Minor errors or omissions outside the appeals process FAQ

Can minor errors or omissions be corrected outside of the appeals process?

 Yes. A clerical error reopening can be initiated via the telephone or in writing; or, in many cases, the denied service(s) can simply be resubmitted. Resubmitting claims to correct minor clerical errors or omissions is the most efficient method for addressing certain denied services.*

*Resubmit the denied service(s) ONLY - resubmitting an entire claim will create a duplicate denial.

If these issues are received via written and telephone requests, it may take up to 60 days to process and finalize an adjustment, versus 14-30 days for a resubmitted claim. Ensure that you review the type of clerical error or omission you are attempting to correct and select the most efficient option available.

Note: Single-line clerical reopenings can now be requested through the Part B Interactive Voice Response unit (IVR).

Determine if the error can be corrected and resubmitted prior to writing in or calling to request a clerical error reopening.

• Minor clerical errors or omissions that can be corrected and resubmitted:

• Change of diagnosis codes

• Add, change, or delete modifiers (e.g., 24, 25, 50, 59, 78, 79, RT, LT)

• Incorrect place of service

• Written or telephone clerical error reopenings are appropriate only for services that were processed and received an approved amount, and could include the following types of situations:

• Number of services (NB) billed

• Submitted charge amount

• Date of service (DOS)

• Add, change or delete certain modifiers

• Procedure code; excluding codes requiring documentation on the initial submission or codes being upcoded

compare Medicare and Medicaid EHR program

Notable Differences between the Medicare and Medicaid EHR Incentive Programs

Medicare                                

• Federal Government will implement (will be an option nationally)
• Payment reduction begin in 2015 for providers that do not demonstrate Meaningful Use

• Must demonstrate MU in year 1
• Maximum incentive is $44,000 for EPs (10% bonus for EPs in HPSAs)
• Meaningful Use definition is common for Medicare
• Last year a provider may initiate program is 2014; Last year to register is 2016; Payment adjustments begin in 2015
• Only physicians, subsection (d) hospitals and CAHsVoluntary for States to implement (may not be an option in every state)

Medicaid

• Voluntary for States to implement (may not be an option in every state)

• No Medicaid payment reductions
• A/I/U option for 1st participation year
• Maximum incentive is $63,750 for EPs
• States can adopt certain additional requirements for Meaningful Use
• Last year a provider may initiate program is 2016; Last year to register is 2016
• 5 types of Eps, acute care hospitals (including CAHs) and children hospitals

Acronym Translation

A/I/U – Adopt, Implement or Upgrade

CAH – Critical Access Hospital

EHR – Electronic Health Record

EP – Eligible Professional

HPSA – Health Professional Shortage Area

Medicaid EHR adopting, implementing or upgrading final rule

The Medicaid provisions of the final rule for Adopting, implementing, or  upgrading certified EHR technology and Demonstrating meaningful use of EHR technology


Adopting, Implementing, or Upgrading Certified EHR Technology

The final rule:

•  Discusses that providers in their first year of participation in the Medicaid incentive payment program may demonstrate that they have adopted (e.g. acquired, purchased or secured access to), implemented (e.g. installed or commenced utilization of ) or upgraded to   certified EHR technology in order to qualify for an incentive payment;

• Describes the methodology for demonstrating adoption, implementation and upgrading, and for states to monitor these activities;

 Demonstrating Meaningful Use of Certified EHR Technology
 The final rule:

•  Finalizes a shared minimum definition of meaningful use with Medicare. However, CMS will allow states to request CMS approval to require that four public health related measures be core instead of menu measures for Medicaid providers and to specify some of the destination and transmission details;

• Discusses how clinical quality measures reporting will be submitted to the states by Medicaid providers, such as via attestation or electronically via EHRs.

Review of practice performance from Medicare - how to get the report

Requesting a comparative billing report -- Part B providers


Comparative billing report (CBR) information is available to providers by request. The purpose of the CBR is to show comparative data Medicare considers when determining how a provider’s billing patterns contrast with other providers in the same specialty. A CBR may be a helpful tool when conducting self-audits or preparing for a seminar or medical society meeting.

Types of comparative billing reports

Part B Provider-Specific

This type of CBR, best suited for individual physicians and non-physician practitioners, contains comparative information for all procedure codes billed. It is also available to specialties such as independent diagnostic testing facilities or clinical laboratories; however, due to the various types of services offered, the results will not be an “apples-to-apples” comparison. This type of CBR does not have value for physician groups.

Since Medicare bases a CBR on dates of service and not processed dates, Medicare must allow two to three months to permit claims to be finalized before a report can be generated. For example, January data is not available until April or May.

Evaluation and Management Distribution -- Provider-Specific

This type of CBR compares an evaluation and management (E/M) code family (example: CPT codes 99211-99215) to the provider’s peer group (specialty) within Florida and the nation. The report is a bar graph distribution and depicts a provider’s percentage of allowed services per procedure code as compared to Florida and the nation. This CBR is useful to identify potential variances in coding within a code family.

Medicare updates the reports two times per year for the following dates of service:

• January through June

• July through December

Since Medicare bases a CBR on dates of service and not processed dates, Medicare must allow three to four months to permit claims to be finalized before a report can be generated. For example, the January through June timeframe is not available until September or October.

Evaluation and Management Distribution -- Service-Specific

This CBR compares Florida’s utilization of E/M codes to the nation by specialty. This report is useful for medical society meetings to show variance within a code family between Florida’s provider specialties and the nation.

The CMS Data Center updates the national data two times per year for the following dates of service:

• January through June

• July through December

Medicare must allow three to four months before a report can be generated. For example, the January through June timeframe is not available until September or October.

How to request a comparative billing report

To request a CBR, providers must follow these steps:

• A provider must request a CBR on office or corporate letterhead and the provider/officer signature must be affixed. A request from a corporate entity must be submitted by a corporate officer, or in the case of a hospital, the hospital administrator. If the requesting provider wants the information sent to another party, it must be noted in the letter.

• The request must include the following information: the type of CBR(s) desired, the individual provider number(s), and the dates of service preferred. Please beware that a CBR cannot be produced using the group Medicare number.

• The mailing address must be stated clearly and legibly in the letter, since these reports will only be sent via the U.S. mail and not electronically.

• The request must be faxed to Statistical and Medical Data Analysis at 904-361-0543 or mailed to:

First Coast Service Options
Statistical and Medical Data Analysis
P.O. Box 44288
Jacksonville, FL 32231-4288

There is no fee for providing these reports.

Once Medicare receives a CBR request, the report and a CBR explanation document will be mailed to the requesting provider (or authorized party) within 10 business days.

Medicare appeal - some basic questions

Appeals process FAQs


Q: During the appeal process, at what point can additional records be submitted?

A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records to the affiliated contractor, or First Coast Service Options Inc.


Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?

A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.


Q: What does the term “amount in controversy” mean?

A: The amount in controversy (AIC) is the amount in dispute, at a minimum, that you must have for the administrative law judge (ALJ) and judicial review levels in the appeal process.



Q: Is there a resource that highlights for providers or beneficiaries what would be considered a relevant appeal to submit?

A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the Centers for Medicare & Medicaid Services (CMS), Internet only manuals (IOM).


Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?

A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.



Q: What are the reason code ranges for claims when they’ve denied?

A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.

Evaluation and management (E/M) service tips and tools

Key point to remember

As stated in the Centers for Medicare & Medicaid Services (CMS) Internet-only Manuals (IOM) 100-04, Chapter 12, Section 30.6.1:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

The key components (elements of service) of evaluation & management (E/M) services are:

1. History

2. Examination

3. Medical decision-making

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Tips pertaining to different types of E/M services can be located by accessing the links in the table below:

CPT code range                                   Type of E/M service

99201-99205                                    Office or other outpatient E/M services for new patients

99211-99215                                    Office or other outpatient E/M services for established patients

99221-99223                                    Initial hospital care E/M services

99231-99233                                    Subsequent hospital care E/M services

96150-96152, G0425-G0427           Telehealth Services Medicare Payment for Telehealth services

payment denied as bundled - outpatient services

Bundling of Payments for Services Provided to Outpatients Who Later Are Admitted as Inpatients


Bundling of Payments for Services Provided to Outpatients Who Later Are Admitted as Inpatients: 3-Day Payment Window Policy and the Impact on Wholly Owned or Wholly Operated Physician Offices



On June 25, 2010, the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (PACMBPRA) (Pub. L. 111-192) was enacted. Section 102 of this Act entitled, "Clarification of 3-Day Payment Window," clarified when certain nondiagnostic services furnished to Medicare beneficiaries in the 3-days (or, in the case of a hospital that is not a Subsection (d) hospital, (e.g. psychiatric, inpatient rehabilitation, or long-term care) during the 1 day) preceding an inpatient admission should be considered “operating costs of inpatient hospital services” and therefore included in the hospital’s payment under the Hospital Inpatient Prospective Payment System (IPPS). This policy is generally known as the "3-day payment window."

Under the 3-day payment window, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the inpatient claim for a Medicare beneficiary’s inpatient stay, the technical portion of all outpatient diagnostic services and admission-related nondiagnostic services provided during the payment window. The statute makes no changes to the existing policy regarding billing of diagnostic services.

Prior to June 25, 2010, and the enactment of Public Law 111–192, the payment window policy for preadmission nondiagnostic services was rarely applied as the policy required an exact match between the principal ICD–9 CM diagnosis codes for the outpatient services and the inpatient admission. The requirement of the exact match resulted in very few services furnished in an entity that is wholly owned or operated by the hospital being subject to the policy. The statutory change to the payment window policy made by Public Law 111–192 significantly broadens the definition of nondiagnostic services that are subject to the payment window to include any nondiagnostic service that is clinically related to the reason for a patient’s inpatient admission, regardless of whether the inpatient and outpatient diagnoses are the same.

In accordance with Section 102(a)(1) of the PACMBPRA, for outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiary’s inpatient admission are deemed related to the admission and, therefore, must be included on the bill for the inpatient stay. Also, the technical portion of outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and the third calendar days (1 calendar day for a nonsubsection (d) hospital) immediately preceding the date of admission are deemed related to the admission and, therefore, must be billed with the inpatient stay.

PACMBPRA did not change the requirement that the technical portion of all diagnostic services provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must be billed with the inpatient admission.

NOTE: If the nondiagnostic services are unrelated to the inpatient hospital claims, that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary’s inpatient admission, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the wholly owned or wholly operated entity shall include the technical portion of the services in their billing.

Implementation of the 3-day Payment Window Policy in Wholly Owned or Wholly Operated Entities

Wholly owned or wholly operated entities are subject to the 3-day (or 1-day) payment window policy when they furnish preadmission diagnostic services to a patient who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day), or when they furnish preadmission nondiagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day) for related medical care.

When an entity that is wholly owned or wholly operated by a hospital furnishes a service subject to the 3-day window policy, Medicare will pay the professional component of services with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split. Once the entity has received confirmation of a beneficiary’s inpatient admission from the admitting hospital, they shall, for services furnished during the 3-day window, append a CMS payment modifier to all claim lines for diagnostic services and for those nondiagnostic services that have been identified as related to the inpatient stay. Physician nondiagnostic services that are unrelated to the hospital admission are not subject to the payment window and shall be billed without the payment modifier.



Defining Wholly Owned and Wholly Operated Entities

Wholly owned or wholly operated entities are defined in 42 CFR §412.2: "An entity is wholly owned by the hospital if the hospital is the sole owner of the entity.” And, “an entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entity’s routine operations, regardless of whether the hospital also has policymaking authority over the entity."

Payment Methodology

CMS has established new payment modifier PD (Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days), and require that the modifier be appended to the entity’s preadmission diagnostic and admission-related nondiagnostic services, reported with HCPCS/CPT codes, which are subject to the 3-day payment window policy. The wholly owned or wholly operated entity will need to manage their billing processes to ensure that they bill for their physician services appropriately when a related inpatient admission has occurred. The hospital is responsible for notifying the entity of an inpatient admission for a patient who received services in a wholly owned or wholly operated entity within the 3-day (or, when appropriate, 1-day) payment window prior to the inpatient stay.

The modifier is available for claims with dates of service on or after January 1, 2012, and entities may begin to coordinate their billing practices and claims processing procedures with their hospitals to ensure compliance with the 3-day payment window policy no later than for claims received on or after July 1, 2012.

When the modifier is present on claims for service CMS shall pay:

• Only the Professional Component (PC) for CPT/HCPCS codes with a Technical Component (TC)/PC split that are provided in the 3- calendar day (or, 1- calendar day) payment window; and

• The facility rate for codes without a TC/PC split.

Global Surgical Services and the 3-day Payment Window Policy

We note that the time frames associated with 10 and 90 day global surgical packages could overlap with the 3-day (or 1-day) payment window policy. The 3-day payment window makes no change in billing surgical services according to global surgical rules, and pre- and post-operative services continue to be included in the payment for the surgery. However, there may be times when the surgery itself is subject to the three-day window policy, as would occur if the surgery were performed within the three-day window. For example, a patient could have a minor surgery in a wholly owned or wholly operated entity and then, due to a complication, be admitted as an inpatient. In such cases the modifier shall be appended to the appropriate surgical HCPCS/CPT code.

Medicare part b payment and deductible update as of Feb 2012

New law includes physician update fix through February 2012




On Friday, December 23, 2011, President Obama signed into law the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA). This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect immediately. While the negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012, the administration remains strongly opposed to letting this cut take effect. As he has repeatedly made clear, President Obama is committed to a permanent solution to eliminating the sustainable growth rate’s cut. We will continue to work with Congress to achieve this goal.

The Centers for Medicare & Medicaid Services (CMS) has also recently implemented several important changes for Medicare providers and beneficiaries, and we would like to remind physicians and practitioners of some of these key changes for 2012. For many of your patients, Medicare costs will go down. Medicare cost-sharing for Part B services will decline in some cases and, for the first time, the Part B deductible will decrease, by $22, to $140.

Additionally, health care professionals will be paid more to provide certain important services for people with Medicare. CMS has increased the payment amount for the initial and annual wellness visit -- which has no cost sharing for patients -- to account for the introduction of health risk assessment (HRA). CMS believes it is important to balance the comprehensiveness of the HRA with the potential burden on patients and health professional time constraints. As such, in 2012, CMS will allow for variation in the content of the HRA.

The Medicare Part D prescription drug program has also been enhanced for 2012, with the coverage gap being further reduced as it is phased-out over the next several years. These improvements to the drug benefit from the Affordable Care Act have already saved millions of seniors nearly $2 billion.

CMS wishes to remind physicians and practitioners about the Primary Care Incentive Program. Again in 2012, primary care physicians, nurse practitioners, clinical nurse specialists, and physician assistants may be eligible to receive an incentive payment equal to 10 percent of their allowed charges for primary care services under Medicare Part B. This incentive is paid in addition to any physician incentive payments for services furnished in Health Professional Shortage Areas. Please remember that if a practitioner has reassigned his or her benefits to another entity, such as a group practice, Medicare will pay that entity and not the individual practitioner.

Provider - who is eligible for HPSA payments

HPSA bonus payment policy reminders


Physicians who furnish services to Medicare beneficiaries in areas designated as primary care geographic HPSAs by the Health Resources and Services Administration (HRSA) as of December 31, 2011, are eligible for a 10 percent bonus payment for services furnished from January 1, 2012, to December 31, 2012. If an area does not have a geographic primary care HPSA designation, but does have a geographic mental health HPSA designation, then only psychiatrists furnishing services to Medicare beneficiaries in the designated area are eligible for the ten percent bonus.

The physician must determine whether a service is furnished in a geographic primary care (or mental health) HPSA. Eligibility is determined annually based on the status of the designation, as of December 31 of the prior year. That is, a physician who was eligible for the 10 percent bonus in 2011 may not be eligible for the bonus in 2012. A physician or provider that was not eligible for the 10 percent bonus in 2011 may be eligible for the bonus in 2012.



The Centers for Medicare & Medicaid Services (CMS) publishes an annual list of ZIP codes that automatically receive the HPSA bonus. Only areas where the entire ZIP code falls within the designated area at the time the list is developed are listed. Services provided in eligible areas that are not listed for automatic bonus payment must use the AQ modifier to receive the bonus.



Only physicians who furnish services in areas designated as a geographic primary care HPSA, as of December 31, 2011, and whose ZIP code is not on the list should use the modifier. Only psychiatrists who furnish services in areas that are not designated as primary care HPSAs, as of December 31, 2011, but are designated as a geographic mental health HPSA, should use the modifier if the ZIP code is not on the list for automatic payment.