Wednesday, August 26, 2015

Skilled Nursing Facility Coverage Requirements and Benefit Period



To qualify for Medicare Part A coverage of SNF services, the following conditions must be met:
◘ The beneficiary was an inpatient of a hospital for a medically necessary stay of at least 3 consecutive days;
◘ The beneficiary transferred to a participating SNF within 30 days after discharge from the hospital (unless the beneficiary’s condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after discharge and it is medically predictable at the time of the hospital discharge the beneficiary will require covered care within a predictable time period);
◘ The beneficiary requires skilled nursing services or skilled rehabilitation services on a daily basis. Skilled services must be:
■ Performed by or under the supervision of professional or technical personnel;
■ Ordered by a physician; and
■ Rendered for an ongoing condition for which the beneficiary had also received inpatient hospital services or for a new condition that arose during the SNF care for that ongoing condition;
◘ As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; and
◘ The services delivered are reasonable and necessary for the treatment of the beneficiary’s inpatient illness or injury and are reasonable in terms of duration and quantity.

Benefit Period
Coverage for care in SNFs is measured in “benefit periods” (sometimes called a “spell of illness”). In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for
each day. After 100 days, the SNF coverage available during that benefit period is “exhausted,” and the beneficiary pays for all care, except for certain Medicare Part B services.
A benefit period begins the day the Medicare beneficiary is admitted to a hospital or SNF as an inpatient and ends after the beneficiary has not been in a hospital (or received skilled care in a SNF) for 60 consecutive days. Once the benefit period ends, a new benefit period
begins when the beneficiary has an inpatient admission to a hospital or SNF. New benefit periods do not begin due to a change in diagnosis, condition, or calendar year. Understanding the benefit period is important because SNFs must sometimes submit claims for which they do not expect to receive payment to ensure the benefit period is properly tracked in the Common Working File (CWF).

Medicare Part A Payment
The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services. Part A payment is primarily based on the Resource Utilization Group (RUG) assigned to the beneficiary following required Minimum Data Set (MDS) 3.0 assessments. As a part of the
Resident Assessment Instrument (RAI), the MDS 3.0 is a data collection tool that classifies beneficiaries into groups based on the average resources needed to care for someone with similar needs. The MDS 3.0 provides a core set of screening, clinical, and functional status
elements, including common definitions and coding categories. It standardizes communication about resident problems and conditions.
General Payment Tips
• Medicare will not pay under the SNF PPS unless you bill a covered day.
• Ancillary charges are only allowed for covered days and are included in the PPS rate.

Medicare Part B Payment

Medicare Part B may pay for:
◘ Some services provided to beneficiaries residing in a SNF whose benefit period exhausted or who are not otherwise entitled to payment under Part A;
◘ Outpatient services rendered to beneficiaries who are not inpatients of a SNF; and
◘ Services excluded from SNF PPS and SNF consolidated billing.

Consolidated Billing Under the consolidated billing provision, SNF Part A inpatient services include all Medicare Part A services considered within the scope or capability of SNFs. In
some cases, the SNF must obtain some services it does not provide directly. For these services, the SNF must make arrangements to pay for the services and must not bill Medicare separately for those services.

Skilled Services

Skilled Nursing and skilled rehabilitation services are those services furnished pursuant to physician orders that:
•    Require the skills of qualified technical or professional health personnel, such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and
•    Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the beneficiary and to achieve the medically desire result.

Monday, August 17, 2015

New or modified Remittance Advice Remark and Claims Adjustment Reason Code

New Codes – RARC Code Modified Narrative         Effective Date

N753  Missing/Incomplete/Invalid Attachment Control Number. 07/01/2015
N754 Missing/Incomplete/Invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form. 07/01/2015
N755 Missing/Incomplete/Invalid ICD Indicator on the 1500 Claim Form. 07/01/2015
N756 Missing/Incomplete/Invalid point of drop-off address, 07/01/2015
N757 Adjusted based on the Federal Indian Fees schedule (MLR). 07/01/2015
N758 Adjusted based on the prior authorization decision. 07/01/2015
N759 Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. 07/01/2015
M47 Missing/Incomplete/Invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN). 07/01/2015
MA74 ALERT: This payment replaces an earlier payment for this claim that was either lost, damaged or returned. 07/01/2015
N432 ALERT: Adjustment based on a Recovery Audit. 07/01/2015
N22 ALERT: This procedure code was added/changed because it more accurately describes the services rendered. 07/01/2015
M39 ALERT: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. 07/01/2015
M109 ALERT: This claim/service was chosen for complex review. 07/01/2015
M38 ALERT: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges. 07/01/2015
N381 ALERT: Consult our contractual agreement for restrictions/billing/payment information related to these charges. 07/01/2015
MA91 ALERT: This determination is the result of the appeal you filed. 07/01/2015
270 Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration. 07/01/2015
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability.) 11/01/15

Friday, August 14, 2015

Specific Modifiers for Distinct Procedural Services


New coding requirements related to Healthcare Common Procedure Coding System (HCPCS) modifier -59 could impact your reimbursement.

Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare and Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifier, a modifier used to define a "Distinct Procedural Service"

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

CR 8863 discusses changes to HCPCS modifier- 59, a modifier which is used to define a "Distinct Procedural Service." Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The 59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with the 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
•    Different encounters;
•    Different anatomic sites; and
•    Distinct services.

The 59 modifier is
•    Infrequently (and usually correctly) used to identify a separate encounter;
•    Less commonly (and less correctly)used to define a separate anatomic site; and
•    More commonly (and frequently incorrectly) used to define a distinct service.

The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place.CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CR 8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU} modifiers) to define specific subsets of the 59 modifier:
XE Separate Encounter, A Service That Is Distinct Because IT Occurred During A Separate Encounter,
XS Separate Structure, A Service That Is Distinct Because It Was Performed on a Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It was performed by a different practitioner, and
XU Unusual Non-Overlapping Service, The Use of a Service That Is Distinct Because It Does Not Overlap Usual Components Of the Main Service.

CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the - XE separate encounter modifier but not the 59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a 59 modifier or a more selective - X {EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.

Wednesday, August 5, 2015

Global Surgery Coding and Billing Guidelines - what modifier to use


Physicians Who Furnish the Entire Global Package

Physicians who furnish the surgery and furnish all of the usual pre-and post-operative work may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package. When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.

Physicians Who Furnish Part of a Global Surgical Package

More than one physician may furnish services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the post-operative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount. The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. Split global-care billing does not apply to procedure codes with a zero day post-operative period.

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:
• Surgical care only (modifier “-54”); or
• Post-operative management only (modifier “-55”). For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished. Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.
• Modifier “-54” does not apply to assistant-at-surgery services.
• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees. The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”
• Use modifier “-55” with the CPT procedure code for global periods of 10 or 90 days.
• Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.
• The receiving physician must provide at least one service before billing for any part of the post-operative care.
• This modifier is not appropriate for assistant-at- surgery services or for ASC’s facility fees.

Exceptions to the Use of Modifiers “-54” and “-55”

Where a transfer of care does not occur, occasional  post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier. If the services of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.

Wednesday, July 29, 2015

Medicare Overpayment Collection Process



If you are a Medicare Fee-For-Service provider who submits claims to Medicare Administrative Contractors, or MACs, you will benefit from this podcast! It will give you information to help you comply with requirements for the collection of Medicare physician and supplier overpayments, including the definition of an overpayment, the collection process, and resources.
This podcast is based on the MLN fact sheet titled "The Medicare Overpayment Collection Process" which CMS issued to help physicians and suppliers comply with Federal law requiring CMS to recover all identified overpayments.

The fact sheet included three helpful pieces of information which we will be discussing with you today:

•    First, the definition of an overpayment
•    Second, the overpayment collection process and
•    Third, resources to find additional information about the process.

You should consider this important information, and take the necessary steps to meet Medicare requirements. The fact sheet information is intended as an educational guide and doesnot ensure compliance with Medicare regulations.

Let's begin with the definition of a Medicare physician or supplier overpayment. It is a payment a physician or supplier receives that exceeds amounts due and payable under Medicare statute and regulations. Once the overpayment is determined, the amount becomes a debt owed by the debtor to the Federal government. Federal law requires CMS to seek the recovery of all identified overpayments.

In Medicare there are four (4) ways that physician or supplier overpayment occur:

•    One (1) Duplicate submission of the same service or claim;
•    Two (2) Payment to the incorrect payee;
•    Three (3) Payment for excluded or medically unnecessaary services; and
•    Four (4) A pattern of furnishing and billing for excessive or non-covered services.

Now we'ill discuss the Overpayment Collection Process. This begins when Medicare discovers an overpayment of $10 or more.
This first demand letter is sent requesting payment. This post will explains that interest accrues from the date of the letter if the overpayment is not received by the 31st calendar day.
If no response is received from the physician or supplier 30 calendar days after the date of the first demand letter, a second demand letter may be sent.
If a full payment is not received 40 calendar days after the date if the first demand letter, recoupment procedures will begin on day 41. Recoupment means that the overpayment will be recovered from current payments due or from future claims submitted. If a debt has not been paid or recouped (unless a valid appeal is filed) an Intent to Refer letter is sent within 120 days indicating that the overpayment may be eligible for referral to the Department of the Treasury for offset or collection.
Next we will briefly describe extended repayment plans, rebuttals, appeals and their respective timeliness requirements.

If the physician or supplier is unable to pay the entire amount of the overpayment in full they may request an extended repayment plan from the Medicare Contractor.
A physician or supplier may submit a rebuttal statement to the Contractor within 15 calendar days from the date of a demand letter. The rebuttal statement explains or provides evidence why recoupment should not be initiated. The rebuttal process is not considered an appeal, and does not stop the Contractor’s recoupment activities.

If a physician or supplier disagrees with an overpayment decision, they may file an appeal with the Contractor that issued the original decision. A redetermination is the first level of appeal in which a qualified employee if the Contractor conducts an independent review of the decision. Section 1893 paragraph (f) (2) (a) of the Social Security Act provides limitations on the recoupment of Medicare overpayments. Overpayments subject to Section 935 paragraph (f) (2) of the Medicare Modernization Act (or MMA) must be filed within 120 calendar days from the date of the demand letter.
In order to stop the initial recoupment process, the redetermination request must be filed within 30 days from the date of the demand letter. If the redetermination request is received and validated later than 30 days from the date of the demand letter, the recoupment process will stop for those overpayments subject to Section 935 paragraph (f) (2) of the MMA. Any recoupment already taken will not be refunded to the physician or supplier.

Following an unfavorable or partially favorable redetermination decision, a physician or supplier may request a second level of appeal or reconsideration by a Qualified Independent Contractor (or OIC - "quick"). A request for reconsideration by a QIC must be filed within 180 calendar days of the date the reconsideration is received. in order to stop the recoupment process, a reconsideration must be filed within 60 days from the redetermination decision date. The recoupment process will stop when the reconsideration request is received and validated by the QIC. After the QIC's decision or dismissal, the recoupment process will resume for any overpayment amount that was not paid in full - regardless of whether the physician or supplier requests further appeal levels.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download