Sunday, January 25, 2015

Preventive Services and Screenings Covered by Medicare and Waiver of Coins/Copay/Dedt

•    Abdominal Aortic Aneurysm Screening
•    Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care
•    Annual Wellness Visit (Including Personalized Prevention Plan Services)
•    Bone Mass Measurements
•    Cancer Screenings
•    Breast Cancer (mammograms and clinical breast exam)
•    Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])
•    Colorectal Cancer
             o    Fecal Occult Blood Test
             o    Flexible Sigmoidoscopy
             o    Colonoscopy
             o    Barium Enema
•    Prostate (PSA blood test and Digital Rectal Exam)
•    Cardiovascular Disease Screening
•    Depression Screening in Adults
•    Diabetes Screening
•    Diabetes Self-Management Training
•    Glaucoma Screening
•    Human Immunodeficiency Virus (HIV) Screening
•    Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
•    Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)
•    Intensive Behavioral Therapy for Cardiovascular Disease
•    Intensive Behavioral Therapy for Obesity
•    Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
•    Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs
•    Tobacco-Use Cessation Counseling

As a result of the Affordable Care Act, Medicare now covers many of these services without cost to patients, including the Annual Wellness Visit that was created under the Affordable Care Act.
Waiver of Coinsurance,Copayment and Deductible for Preventive Services and Screenings

The coinsurance or copayment represents the beneficiary’s share of the payment to the provider or s
upplier for furnished services. Coinsurance generally refers to a percentage (for example, 20 percent) of the Medicare payment rate for which the beneficiary is liable and is applicable under the PFS, while copayment generally refers to an established amount that the beneficiary must pay that is not necessarily related to a particular percentage of the Medicare payment, and is applicable under the hospital Outpatient Prospective Payment System (OPPS).

Not all preventive services allowed in Medicare and recommended by the USPSTF have a Grade of A or B, and therefore, some of the preventive services do not meet the criteria in sections 1833(a)(1) and (b)(1) of the Act for the waiver of deductible and coinsurance.

For Carriers/AB MACs, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal vaccines and influenza virus vaccines and their administration. Part B deductible and coinsurance do not apply for pneumococcal and influenza virus vaccine.

Part B of Medicare also covers the hepatitis B vaccine and its administration. Part B deductible and coinsurance do apply for hepatitis B vaccine. State laws governing who may administer pneumococcal and influenza virus vaccinations and how the vaccines may be transported vary widely. Medicare contractors should instruct physicians, suppliers, and providers to become familiar with State regulations for all vaccines in the areas where they will be immunizing.

Sunday, January 18, 2015

Medicaid increases the payment of Pediatric

Pediatric Physician Rate Increase

Effective January 1, 2015, Current Procedural Terminology (CPT®) codes 99201 through 99496 will be reimbursed with an enhanced rate to pediatric physicians billing fee-for-service with one of the following specialty codes: 001, 019, 023 035, 036, 037, 038, 039, 043, 049, 059, 101,102.  The Physician Evaluation and Management Fee Schedule will be amended to reflect this change. 

Providers receiving reimbursement through a Medicaid managed care plan should refer to their contract with each plan to determine whether this change will impact their reimbursement from the plan.

Monday, January 12, 2015

When to file an appeal - Big question in Medical billing

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

Appeal level Time limit for filing request Where to file an appeal
First level: Redetermination 120 days from the initial claim determination Medicare administrative contractor (MAC)
Second level: Reconsideration 180 days from the redetermination decision Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)  60 days from the date of the reconsideration decision               Submit request by:
Monetary threshold for requests filed before December 31, 2014: $140
Monetary threshold for requests filed on or after January 1, 2015: $150 
Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council 60 days from the date of the ALJ decision Departmental Appeals Board
Fifth level: Judicial review:  60 days from the date of the Medicare Appeals Council decision                                 Submit request by:
Monetary threshold for requests made before December 31, 2014: $1,430.
Monetary threshold for requests made on or after January 1, 2015: $1,460.
Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Part B clerical reopening

A clerical error could occur when one of the following happens to your claims:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service

There are two options for conducting a clerical reopening of a claim:
• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
• For the IVR reopening request help sheet, click here .
• For reopening requests in writing, use the clerical reopening .

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)
If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fourth level of appeal: Review by the Medicare Appeals Council
If a party to the an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.
• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Tuesday, December 30, 2014

How to fill/completing the PWK fax/mail coversheet

First Coast Service Options' (First Coast's) claims department is receiving a high volume of invalid or unnecessary PWK (5010 paperwork segment) fax/mail coversheets. If a coversheet is received containing inaccurate, incomplete, or invalid information, the coversheet will be either faxed or mailed back to the originating source, but without the documentation. Coversheets returned in this manner should not be resent; instead, the provider should await an additional documentation request (ADR) before submitting the documentation again to First Coast.

PWK issues

In other cases, the coversheets and additional documentation are not able to be appropriately attached to a claim due to several reasons. The following list has been developed to assist you in avoiding these situations.
1. PWK coversheet is received, completed accurately with documentation, but the claim was submitted without the indicators in the PWK loop.
• This will not allow us to assign the documentation in the system to the appropriate claim. If the claim requires documentation, an ADR letter will be sent and providers will need to respond to the letter.
2. PWK coversheet is received with the related documentation attached and a copy of our additional documentation request (ADR) letter. Again, the PWK loop indicators are not on the claim.
• There are two issues here: 1) without the PWK loop completed, the claim will not suspend to look for any anticipated documentation. Most importantly 2) the claim has already suspended for additional documentation; therefore, providers only need to respond to the ADR letter with appropriate documentation.
3. PWK coversheet is received with a request for an appeal/redetermination in the information box.
• The PWK process may only be used on initial claim submission. PWK cannot be used to bypass the standard appeals process. Please use the appropriate level of the appeals process if your claim has been denied or you need to make adjustments/corrections. Appeal requests submitted via the PWK fax/mail process will not be acknowledged.
4. In all of these instances, since the PWK fax/mail coversheet and/or claim is not being submitted correctly or with the correct information, the supporting documentation submitted to us is not being utilized to adjudicate the claim. Also, since in most cases this is outside of the standards for PWK, providers affected by these scenarios will not receive a response concerning the outcome or lack thereof.
5. Our internal claims area is being negatively impacted as well as our electronic storage capacity is being overwhelmed by unneeded, unusable documentation. Providers affected by this will more than likely never receive any indication of the negative impacts this is having on their claims.


Here are some items to verify before faxing or mailing your form:

• Verify you have indicated the 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) on the fax/mail coversheet.

• Include an address to mail the coversheet to, in case we are unable to fax it back to the originating number.

• Fax users: ensure to send your PWK fax coversheet and documentation to the appropriate locality fax line. Example: claims for providers in Puerto Rico should be faxed to the Puerto Rico fax line; claims for Florida providers to the Florida fax line; etc. If a coversheet is received into the incorrect faxination account, we will be unable to locate the claim.

• Do not send in documentation without the completed fax/mail coversheet.

• Do not use the PWK coversheet for any reason other than the PWK process.

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.

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