Wednesday, December 17, 2014

How to submit document during first claim submission - detailed review - PWK segment

PWK allows documentation to be submitted with an initial claim

Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.

PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.

Although PWK ultimately will allow electronic submission of additional documentation, the October implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).

First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.

PWK Fax/mail coversheets

First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, Billing provider's name and NPI (national provider identifier).
First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).

• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.
PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.

If the PWK segment is completed and additional documentation is needed for adjudication, First Coast will allow seven calendar "waiting" days (from the claim date of receipt) for the paperwork documentation to be faxed or ten calendar waiting days to be mailed. The seven and ten day waiting periods apply to claims for both Part A and Part B.

If the PWK data is not received within the waiting timeframe and additional documentation is needed, a development request will be sent. If documentation is received after the timeframe has elapsed, the documentation will not be used for adjudication of the claim. Thus, the paperwork will need to then accompany our request for additional documentation to prevent possible claim denials.

Claims submitted with a PWK segment, that would not otherwise suspend for review and/or require additional development, will process routinely and will not be held for the seven or ten day waiting period.

Faxination numbers
First Coast has provided designated faxination lines to expedite receipt of the PWK coversheets/attachments, depending on the provider’s line of business and location (Part A or Part B; Florida, Puerto Rico, or the U.S. Virgin Islands.

Each fax/mail coversheet includes the appropriate First Coast return mailing address and faxination number, based on the provider's selection.

Sunday, December 14, 2014

Will Medicare pay G0101 AND Q0091

Payment for G0101 and Q0091 in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that Bill Under the All-Inclusive Rate (AIR) System.

Provider Types Affected

This MLN Matters Article is intended for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who are authorized to bill under the All Inclusive Rate (AIR) system and submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 8927 adds Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) to the list of preventive services paid based on the All-Inclusive Rate (AIR) for RHCs and FQHCs. Make sure your billing staffs are aware of this changes.


The Centers for Medicare and Medicaid Services (CMS) has determined that HCPCS codes G0101 and Q0091 are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.

CR8927 instructs MACs to allow HCPCS codes G0101 and Q0091 to be billed as a stand-alone encounter/visit. These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Tyoes of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to G0101 or Q0091. If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.

G0101 or Q0091 are payable annually for women at high risk for developing cervical or vaginal cancer, and women of childbearing age who have had an abnormal Pap test within the past 3 years. It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, G0101 and Q0091 are qualifying visit when billed with FQHC payment HCPCS codes G0466 or G0467.

Your MAC will not search for claims that have been denied with HCPCS code G0101 or Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.

Thursday, December 11, 2014

MEDICARE SPOT - Faxed reopening requests will not be accepted after November 30

Expedite your Part B clerical reopening requests with the ‘SPOT’ or IVR

In the past, providers had only two available methods to submit clerical reopening requests to First Coast Service Options Inc.: Mail or fax. However, these submission methods were neither time nor cost efficient.

Today, members of First Coast’s provider community have the opportunity to submit clerical reopening requests through more efficient channels: the Secure Provider Online Tool (SPOT) and the interactive voice response system (IVR).
The SPOT and the IVR allow providers to submit clerical reopening requests directly into a secure database, which helps shorten processing time.

Since the availability of these more expedient submission channels has eliminated the need for providers to fax clerical reopening requests, First Coast will no longer offer that option starting December 1.

Option 1: Correct your claim online with the ‘SPOT’
The SPOT offers registered users the time-saving advantage of not only viewing claim data online but also the option of correcting minor clerical errors in their eligible Part B claims quickly, easily, and securely -- online.
To begin, search for the claim you wish to correct by its ICN or by its date(s) of service in Claim Status. The SPOT will automatically determine if any line items are eligible and prepopulate the online request form accordingly.

You may select the request type for any eligible line item based upon the fields you wish to correct: Date(s) of Service, Procedure Code, Modifier, or Diagnosis Code.

The type of reopening request selected will determine which fields are editable. Once you have completed and reviewed your corrections, submit your request. You will receive a confirmation email that will outline the changes you made.

Option 2: Correct your claim on the telephone with the IVR

If you don’t have online access, you may submit your Part B clerical reopening request through First Coast’s IVR system. Although the IVR offers the same primary request types as the SPOT, the IVR offers the additional option of making history corrections to your claim.

To access your claim through the IVR, you must enter the billing provider’s information (i.e., NPI, PTAN, and TIN), the beneficiary’s information (i.e., name, date of birth, Medicare number), and the ICN of the claim you wish to correct.

After you have selected the request type and have entered corrections for applicable fields, you will be asked to confirm your choices and submit the request. If the request is approved, you will receive a letter and new remittance advice notice.

If you would like to take advantage of First Coast’s telephone submission method for clerical reopening requests, please refer to Telephone reopening requests via the IVR.

Remember, whether you prefer to correct your claims online or on the telephone, you won’t have to wait until December 1. You can fix your claims faster on the SPOT and IVR -- today.

Monday, December 8, 2014

2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus - Update from Medicare

Provider Action Needed:

Change Request (CR) 8942 alerts you that the annual HPSA bonus payment file for 2015 will be made available by the Centers for Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA bonus payments on applicable claims with dates of service on or after January 1, 2015, through December 31, 2015. You should review Physican Bonuses below , whether you need to add modifer AQ to your claim in order to receive the bonus payment, or to see if the ZIP code in which you rendered services will automatically receive the HPSA bonus payment. Make sure that our billing staffs are aware of thes changes.

HPSA Designations

The Health Resources and Services Administration (HRSA) published an updated Federal Register Notice on June 27, 2013, that contains important information about new and withdrawn HPSA designations. For purposes of the Medicare Physician Bonus and the Medicare Surgical Bonus programs, changes in designation status are effective for dates of services on and after January 1 of the year following the designation date. Therefore, areas whose designation is shown as “Withdrawn” on the June 27, 2013 Federal Register list, remain eligible for the HPSA bonuses through December 31, 2013.

MMA Section 413(b) required CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

MMA Changes

Effective January 1, 2005, a modifier no longer has to be included on claims to receive the HPSA bonus payment, which will be paid automatically, if services are provided in ZIP code areas that either:
  • Fall entirely in a county designated as a full-county HPSA; or
  • Fall entirely within the county, through a USPS determination of dominance; or
  • Fall entirely within a partial county HPSA.
However, if services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.
The following are the specific instances in which a modifier must be entered:
  • When services are provided in ZIP code areas that do not fall entirely within a designated full county HPSA bonus area;
  • When services are provided in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
  • When services are provided in a ZIP code area that falls partially within a non-full county HPSA;
  • When services are provided in a ZIP code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.
To determine if a service will automatically qualify to receive the bonus payment, review the information provided on the CMS Web site.  The HRSA website should be reviewed for the most recent designations.  Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims.
Some points to remember include the following:
  • Medicare contractors will base the bonus on the amount actually paid (not the Medicare approved payment amount for each service) and the ten-percent bonus will be paid on a quarterly basis.
  • The HPSA bonus pertains only to physician's professional services. Should a service be billed that has both a professional and technical component, only the professional component will receive the bonus payment.
  • The key to eligibility is not that the beneficiary lives in a HPSA nor that the physician's office or primary location is in a HPSA, but rather that the services are actually rendered in a HPSA.
  • To be considered for the bonus payment, the name, address, and ZIP code of the location where the service was rendered must be included on all electronic and paper claim submissions.
  • Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
  • Services submitted with the AQ modifier will be subject to validation by Medicare.

Affordable Care Act of 2010 Changes (New for January 2011 for the HSIP Bonus)

The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs.  Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period.  This additional payment, referred to as the HPSA Surgical Incentive Payment (HSIP) will be combined with the original HPSA payment and will be paid on a quarterly basis.  Modifier AQ should be appended for these major surgical procedures similar to claims for the Medicare original HPSA bonus when services are provided in ZIP code areas that do not fall entirely within a full or partial county HPSA.
Some points to remember:
  •  The current HPSA physician bonus program requirements will remain intact.
  • Medicare contractors will identify and pay the additional bonus on eligible services rendered in eligible ZIP code areas based on the HPSA ZIP code file as of December 31st of the prior year.
  • Medicare contractors will calculate the bonus amount based on the amount actually paid for the service, not the Medicare approved amount
Services submitted with modifier AQ will be subject to validation by Medicare.

Thursday, November 27, 2014

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 being 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 1500 claim form, 02/12; and
·         On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 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 differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of 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 Medicare therefore for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore ssuppoers the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception.

News Flash : Generally, Medicare Part B covers one fly vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries. Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers and patients.
Note: The flu vaccine is not a Part-D covered drug.

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) +

Medicare fee schedule download