Update - md aaham

Novitas Solutions:
Medicare Updates
Maryland AAHAM
December 20, 2013
All Current Procedural Terminology (CPT) only copyright 2012 American Medical Association (AMA). All rights
reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition
Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are
not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to
the source documents have been provided within the document for your reference. This presentation was
prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
Although every reasonable effort has been made to assure the accuracy of the information within these pages, the
ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the
provider of services.
Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this
compilation of Medicare information is error-free and will bear no responsibility or liability for the results or
consequences of the use of this guide.
This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal
document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
Novitas Solutions does not permit videotaping or audio recording of training events.
• Medicare Updates and Notifications
• International Classification of Disease
Tenth Edition (ICD-10) Update
• Contractor Updates
• Comprehensive Error Rate Testing
Program (CERT)
• Self Service Options
Medicare Updates and
2014 Deductible and
• Change Request # 8527
• Effective January 1, 2014
• Part A
– Deductible – $1216.00
– Coinsurance
• $304.00 per day 61st – 90th
• $608.00 per day 91st – 150th
• $152.00 per day 21st – 100th Skilled Nursing Facility
• Part B
– Deductible – $147.00 per year
– Coinsurance – 20 percent
• For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8527.pdf
Part A and Part B
Incarcerated Beneficiary
Recently, the Centers for Medicare & Medicaid Services (CMS) initiated recoveries from
providers and suppliers based on data that indicated a beneficiary was incarcerated on the
date of service. Medicare will generally not pay for medical items and services furnished to
a beneficiary who was incarcerated when the items and services were furnished.
A beneficiary that is considered to be incarcerated is one that is not only confined within a
‘penal facility’ but may also include a beneficiary who is on a supervised release, on
medical furlough, residing in a half way house or similar situation.
As a result, a large number of overpayments were identified, demand letters released, and,
in many cases, automatic recoupment of overpayments made. CMS has since learned that
the information related to these periods of incarcerations was, in some cases, incomplete
for CMS purposes.
As of the beginning of December, refunds for affected claims were issued. There will not be
remittance advices or Medicare summary notices issued for these claims.
As of December 12, letters and spreadsheets related to the refund requests for claim
denials due to incarcerated status were sent to providers.
Part A and Part B
Incarcerated Beneficiary
CMS has posted frequently asked questions (FAQs) about incarcerated beneficiary claim denials. These
FAQs will be updated as more information becomes available.
Review IOM 100-04, chapter 1, section 10.4 for CMS guidelines on items or services furnished to
Medicare beneficiaries in state or local custody under a penal authority
New fact sheet titled: Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody
Under a Penal Authority
For any questions regarding the Social Security records indicating that the patient was in custody when
the service was rendered please call the Customer Contact Center (CCC)
The CCC can tell you for your date of service if the beneficiary was incarcerated or not, but will not be able to provide
the from and through dates of incarceration
This information is not available through the Interactive Voice Response (IVR) or on-line eligibility verification systems
The automated response to your inquiry provides the dates for the period of inactivity, but it does not provide the reason for
such inactivity
Providers and beneficiaries do have the right to appeal any claims that were denied in error
Part A and Part B
Revised Beneficiary Liability and Messages
Associated with Denials for Claims for Services
Furnished to Incarcerated Beneficiaries
Change Request #8488
Effective: February 24, 2014, Implementation: February 24, 2014
Key Points
– Update to the Claim Adjustment Reason Code (CARC) , Remittance Advice Remark
Code (RARC), and Group Code when denying claims for services furnished to
incarcerated beneficiaries
CARC: 258 – Claim/service is not covered when patient is in custody or incarcerated.
Appropriate Federal, State or Local authority may cover this claim/service.
RARC: N103 –Medicare records indicate this patient was a prisoner or in custody of a
Federal, State or local authority when the service was rendered.
Group Code: OA- Other Adjustment
The provider or supplier should seek repayment for the cost of its services provided from the authority
that was in custody of the beneficiary on the date of service.
For more information
– MLN Matters® Number: MM8488
Part A and Part B
Liability Assignment Regarding
Therapy Cap Claim Denials
Change Request #8321
Effective: January 1, 2013, Implementation: October 1, 2013
Key Points:
– The payment liability for therapy limit denials was revised changing denials from beneficiary
liability to provider liability. As a result, when Medicare denies professional claims with Dates
of Service (DOS) on or after January 1, 2013, that exceed the therapy caps and do not
contain the GA modifier, claims denied with Group code CO (Contractual Obligation).
Assignment of the PR (Patient Responsibility) code for DOS prior to January 1, 2013.
Medicare will not adjust claims with a DOS on or after January 1, 2013, denied with the
incorrect Group Code of PR prior to the implementation. Providers are required to refund any
payments collected from beneficiaries associated with such denied claims and to take steps
to avoid further collections from such beneficiaries based on the incorrect assigned liability
on those denied claims.
For more Information:
– MLN Matters® Number: MM8321
• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8321.pdf
Part A and Part B
New Claim Adjustment Reason Code
(CARC) to Identify a Reduction in
Payment Due to Sequestration
• Change Request #8378
• Effective: June 3, 2013, Implementation: January 6, 2014
• Key Points:
– A new Claim Adjustment Reason Code (CARC) reported when
payments are reduced due to Sequestration
– The new CARC is as follows:
• 253 – Sequestration – Reduction in Federal Spending
– For more information:
• http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8378.pdf
Part A and Part B
Enrollment Denials When
Overpayment Exists
• Change Request #8039
• Effective: October 1, 2013, Implementation: October 7, 2013
• Key Points:
– Medicare contractors may deny a Form CMS-855 enrollment application
if the current owner of the enrolling provider or supplier or the enrolling
physician or non-physician practitioner has an existing or delinquent
overpayment that has not been repaid in full at the time an application
for new enrollment or Change of Ownership (CHOW) is filed.
• For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM8039.pdf
Part A and Part B
Influenza Vaccine Payment
Allowances – Annual Update for
2013-2014 Season
• Change Request #8433
• Effective: August 1, 2013, Implementation: October 25, 2013
• Key Points:
– Influenza vaccine payment allowance for 2013-2014 season
– Payment allowances effective for August 1, 2013 – July 31, 2014
– Reminders
• Part B deductible and coinsurance amounts do not apply
• For more information:
– http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R761OTN.pdf
Part A and Part B
Mandatory Reporting of an 8-Digit
Clinical Trial Number on Claims
Change Request #8401
Effective: January 1, 2014, Implementation: January 6, 2014
Key Points:
– It will be mandatory to report a clinical trial number on claims for items and services
provided in clinical trials that are qualified for coverage as specified in the "Medicare
National Coverage Determination (NCD) Manual," Section 310.1
– For institutional paper or direct data entry (DDE) claims, the 8-digit clinical trial number
is to be placed in the value amount for paper only value code D4/DDE claim UB-04
(Form Locators 39-41)
Electronic Submission - Loop 2300 REF02 (REF01=P4)
– For carrier claims, the 8-digit clinical trial registry number proceeded by the 2 alpha
characters “CT” will be placed in Field 19 of the paper Form CMS-1500
Electronic Submission – Loop 2300 REF02(REF01=PF)
For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8401.pdf
Part A and Part B
CMS Rule 1599-F
Fiscal Year 2014 Hospital Inpatient Payment Rule
– CMS issued on August 2, 2013
– Published in Federal Register on August 19, 2013
– Posted on CMS FY 2014 IPPS Final Rule Home Page
– Change Request has not yet been issued to Contractors
Addresses the following:
Updates fiscal year 2014 payment policies and rates
Improves value and quality of hospital care
Provides clarification about when a patient should be admitted to the hospital
Responds to recent concerns about extended beneficiary stays in the hospital
outpatient department
Information on Inpatient Hospital Reviews:
– http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medical-Review/InpatientHospitalReviews.html
Part A
Inpatient Hospital
• The Centers for Medicare & Medicaid Services (CMS)
issued guidance for reviewing inpatient hospital claims
impacted by the Final Rule
– Prepayment review
• Prepayment patient status review for inpatient hospital claims
spanning less than two midnights after formal admission with
dates of admission on or after October 1, 2013 but before March
31, 2014
– Medicare Administrative Contractors (MACS) sample 10 claims for
small hospitals and 25 claims for large hospitals
– Based on results of these initial reviews, MACs will conduct educational
outreach and repeat process as necessary
• http://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/MedicalReview/InpatientHospitalReviews.html
Part A
Inpatient Hospital Review
Hospital Inpatient Admission Order and Certification
Special Open Door Forums on Final Rule CMS-1599F
Selecting Hospital Claims for Patient Status Reviews: Admissions On or After October 1, 2013
August 15, 2013 CMS Rule 1599-F: Inpatient Hospital Admission and Medical Review Criteria (2-Midnight Provision)
and Part B Inpatient Billing in Hospitals
September 26, 2013 CMS Rule 1599-F: Inpatient Hospital Admission and Medical Review Criteria (2-Midnight
Provision) and Part B Inpatient Billing in Hospitals
November 12, 2013 CMS Rule 1599-F: Discussion of the Hospital Inpatient Admission Order and Certification: 2
Midnight Benchmark for Inpatient Hospital Admissions
Frequently Asked Questions (FAQs) 2 Midnight Inpatient Admission Guidance &Patient Status Reviews
for Admissions on or after October 1, 2013
Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013
Part A
Temporary Instructions for Implementation
of Final Rule 1599-F for Part A to Part B
Billing of Denied Hospital Inpatient Claims
Special Edition Article SE1333
Key Points:
– For Admissions on or after October 1, 2013
– When an inpatient admission is found to be not reasonable and necessary
– Payment will be allowed for all hospital services that were furnished and would have
been reasonable and necessary if the beneficiary had been treated as an outpatient,
rather than admitted to the hospital as an inpatient
– If the hospital already submitted a claim to Medicare for payment under Part A, the
hospital would be required to cancel its Part A claim prior to submitting a claim for
payment of Part B inpatient services
– Medicare requires the hospital to submit a Part A claim indicating that the provider is
Occurrence Span Code “M1” and the inpatient admission Dates of Service
– Timely filing restrictions will apply for Part B inpatient services
For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1333.pdf
Part A
International Classification of Disease
Tenth Edition (ICD-10) Update
ICD-10 Implementation
• October 1, 2014 – Compliance date for implementation of
ICD-10-CM (diagnoses) and ICD-10-PCS (procedures)
• No more delays
• ICD-10-CM will be used by all providers in every health care
• ICD-10-PCS will be used only for hospital claims for inpatient
hospital procedures
– ICD-10-PCS will not be used on physician claims, even those for
inpatient visits
ICD-10 Implementation
• Single implementation date of October 1,
2014 for all users
– Date of service for ambulatory and physician
• Ambulatory and physician services provided on or after
October 1, 2014 will use ICD-10-CM diagnosis codes
– Date of discharge for hospital claims for inpatient
• Inpatient discharges occurring on or after October 1,
2014 will use ICD-10-CM and ICD-10-PCS codes
Split Claim Billing
• Claims that Span October 1, 2014
• Outpatient claims – SPLIT claim and Use FROM
• Inpatient claims – Use ONLY THROUGH
date/DISCHARGE date – use ICD-10 codes
• http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1325.pdf
Not Affected
• No impact on Current Procedure
Terminology (CPT) and Healthcare
Common Procedure Coding System
(HCPCS) codes
• CPT and HCPCS will continue to be used
ICD-10 Conversion from ICD-9 and Related Code
Infrastructure of the Medicare Shared Systems as
They Relate to the Centers for Medicare & Medicaid
Services (CMS) National Coverage Determination
Change Request #8109 and 8197
Key Points:
Medicare contractors and Shared System Maintainers create and update National Coverage
Determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with
comparable ICD-10 diagnosis codes plus all associated coding infrastructure, such as procedure
codes, Healthcare Common Procedure Coding System (HCPCS) and Current Procedural
Terminology (CPT) codes, denial messages, frequency edits, Place of Service (POS), Type of Bill
(TOB) and provider specialties, etc.
Operational changes that are necessary to implement the conversion of the Medicare system
diagnosis codes specific to the Medicare National Coverage Database (NCD) spreadsheets
attached to CR8109 and 8197.
For more information:
Display of ICD-10 Local Coverage
Determinations (LCDs) on the
Medicare Coverage Database (MCD)
• Change Request #8348
• Effective: October 2, 2013, Implementation: April 10, 2014
• Key Points:
– All ICD-10 LCDs and associated ICD-10 Articles shall be
published on the MCD no later than April 10, 2014
– All LCDs and Articles will receive a new LCD/Article ID number
• For more information:
– http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1293OTN.pdf
ICD-10 Testing
All Medicare Administrative Contractors to implement an ICD-10 testing
week with trading partners
The ICD-10 testing week was created to generate awareness and interest,
and to instill confidence in the community of the MACs readiness for
The testing week will allow trading partners access to the MAC for testing
with real time help desk support
The event will be done virtually and will be posted to our website
– March 3, through March 7, 2014
Change Request 8465
– http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1303OTN.pdf
Register for ICD-10 Testing Week:
– http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00025466
ICD-10 Resources
Provider Resources
MedScape Modules
CMS Sponsored ICD-10 Teleconferences
Medicare Fee-For-Service Resources
Sign up for the Centers for Medicare & Medicaid Services (CMS) ICD-10 Industry Email
Follow @CMSGov on Twitter
Subscribe to Latest News Page Watch https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609
Contractor Updates
Electronic Submission of Medically
Reviewed Cancel Claims
• Effective now, Novitas Solutions will allow electronic
submission of cancel claims with denied items or
– Remarks must be specific
• Overlapping an inpatient claim
• Certain situations where hardcopy submissions maybe
– Cancel requests for Medicare Secondary Payer (MSP)
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pa
Retired Local Coverage
Determinations (LCDs)
• Novitas began directing customers to the
Medicare Coverage Database (MCD) for retired
LCDs and previous versions for currently active
• Medical Policy page has been updated with a link
to the MCD
– http://www.cms.gov/medicare-coverage-database/
• Active and Draft policies can be found on our
– http://www.novitassolutions.com/webcenter/spaces/MedicalPolicy_JL
Website Improvements
• Effective September 29, 2013 Novitas Solutions website
improvements began!
• New features include:
– Separate Website for Jurisdiction H and Jurisdiction L
– Improved Search Functionality
– Navigation Enhancements
• Webinar tours will be conducted – register for one now:
– http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?co
New Novitas Website
Updated Landing Page
Part A Landing Page
New Credit Balance Status Tool
This New Tool provides status of Part A and B (of A) Credit Balance
Search Criteria
– Provider Transaction Access Number (PTAN)
Enter no less than six characters and no more than seven
– Quarter Date
Enter date in MM//DD/YYYY format
Only one year of history is available
– Click “Submit Query”
Each response will include:
Plan – A or B
Received Dt – Date or dates received
Total Credit Balance Amounts
Status – Open or Closed
Credit Balance Status Tool (cont’d)
Comprehensive Error Rate Testing
Comprehensive Error Rate Testing
• National Claim Paid Error Rate
– 6.8 % Inpatient hospitals
– 4.8 % Non-inpatient hospital facilities
– 9.9 % Physician/Lab /Ambulance
• Impacts all providers submitting Fee for Service claims
• Limited random claim sample
• Record requests must be received within 30 days from the
initial CERT letter
• Right to Appeal? Yes
JL Part A Common Errors
• Insufficient documentation:
No valid physician’s order
Inpatient stay
Missing or illegible physician signature
Missing documentation to support intensity of therapy services
Missing physician's hospital inpatient discharge summary
Skilled Nursing Facility 3-day qualifying stay
• Medical necessity errors:
o Need for an inpatient stay
o Related services
• Other errors:
Diagnosis Related Group
Discharge disposition code
Resource Utilization Group
Laboratory services
Comprehensive Error Rate
Testing (CERT) Center
Self Service Options
Customer Contact
– 1-877-235-8073
– Hours of Operation, Eastern Time (ET)
Monday - Thursday: 8:00 am – 4:00 pm ET
Friday: 8:00 am – 2:00 pm ET
Interactive Voice Response (IVR)
– Hours of Operation
Eligibility and General Information
Full IVR Options
24 Hours a day 7 Days a week
Mon- Fri 6:00am – 9:00pm ET
Saturday 6:00am - 4:00pm ET
Step-by-Step Guide
Fiscal Intermediary Standard System
• District of Columbia (DC), Maryland (MD), New Jersey
(NJ), Pennsylvania (PA)
– Monday – Friday
• 6 am – 9 pm, Eastern Time (ET)
– Saturdays
• 6 am – 4 pm ET
• Delaware (DE)
– Monday – Friday
• 6 am – 6 pm ET
– Saturdays
• 6 am – 4 pm ET
Reminder – Special
Edition Article SE1249
• The HIPAA (Health Insurance Portability and Accountability
Act) Eligibility Transaction System (HETS) will replace
Common Working File (CWF) eligibility inquiries.
– Part B -April 2013 access to CWF eligibility queries has been
removed from Professional Provider Telecommunication Network
– Part A – April 2014, access to Health Insurance Query Access
(HIQA) and CWF inquiry menu option 10 will be terminated
– For more information:
– http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1249.pdf
EDI ConnectionsPartnering for the Future
This hostname will be disconnected on December 13, 2013 after 5pm ET
Action: Trading Partners must begin using the Prod-Smartxfer.Novitas-Solutions.com hostname
in order to submit claims
Trading Partners must select “YES” or agree to the security certificate when they connect to the
new hostname
Hostname IP will be repointed to the FL Network on December 13, 2013
Action: Trading Partners will receive a security certificate that they will have to select “YES” to
agree to
The 717 number will be remote call forwarded to the new 904-371-9510 number on December 13,
2013, after 5pm ET
Trading Partners may experience the following:
Inability to connect for claim submissions, remittance and/or report retrieval
Decreased connection quality
Frequent connection time-outs
If your modem is more than four years old, you may need to purchase a new dial-up modem in order to connect
Action: We strongly encourage Trading Partners to begin using the new 904-371-9510 number due
to call path complexities
Fax to Image
Were you aware records for an Additional Development Request (ADR) can be faxed
directly to Novitas Solutions?
The fax to image option allows for documentation to be submitted directly to Novitas
Available 24 hours a day, 7 days a week
Fax ADR response to 1-877-439-5479
Faxes should not exceed 200 pages
The original ADR request must be submitted as the cover sheet to the records
Supporting documentation, or requested medical records, should follow the ADR letter
Each ADR request must be faxed separately
Additional Tips
• Novitas identifies overpayment and sends
demand letter
– Copy of demand letter sent with check
– No form involved with demanded debt
• Provider identifies overpayment
– Voluntarily sends unsolicited check
– Use return of monies form
• http://www.novitassolutions.com/webcenter/content/conn/UCM_
Provider Enrollment
• Provider Enrollment Status Inquiry Tool
– JL
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId
• Release of Information
– Individual Physician or Practitioner
– Authorized Delegated Official
• Upcoming Revalidation Mailings
– http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.html
Stay Up-to-Date
• Weekly Podcast
– Weekly podcast of the latest Medicare Updates
and other informative topics
– Subscribe• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag
• Web Updates
– Daily E-mail of the latest Medicare Updates
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pag
Calendar of Events
• Our Training and Events Center offers a wide
variety of education
• Join us for Workshops, Teleconferences, and
• To view the most current calendar of events, visit:
– JL
• http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid
MLN Connects™ Provider eNews
Part of the Medicare Learning Network®
Medicare Learning Network Connects or “MLN Connects™”; is a publication
connecting health care professionals to trusted Centers for Medicare & Medicaid
Services (CMS) program news and information. MLN Connects is a part of the
Medicare Learning Network® (MLN), a registered trademark of the CMS and the
brand name for official information health care professionals can trust.
o The following education and outreach programs have been renamed as
 CMS Medicare Fee-for-Service Provider e-News is now the MLN
Connects Provider eNews
 MLN National Provider Calls (NPCs) are now MLN Connects National
Provider Calls
 MLN Provider Partnership Program is now MLN Connects Provider
Association Partnerships
For more information:
o http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2013-06-27Enews.pdf
Centers for Medicare &
Medicaid Services (CMS)
• The CMS website offers valuable
resources such as:
– CMS Internet Only Manuals (IOMs)
– Medicare Learning Network (MLN) Matters
– Open Door Forum
• For additional resources visit:
– http://www.cms.gov/
Thank You
• Janice Mumma
– Outreach and Education Supervisor
– (717) 526-3645
– [email protected]

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