Medicare has the following parts:
• Part A helps pay for inpatient hospital stays but also helps cover skilled nursing \
care, home health care, and hospice care.
• Part B helps cover medically necessary services like doctors visits and outpatient care. Part B also covers some preventive services including screening tests and shots, diagnostic tests, some therapies,
and durable medical equipment like wheelchairs and walkers.
• Part C is another way to get your Medicare Benefits. It combines Parts A and B, and
sometimes Part D (prescription drug coverage). Medicare Advantage Plans are managed
by private insurance companies approved by Medicare. These plans must cover medically
necessary services. However, plans can charge different copayments, coinsurance, or
deductibles for these services.
• Part D Medicare drug coverage helps pay for outpatient prescription drugs.
Most people don’t have to pay a monthly payment (premium) for Medicare Part A because they or their spouse paid Medicare or FICA taxes while they were working. (FICA stands for “Federal Insurance Contributions Act.” This is the tax withheld from your salary, or that you pay from your selfemployment income, that funds the Social Security and Medicare programs.) When
people pay these taxes on their earnings, it is called “Medicare-covered employment.”
If a person and his or her spouse did not pay Medicare taxes while they were working, or
did not work long enough (10 years in most cases) to qualify for premium-free Part A, he
or she may still be able to get Medicare Part A by paying a monthly premium. In 2009, the
Part A premium is $244 (for a person who has worked 30-39 quarters) or $443 (for a person
who has worked less than 30 quarters) in Medicare-covered employment.
For information on Part A entitlement, enrollment, or premiums, call the Social Security
Administration at 1-800-772-1213 or 1-800-325-0778 for TTY users.
People can choose whether or not to enroll in Part B (Medical Insurance). Those who enroll are responsible for a monthly premium for Medicare Part B, which is $96.40 in 2009.
Since January 1, 2007, some people with higher annual incomes pay a higher Part B premium. In 2009, people with annual incomes over $85,000 if you file an individual tax return or over $170,000 if you are married filing jointly, pay these higher premiums. These amounts change each year. Most people
still pay the standard Part B premium.)
People can sign up for Part B any time during a 7-month period that begins 3 months
before the month they become eligible for Medicare. This is called the Initial Enrollment
Period (IEP).
People who don’t take Part B when they are first eligible may have to wait to sign up
during a General Enrollment Period (GEP). This period runs from January 1 through March
31 of each year, with coverage effective July 1 of that year.
Most people who don’t take Part B when they are first eligible will also have to pay a
premium penalty of 10% for each full 12-month period they could have had Part B but
didn’t sign up for it, except in special situations. In most cases, they will have to pay this
penalty for as long as they have Part B
Most people covered by a group health plan based on current employment (their own or their spouse’s) can delay enrolling in Part B without a penalty.
These people get a Special Enrollment Period. They can enroll in Part B anytime they are still covered by the employer or union group health plan based on current employment, or during the 8 months following the month the employment ends or the group health plan coverage ends, whichever is first.
Most people who sign up for Part B during a Special Enrollment Period don’t pay higher premiums
Let’s look at an example.
Marie turned 65 on June 25, 2009, and plans to retire on December 31, 2009. She has group health plan coverage from her employer.
Her Initial Enrollment Period began March 1, 3 months before the month of her birthday,
and ends 3 months after her birthday month, at the end of September.
Her Special Enrollment Period begins the following month and continues for the 8 months
after she loses her coverage based on current employment.
The General Enrollment Period, for all people with Medicare, runs from January 1 through
March 31 of every year.
Sunday, April 29, 2012
Thursday, April 26, 2012
Understand Medicare basic coverage
Medicare was created by Congress in 1965.
It is a health insurance program for:
• People age 65 and older
• People under age 65 with disabilities who have been receiving Social Security disability benefits for a set amount of time (24 months in most cases). People with Amyotrophic Lateral Sclerosis (ALS),
also known as Lou Gehrig’s Disease, automatically get Medicare Parts A and B the month their disability benefits begin.
• People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare is the nation’s largest health insurance program, currently covering about 44 million Americans.
While Medicare is administered by the Centers for Medicare & Medicaid Services (CMS),
the Social Security Administration (SSA) is responsible for enrolling most people in
Medicare. The Railroad Retirement Board (RRB) is responsible for enrolling railroad
retirees in Medicare.
The Social Security Administration advises people to apply for Medicare benefits 3 months before age 65. People do not have to be retired to get Medicare. Unlike Social Security (for which the full retirement age is gradually increasing to 67), people can still receive full Medicare benefits at age 65.
Medicare benefits can begin no earlier than age 65 except for some people with a disability or End-Stage Renal Disease.
People who are already receiving Social Security benefits (for example, getting early retirement) will be automatically enrolled in Medicare without an additional application.
They will receive a Medicare card and other information about 3 months before age 65
or their 25th month of disability benefits.
It is a health insurance program for:
• People age 65 and older
• People under age 65 with disabilities who have been receiving Social Security disability benefits for a set amount of time (24 months in most cases). People with Amyotrophic Lateral Sclerosis (ALS),
also known as Lou Gehrig’s Disease, automatically get Medicare Parts A and B the month their disability benefits begin.
• People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare is the nation’s largest health insurance program, currently covering about 44 million Americans.
While Medicare is administered by the Centers for Medicare & Medicaid Services (CMS),
the Social Security Administration (SSA) is responsible for enrolling most people in
Medicare. The Railroad Retirement Board (RRB) is responsible for enrolling railroad
retirees in Medicare.
The Social Security Administration advises people to apply for Medicare benefits 3 months before age 65. People do not have to be retired to get Medicare. Unlike Social Security (for which the full retirement age is gradually increasing to 67), people can still receive full Medicare benefits at age 65.
Medicare benefits can begin no earlier than age 65 except for some people with a disability or End-Stage Renal Disease.
People who are already receiving Social Security benefits (for example, getting early retirement) will be automatically enrolled in Medicare without an additional application.
They will receive a Medicare card and other information about 3 months before age 65
or their 25th month of disability benefits.
Wednesday, April 18, 2012
what is E & M SERVICES
Evaluation and Management Services
According to Medicare’s Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.
The problems and data are evaluated using a system of weighted points depicted in the tables. These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.
An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one “problem” point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.
The risk table is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.
After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The “Medical decision making” table shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.
According to Medicare’s Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.
The problems and data are evaluated using a system of weighted points depicted in the tables. These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.
An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one “problem” point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.
The risk table is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.
After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The “Medical decision making” table shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.
Sunday, April 15, 2012
MAC J9 Part A improper payments and inpatient prepayment medical review
As the Medicare administrative contractor (MAC) for jurisdiction 9 (J9), First Coast Service Options Inc. (FCSO) is committed to assisting the Centers for Medicare & Medicaid Services (CMS) in reaching the goal of reducing the national Medicare fee-for-service (FFS) paid claims error rate. Although FCSO has been successful in maintaining exceptional Part A error rates in the past, there are challenges that are impacting FCSO’s ability to achieve CMS’ current error rate reduction goal. As reflected in CMS’ November 15, 2011,
the overall national improper payment rate was 8.6 percent with an inpatient hospital payment error rate of 7.9 percent. The projected November 2011 MAC J9 overall Part A error rate and inpatient hospital specific error rate are significantly higher than the national rates and are driven by J9 hospitals (with the exception of Puerto Rico and U.S. Virgin Islands hospitals). The purpose of this article is to provide additional information regarding J9 payment errors, including insight into the reasons for these errors.
Throughout 2011, FCSO has conducted an aggressive provider outreach approach and has performed significant prepayment medical record reviews related to Medicare severity-diagnosis-related-group (MS-DRG) services in an effort to reduce the MAC J9 Part A paid claims error rate.
FCSO’s provider education and outreach has included:
• Numerous articles (please refer to references below)
• 13 hospital onsite sessions which represented 43 unique facilities
• Three webcasts
• Three face-to-face educational sessions during FCSO’s Medifest symposium
• Four association meetings
• 42 provider-specific letters to targeted hospitals, providing detailed hospital specific error rate information
In addition to education and outreach efforts, FCSO provided notice to the provider community and implemented prepayment medical record review for targeted MS-DRGs (see MS-DRG breakdown below) throughout 2011. Unfortunately, the number of comprehensive error rate testing (CERT) findings show that error rates related to inpatient admissions are not improving and that high-dollar MS-DRG medical necessity denials involving surgical procedures and short-stay MS-DRG admissions were driving J9 payment errors. Therefore, FCSO continued to partner with key stakeholders to provide open communication and published an article in the November 2011, Part A publication (see article references below), which provided notice regarding upcoming additional prepayment medical review for 15 targeted MS-DRGs. As noted in the November article, FCSO plans to take a staggered approach to implementing additional prepayment edits. As Part A errors significantly decrease for the MS-DRGs identified in the J9 prepayment error prevention strategy, prepayment medical review of those MS-DRGs will be decreased or discontinued. Also, as individual providers' performance shows consistent compliance with requirements, which results in low error rates, those providers will be removed from prepayment medical review of the applicable MS-DRG code(s). FCSO will continue to educate hospitals with persistent high error rates. If a provider fails to correct their compliance issues and billing practices, it may lead to 100 percent review for high error-prone MS-DRGs.
FCSO will continue to provide education and feedback on the prepayment review process and will partner with associations, medical societies, and provider groups in order to successfully lower the error rates. Hospitals should consider this information when evaluating internal coding and billing processes. Hospitals should also work with the physicians associated with these services to ensure they have a clear understanding of inpatient level of care requirements and the importance of documentation to support the medical necessity of services (particularly medical necessity for procedures and any related national coverage determination (NCD) and/or local coverage determination (LCD) requirements). FCSO will continue to provide outreach and education to the physician associations and Part B providers associated with high payment error risk MS-DRG services.
Effective February 1, 2012, FCSO will also perform post-payment review/recoupment of the admitting physician's and/or surgeon's Part B services. For services related to inpatient admissions that are denied because they do not meet an inpatient level of care (i.e., services could have been provided in a less intensive setting such as outpatient or observation), FCSO will review the hospital record and if the physician service was reasonable and necessary just not at an inpatient level of care, the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician’s progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment will occur for the performing physician’s Part B service.
Thursday, April 12, 2012
HIPAA 5010 AND CO-ORDINATION BENEFIT
Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Processing
Supplemental payers are transitioning to HIPAA 5010 or National Council for Prescription Drug Programs (NCPDP) D.0 under the National Crossover Process. Currently, the Centers for Medicare & Medicaid Services (CMS) is transitioning supplemental payers that participate in the national Coordination of Benefits Agreement (COBA) crossover process from their production version 4010A1 HIPAA 837 claims to HIPAA versions 5010A1 and 5010A2 837 claims. As COBA supplemental payers move into production on the 5010A1 and A2 claim formats, CMS requires that they continue to accept their “pre-HIPAA 5010” production version 4010A1 claims for 14 full calender days after their cut-over to the new claim formats.
The following is an example to further illustrate this point:
Payer A moved to HIPAA 5010 production on November 7, 2011. Medicare will then systematically transfer to Payer A all “clean” electronically received 4010A1 claims that are already on the payment floor and tagged for crossover as of November 3 & 4, 2011. Beginning with claims that CMS Coordination of Benefits Contractor (COBC) received that have a file date of November 22, 2011, Meidcare, through the COBC, will no longer be able to transfer production 4010A1 claims to payer A. This is because 14 full calendar days have elapsed since Payer A moved into production on the HIPAA 5010 claim formats.
Note : The same premise will hold for inbound version 5.1 batch National Council for Prescriotion Drug Programs (NCPDP) claims when a supplemental payer moves into production on the NCPDP D.0, version 5.2 batch format for receipt of crossover claims.
As provided in CMS Change Requests (Crs) 6658* and 6664*, the COBC activates the following edits once COBA trading partners move into HIPAA 5010 or NCPDP D.0 production
Provider, physicians and suppliers should note that they will see the foregoing edit codes on the special provider notification letters that Medicare mails to them at their on-file correspondence address when Medicare is unable to send various claims for crossover purpose. Receipt of these codes on the special provider notification letters denotes that:
1. The patient's supplemental payer has moved into HIPAA 5010 or NCPDP D.0 production receipt for all Medicare crossover claims; and
2. For a limited timeframe (likely 30 days after a supplemental payer cuts over to version 5010 for crossover claims receipt), providers, physicians, and suppliers will need to file the affected claims directly with their patients' supplemental payers.
Supplemental payers are transitioning to HIPAA 5010 or National Council for Prescription Drug Programs (NCPDP) D.0 under the National Crossover Process. Currently, the Centers for Medicare & Medicaid Services (CMS) is transitioning supplemental payers that participate in the national Coordination of Benefits Agreement (COBA) crossover process from their production version 4010A1 HIPAA 837 claims to HIPAA versions 5010A1 and 5010A2 837 claims. As COBA supplemental payers move into production on the 5010A1 and A2 claim formats, CMS requires that they continue to accept their “pre-HIPAA 5010” production version 4010A1 claims for 14 full calender days after their cut-over to the new claim formats.
The following is an example to further illustrate this point:
Payer A moved to HIPAA 5010 production on November 7, 2011. Medicare will then systematically transfer to Payer A all “clean” electronically received 4010A1 claims that are already on the payment floor and tagged for crossover as of November 3 & 4, 2011. Beginning with claims that CMS Coordination of Benefits Contractor (COBC) received that have a file date of November 22, 2011, Meidcare, through the COBC, will no longer be able to transfer production 4010A1 claims to payer A. This is because 14 full calendar days have elapsed since Payer A moved into production on the HIPAA 5010 claim formats.
Note : The same premise will hold for inbound version 5.1 batch National Council for Prescriotion Drug Programs (NCPDP) claims when a supplemental payer moves into production on the NCPDP D.0, version 5.2 batch format for receipt of crossover claims.
As provided in CMS Change Requests (Crs) 6658* and 6664*, the COBC activates the following edits once COBA trading partners move into HIPAA 5010 or NCPDP D.0 production
- N22226- “4010A1 production claim received, but the COBA trading partner is not accepting 4010A1 production claims.”
- N22230- “NCPDP 5.1 production claim receive, but the COBA trading partner is not accepting NCPDP 5.1 production claims”.
Provider, physicians and suppliers should note that they will see the foregoing edit codes on the special provider notification letters that Medicare mails to them at their on-file correspondence address when Medicare is unable to send various claims for crossover purpose. Receipt of these codes on the special provider notification letters denotes that:
1. The patient's supplemental payer has moved into HIPAA 5010 or NCPDP D.0 production receipt for all Medicare crossover claims; and
2. For a limited timeframe (likely 30 days after a supplemental payer cuts over to version 5010 for crossover claims receipt), providers, physicians, and suppliers will need to file the affected claims directly with their patients' supplemental payers.
Sunday, April 8, 2012
Improper payments and inpatient prepayment medical review MAC J9 Part A
The following provides detailed information related to MS-DRG services currently on FCSO’s prepayment medical review MS-DRG strategy. The MAC J9 CERT payment error findings are included for claims sampled in the November 2010 and November 2011 report periods. Denial information is also provided for those services previously subject to FCSO medical review activities.
226 -- Cardiac defibrillator implant without (w/o) cardiac catheter with (w/) major complications or comorbidities (MCC); Applicable NCD: 20.4
CERT error findings:
• 60 percent did not meet the NCD criteria for the procedure, and the admission was not medically reasonable and necessary for an inpatient level of care
• 20 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary, and the patient met inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 20 percent met the NCD criteria and inpatient level of care, but the MS-DRG was re-coded based on complications or comorbidities
227 -- Cardiac defibrillator implant w/o cardiac catheter w/o MCC; Applicable NCD: 20.4
CERT error findings:
• 70 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
• 20 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care
• 10 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an impatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
242 -- Permanent cardiac pacemaker implant with MCC; Applicable NCD: 20.8
CERT error findings:
• 86 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 14 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care.
243 -- Permanent cardiac pacemaker implant with CC; Applicable NCD: 20.8
CERT error findings:
• 100 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
244 -- Permanent cardiac pacemaker implant w/o CC or MCC; Applicable NCD: 20.8
CERT error findings:
• 69 percent did not meet the NCD criteria for the procedure, but the admission was reasonable and necessary for an inpatient level of care. The admission was allowed with a revised MS-DRG code after removal of the denied procedure
• 19 percent did not meet the NCD criteria for the procedure, and the admission was not reasonable and necessary for an inpatient level of care.
• 6 percent met the NCD criteria for the procedure, and the admission was reasonable and necessary for an inpatient level of care; however, there was miscoding in the DRG and the service was recoded
• 6 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care.
245 -- Automatic implantable cardiac defibrillator (AICD) generator procedures; Applicable NCD: 20.4
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care.
247 -- Percutaneous cardiovascular procedure with drug-eluting stent w/o MCC; Applicable NCD: 20.7
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
251 -- Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC; Applicable NCD: 20.7
CERT error findings:
• 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care
253 -- Other vascular procedures with CC; Applicable NCD: N/A
CERT error findings:
• There were no MAC J9 error findings; however, nationally, most services were denied as the admission was not reasonable and necessary for an inpatient level of care
264 -- Other circulatory system O.R. procedures; Applicable NCD: N/A
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
287 -- Circulatory disorders except acute myocardial infarction (AMI), with cardiac catheter w/o MCC; Applicable NCD: 20.7
CERT error findings:
• In 80 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
• In 20 percent of these cases, the procedure was not considered reasonable and necessary, and the admission was not reasonable and necessary for an inpatient level of care
313 -- Chest pain; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on March 1, 2011, with an 81.6 percent denial rate to date
• Most were denied as the admission was not reasonable and necessary for an inpatient level of care
392 -- Esophagitis, gastroenteritis, and miscellaneous digestive disorders w/o MCC; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
458 -- Spinal fusion except cervical with spinal curve/malign/infection or 9+ fusions w/o CC/MCC Applicable NCD: N/A; Applicable LCD: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32074)
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed spinal fusion procedure code was not on the inpatient-only list)
460 -- Spinal fusion except cervical w/o MCC; Applicable NCD: N/A; Applicable LCD: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions (L32074)
CERT error findings:
• In 60 percent of these cases, the documentation did not support that the procedure was reasonable and necessary
• In 20 percent of these cases, the procedure was reasonable and necessary, but there was no physician’s order for admission
• In 20 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed spinal fusion procedure codes were not on the inpatient-only list)
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on June 23, 2011, with a 41 percent denial rate to date
• Most were denied as the documentation did not support that the procedure was reasonable and necessary
470 -- Major joint replacement or reattachment of lower extremity w/o MCC; Applicable NCD: N/A; Applicable LCD: Major Joint Replacement (Hip and Knee) (L32078)
CERT error findings:
• In 92 percent of these cases, the documentation did not support that the procedure was reasonable and necessary
• In 8 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care (the billed knee replacement procedure code was not on the inpatient-only list)
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on June 1, 2011, with a 62 percent denial rate to date
• Most were denied as the documentation did not support that the procedure was reasonable and necessary
490 -- Back and neck procedures except spinal fusion with CC/MCC or disc device/neurostimulator; Applicable NCD: N/A
CERT error findings:
• In 100 percent of these cases, the procedure was reasonable and necessary, but the admission was not reasonable and necessary for an inpatient level of care
552-- Medical back problems w/o MCC; Applicable NCD: N/A
CERT error findings: N/A
FCSO prepayment review findings:
• 30 percent prepayment edit implemented on April 1, 2011, with a 70 percent denial rate to date
• Most were denied as the admission was not reasonable and necessary for an inpatient level of care
641-- Miscellaneous disorders of nutrition, metabolism, fluids/electrolytes w/o MCC; Applicable NCD: N/A
CERT error findings:
• 100 percent were denied as the admission was not reasonable and necessary for an inpatient level of care
NCD References:
• Medicare National Coverage Determinations Manual, Chapter 1, Part 1 (Sections 10 -- 80.12)
• NCD 20.4 -- Implantable Automatic Defibrillators
• NCD 20.7 -- Percutaneous Transluminal Angioplasty (PTA)
• NCD 20.8 -- Cardiac Pacemakers
Thursday, April 5, 2012
How to request provider comparative billing report from medicare
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.
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.
Monday, April 2, 2012
Reopen the previous request through IVR
Florida Medicare Telephone reopening requests via the IVR
Medicare Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
Features
• This enhancement is designed to make your requests easier and faster to process. Requests for telephone reopenings via the IVR will process the next day.
• Using this self-service feature will result in faster receipt of any applicable payments.
• The hours of availability are beyond the hours of availability for a customer service representative (CSR).
• IVR reopenings will be limited to simple, single-line requests.
• Bonus -- The number of telephone reopening requests via the IVR are unlimited within the allotted 30-minute time frame.
Types of reopenings available via the IVR
The following types of reopening requests are not available through a CSR; you must call the IVR for the following types of requests:
• Change date of service on paid claims (history corrections)
• Change diagnosis code
• Add, delete, change modifier (except modifiers listed below)
• Claims containing single detail lines (except requests to add modifier GV or GW to multiple-line claims for a beneficiary enrolled in hospice)
• Entitlement, Medicare Secondary Payer or Medicare Advantage Plan change in status
Types of reopenings that cannot be performed via the IVR
You may continue to speak with a CSR to request a telephone reopening for types of reopenings not available through the IVR.
• Previously adjusted claims
• Claims containing multiple detail lines (except hospice modifiers GV or GW or Entitlement reopenings)
• Pending claims
• Non-assigned claims
• Drug and drug administrations codes
• Request on claims containing the following modifiers, or requests to add or change these modifiers: 21, 22, 51, 52, 53, 56, 62, 66, 99, CC, GA, GY, GZ, SG, or WU.
Information you must have when calling the IVR for a reopening
• Provider’s National Provider Identifier (NPI), Tax Identification Number (TIN), and Provider Transaction Access Number (PTAN)
• Beneficiary’s last name and first Initial
• Beneficiary’s Medicare health insurance claim (HIC) number
• Beneficiary’s date of birth
• Caller’s name and 10-digit telephone number (3-digit area code and 7-digit number)
• Date of service
• Internal Control Number (ICN) -- can be obtained from your provider remit notice or the IVR when receiving a claim status
• Item(s) or service(s) at issue
• Reason for request
• New/revised information
IVR takes your request -- what’s next?
• IVR will confirm the request at the end of the call.
• If the request is approved, you will receive a letter and new remittance advice notice.
• If the request cannot be processed, a letter will be sent advising the provider of our decision.
• If the request would create an overpayment situation, the IVR will advise you to submit your request via a written redetermination form.
IVR hours of availability for telephone reopenings
• The IVR is available for requests for telephone reopenings from 7:00 a.m. to 6:30 p.m. Monday through Friday, and Saturday 7:00 a.m. to 3:00 p.m. ET.
• The toll-free Part B telephone number is 1-877-847-4992
Additional information
• No limit to the number of calls per day.
• Please have the information listed under “Information You Must Have When Calling the IVR for A Reopening” available when calling for an IVR reopening.
• If you are calling to perform an adjustment on multiples lines or on a claim with multiple issues, please call our customer service center at 1-866-454-9007 for providers in Florida and the U.S. Virgin Islands, and 1-877-715-1921 for providers in Puerto Rico.
• Additional IVR instructions are available via our IVR Part B operating guide.
To ensure you have all the information needed to submit your reopening request(s) via the IVR, we suggest using the IVR reopening request help sheet when preparing to call the IVR.
Medicare Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
Features
• This enhancement is designed to make your requests easier and faster to process. Requests for telephone reopenings via the IVR will process the next day.
• Using this self-service feature will result in faster receipt of any applicable payments.
• The hours of availability are beyond the hours of availability for a customer service representative (CSR).
• IVR reopenings will be limited to simple, single-line requests.
• Bonus -- The number of telephone reopening requests via the IVR are unlimited within the allotted 30-minute time frame.
Types of reopenings available via the IVR
The following types of reopening requests are not available through a CSR; you must call the IVR for the following types of requests:
• Change date of service on paid claims (history corrections)
• Change diagnosis code
• Add, delete, change modifier (except modifiers listed below)
• Claims containing single detail lines (except requests to add modifier GV or GW to multiple-line claims for a beneficiary enrolled in hospice)
• Entitlement, Medicare Secondary Payer or Medicare Advantage Plan change in status
Types of reopenings that cannot be performed via the IVR
You may continue to speak with a CSR to request a telephone reopening for types of reopenings not available through the IVR.
• Previously adjusted claims
• Claims containing multiple detail lines (except hospice modifiers GV or GW or Entitlement reopenings)
• Pending claims
• Non-assigned claims
• Drug and drug administrations codes
• Request on claims containing the following modifiers, or requests to add or change these modifiers: 21, 22, 51, 52, 53, 56, 62, 66, 99, CC, GA, GY, GZ, SG, or WU.
Information you must have when calling the IVR for a reopening
• Provider’s National Provider Identifier (NPI), Tax Identification Number (TIN), and Provider Transaction Access Number (PTAN)
• Beneficiary’s last name and first Initial
• Beneficiary’s Medicare health insurance claim (HIC) number
• Beneficiary’s date of birth
• Caller’s name and 10-digit telephone number (3-digit area code and 7-digit number)
• Date of service
• Internal Control Number (ICN) -- can be obtained from your provider remit notice or the IVR when receiving a claim status
• Item(s) or service(s) at issue
• Reason for request
• New/revised information
IVR takes your request -- what’s next?
• IVR will confirm the request at the end of the call.
• If the request is approved, you will receive a letter and new remittance advice notice.
• If the request cannot be processed, a letter will be sent advising the provider of our decision.
• If the request would create an overpayment situation, the IVR will advise you to submit your request via a written redetermination form.
IVR hours of availability for telephone reopenings
• The IVR is available for requests for telephone reopenings from 7:00 a.m. to 6:30 p.m. Monday through Friday, and Saturday 7:00 a.m. to 3:00 p.m. ET.
• The toll-free Part B telephone number is 1-877-847-4992
Additional information
• No limit to the number of calls per day.
• Please have the information listed under “Information You Must Have When Calling the IVR for A Reopening” available when calling for an IVR reopening.
• If you are calling to perform an adjustment on multiples lines or on a claim with multiple issues, please call our customer service center at 1-866-454-9007 for providers in Florida and the U.S. Virgin Islands, and 1-877-715-1921 for providers in Puerto Rico.
• Additional IVR instructions are available via our IVR Part B operating guide.
To ensure you have all the information needed to submit your reopening request(s) via the IVR, we suggest using the IVR reopening request help sheet when preparing to call the IVR.
Medicare physician fee schedule - Quick overview
