SD MGMA Third Party Payer Day. Presented by: Part B Provider Outreach and Education September 2017

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1 SD MGMA Third Party Payer Day Presented by: Part B Provider Outreach and Education September 2017

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. September

3 Agenda CMS Updates Current Changes Noridian Updates Current Changes & Additions Reviewing Contractor Updates Items of Interest September

4 CMS Updates

5 New Medicare Card Project Social Security Numbers removed from all Medicare cards by April 2019 Replaced with new Medicare Beneficiary Identifier (MBI) Example 1EG4-TE5-MK73 MBI Format Specifications Card/Understanding-the-MBI-with-Format.pdf Transition period April 1, 2018 through December 31, 2019 Beneficiaries may use the new card upon receipt September

6 Elimination of Paper Remits Change Request (CR) Effective 1/01/2018 For all providers/suppliers who receive ERAs for 45 days or more Effective 2/14/2018 For all providers/suppliers EDI enrolled who are receiving ERAs and SPRs Some exceptions, i.e.: Natural disaster or CMS discretion September

7 Noridian Updates

8 Targeted Probe & Educate (TPE) CMS authorized Noridian to conduct TPE Pilot review process Targeted by Medical Review (JF only) Driven by data analysis Educational opportunity for error reduction Note: CR Targeted Probe & Educate Pilot CMS is expanding to three contractors, Jurisdictions B, D, and E September

9 TPE Webpage September

10 Provider Self-Audit with Validation and Extrapolation Pilot (PSAVE) CMS authorized pilot program Noridian education provided while allowing providers to self-audit documentation with many benefits Immunity granted from MAC and RAC reviews on pilot claims involved upon successful completion Visit website for information and PSAVE recording: Questions? Contact us: (800) or September

11 Prolonged Services Findings CPT Prolonged services are intended to be used for unusual circumstances requiring additional time beyond typical/average time of visit code billed Prolonged services is an example of time-based service that requires time be documented in medical record September

12 Medicare Secondary Payer (MSP) Calculator Used to determine line by line payment calculations Will not accurately calculate: Non-participating providers/suppliers Sequestration 100% allowed payments (i.e. lab codes) Psychiatric reduction Tertiary payments September

13 New Additional Static Pages Noridian Website Care Plan Oversight (CPO) Chronic Care Management (CCM) Locate under Browse By Specialty/ E/M Chemotherapy Administration Locate under Browse By Topic/ Drugs & Biologicals Outpatient Therapy Locate under Browse By Specialty September

14 Contractor Updates CERT, RAC, SMRC & OIG

15 Responding to The Letter Request for documentation: CERT, Medical Review, RAC,SMRC Demand letters have a response date Verify your physical address is correct in PECOS Gather the information quickly and neatly Make sure the signatures are present and legible. Ensure the information is sent to the correct person September

16 Updating Address for CERT Letters CERT sends correspondence to Pay-To address in PECOS Update address in PECOS 1 September

17 CERT Webpage September

18 CERT November 2016 Report - JF September

19 CERT November 2016 Report - JF November 2016: JFB Root Causes Errors Weighted Error $ South Dakota Totals 9 $3,686, Chiro-There is no chiropractic treatment plan documented to support a plan of care and documentation does not adequately describe the service billed Missing valid physician order and/or documentation to support intent Does not meet medical decision making and physical exam key element for billed E/M service level Valid ICD-9/ICD-10 code(s) was submitted, however record is insufficient to support services billed Umbilical Hernia repair with mesh billed, record indicates no mesh used 1 $2,174, $748, $525, $224, $13, September

20 Recovery Auditor Contractor (RAC) HMS Federal Solutions (HMS) Contact information Part B Providers Telephone: (877) Fax: (702) September

21 RAC Newest Complex Review Annual Wellness Visits (AWV) for G0439 (subsequent visits) Errors found: Failure to submit documentation Service did not meet key elements September

22 RAC Webpage September

23 Supplemental Medical Review Specialty Contractor (SMRC) September

24 SMRC Sample Letter September

25 Office of Inspector General (OIG) 2017 work plan Current Reporting: publications/workplan/index.asp September

26 Medical Documentation Requirements September

27 Surgical Pathology Medical Documentation Letter Documentation Letter com/documents/10546/ /Surgical+Pathology+Medi cal+documentation+letter September

28 Signature Requirements For Medical Review Purposes For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable. Note: Refer to exceptions for stamped signatures September

29 Valid Signature Valid signature criteria which must be met: Services provided/ordered must be authenticated by ordering practitioner Signatures are: Handwritten Electronic Stamped If requirements to utilize stamped signature are met Signatures are legible September

30 Acceptable Valid if anywhere on document it states Signed or Final September

31 Request for Signature Provider has 20 days from date of receipt of phone call from Noridian to submit attestation Failure to submit records with valid signatures upon request, or valid and timely attestations, will result in your claims being denied Result of signature requirements not met Causes overpayment and recoupment of payment September

32 Signature Errors Missing physician signature on order Incomplete progress notes Unauthenticated medical records No documentation of intent to order services and procedures No signed and dated attestation statement for operative report (if physician signature was missing or illegible) September

33 Utilize Documentation Checklists September

34 Items of Interest

35 Redeterminations and Reopenings via NMP Letters Medicare Redetermination Notices (MRNs) will no longer be mailed Providers /suppliers who submit Redetermination or Reopening requests through NMP will receive MRNs via NMP Ability to view/print determination letters September

36 Advanced Beneficiary Notice of Noncoverage (ABN) Form Effective June 21, 2017 Exp. 3/2020 Alternative format available in Spanish and larger font size Form available on CMS website: are/medicare-generalinformation/bni/abn.html September

37 CMS-1500 Claim Form Updated Version Effective August 30, 2017 CMS-1500 claim version 02/12 only acceptable version Photocopies are NOT acceptable Purchase forms from U.S. Government Printing Office website Call (202) IOM Chapter 26, Section 10 September

38 CMS-1500 Claim Form Updated Version 2 Top Bottom September

39 Noridian Medicare Portal (NMP) September

40 Noridian Upcoming Part B Webinars Date Time (CT / PT) Title 9/13 3 p.m. / 1 p.m. Duplicate Claims 9/14 1 p.m. / 11 a.m. Critical Care 9/19 1 p.m. / 11 a.m. Modifier 59 Clarification and Changes 9/20 3 p.m. / 1 p.m. Basic E/M Avoiding Common Errors 9/26 1 p.m. / 11 a.m. Chronic Care Management (CCM) 9/26 2 p.m. / 12 p.m. CPT Coding Guidance 9/26 3 p.m. / 1 p.m. New Provider-Biller Part I 9/27 3 p.m. / 1 p.m. New Provider-Biller Part II 9/28 3:30 p.m. / 1:30 p.m. Initial Preventive Physical Examination and Annual Wellness Visit REGISTER NOW! Education & Outreach / Schedule of Events September

41 Medicare After Hours Webinars Date Topic 9/28 Chronic Care Management (CCM) 10/26 Roster Billing for Influenza and Pneumonia Immunizations 11/16 Transitional Care Management Services 12/7 Understanding National and Local Coverage Determinations 6 p.m. PT / 8 p.m. CT Webinars also during day - earlier same week All webinars earn 1.0 CEU Register at Noridian: Education and Outreach- Schedule of Events September

42 In Summary Use Noridian/CMS website tools Attend workshops like this presentation Read Medicare s and articles Refer to links to Noridian and CMS website for signature requirements September

43 Questions? Thank you!