upcoding; or

• Participating in schemes that involve collusion between a provider and a beneficiary or between a supplier and a provider, which result in higher costs or charges to the 1199SEIU Benefit Funds.

 What Is Healthcare Abuse?

The 1199SEIU Benefit Funds define healthcare abuse as actions that are inconsistent with sound medical, business or fiscal practices. Abuse directly or indirectly results in higher costs to the 1199SEIU Benefit Funds through improper payments for treatments that are not medically necessary.

Common examples of abuse include:

• Performance of medically unnecessary services;

• Failure to document medical records adequately;

• Intentional, inappropriate billing practices such as misuse of modifiers; or

• Failure to comply with a participation agreement.

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