Knowledge Base Article

The last Wednesday@One of each month includes an article highlighting Medicare Transmittals and Other Updates released by CMS during that month. This month brings the addition of a new standing article highlighting offerings from the Medicare Administrative Contractors or MACs. More specifically, highlights from MAC daily e-newsletters and alerts that provide useful information even when it is not the MAC for your hospitals.  

Background

MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including:

• Process Medicare FFS claims
• Make and account for Medicare FFS payments
• Enroll providers in the Medicare FFS program
• Handle provider reimbursement services and audit institutional provider cost reports
• Handle redetermination requests (1st stage appeals process)
• Respond to provider inquiries
• Educate providers about Medicare FFS billing requirements
• Establish local coverage determinations (LCD’s)
• Review medical records for selected claims
• Coordinate with CMS and other FFS contractors

Currently there are 12 A/B MACs who serve more than 1.5 million health care providers enrolled in the Medicare Fee-for-Service (FFS) program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually. You can learn more about the MACs on the CMS MAC webpage at https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.

It is in the spirit of provider inquiries, education, and medical reviews that prompted the addition of this monthly article to our newsletter.

January 6, 2020 WPS GHA Medicare eNews: Major Joint Replacement (Hip and Knee) CERT Reviews

The Comprehensive Error Rate Testing (CERT) contractor has noted error findings for joint replacement services. In most cases, the CERT contractor found the documentation for these services to be insufficient to support the service(s) according to Medicare guidelines.

 Documentation Reminders

• Physical examination should document the specific patient condition(s), past and present, and plan of care
• Investigation through radiology reports
• Documentation of tried and failed conservative (non-surgical) treatments
• Signed and dated operative report 

For more information, see the MLN Matters article SE1236.

Link to website: https://www.wpsgha.com/wps/portal/mac/site/claim-review/news-and-updates/major-joint-replacement-hip-knee-cert-reviews/!ut/p/z0/fYzNDoIwEISfaLOAkXBVoyGGBk8GejEbWKX8bJtS8fWtL-BtJt98gxob1EKbeVEwVmiOvdX541aWeZkWSVVnKkkO6nLfnYvqWKd7vKL-P4gPmVcn9ULtKAxg5GmxEf6sQNLD2_UUeMVmodF6GK2RAJ7dTB0vHPNgHEzCDB37H9lMVNFNuv0CArAQCg!!/

January 8, 2020 First Coast Service Options, Inc. eNews

Appeals News: Q&A’s to questions regularly received by the First Coast contact center regarding general information about appeals, overpayment appeals, and re-openings. https://medicare.fcso.com/Appeals/0410177.asp

January 8, 2020: Palmetto GBA Provider Contact Center (PCC) FAQs:

Oct – December 2019 FAQs published were based upon data analytics identifying topics generating a high volume of telephone enquiries. Following is an example of one FAQ that MMP gets asked on occasion also:

• Question: When did CMS begin to require one calendar years as timely filing?
• Answer: All claims for services furnished on or after Jan 1, 2010, must be filed to the Medicare contractor no later than one calendar year (12 months) from the date of service or Medicare will deny those claims. You may refer to MM6960, (PDF, 74 KB) MM7080   (PDF, 78 KB) and New Maximum Period for the Submission of Medicare Claims podcast  .

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BKLSNF7223?opendocument

January 9, 2020 NGS Urgent News: [Update} NCD ICD-10 Diagnosis Code Changes for 2020

Date Reported: 12/19/2019

Date Modified: 1/8/2020

Status: Open
Provider Type(s) Impacted: Part A, including home health and hospice (HHH) and federally qualified health centers (FQHCs)
Reason Code(s): Part A RCs, see below
Claim Coding Impact: Multiple ICD-10 codes to be added to the listed national coverage determinations (NCDs).
Description of Issue
On 11/1/2019, the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 11491 and accompanying MLN11491 with an effective date of 4/1/2020. CMS has now issued additional instructions impacting the following NCDs, for which new ICD-10 diagnosis codes will not be systematically implemented until 4/6/2020. Local editing will be temporarily implemented for the following, allowing claims to process:

• NCD 20.9 Artificial Hearts and Related Devices – RC 59242-59243
• NCD 20.34 Percutaneous Left-Atrial Appendage Closure – RC 59267
• NCD 190.11 Home PT/INR – RC 59079-59080
• NCD 260.9 Heart Transplants – RC 59180-59181

Editing will remain in place for the following, and denied claims subject to the standard appeal process:

• NCD 110.4 Extracorporeal Photophoresis RC59019-59020, 59023-59024
• NCD 210.3 Colorectal Cancer Screening RC 59099-59100

National Government Services Action
For NCDs 20.9, 20.34, 190.11 and 260.9, National Government Services (NGS) will now modify internal editing to allow processing for claims with the new ICD-10 diagnosis codes. For NCDs 110.4 and 210.3, denials relative to new ICD-10 codes may be submitted as appeals. In addition, NGS will adjust claims already denied since 10/1/2019 relative to this issue when brought to our attention.

Provider Action
Rejected claims (59267) will be reprocessed. Any claim with a LINE LEVEL denial can be resubmitted instead of filing an appeal (please refer to Submit an Adjustment to Correct Claims Partially Denied by Automated LCD/NCD Denials). Fully denied claims may be submitted as appeals. When submitting associated appeals, providers may identify CR 11491 as a reference.

Proposed Resolution/Fix
Will be systematically implemented on 4/6/2020.

January 9, 2020: Palmetto GBA Daily Newsletter: Medicare Beneficiary Identifier (MBI) Q&A

The following Q&A appeared in Palmetto’s Thursday January 9, 2020 Daily e-Newsletter:

• Question: Can I obtain an MBI for a deceased beneficiary using the eServices MBI Lookup tool?
• Answer: Yes. Users may obtain an MBI as long as the Medicare beneficiary information entered is valid and the beneficiary's date of death is less than 13 months prior to the date the MBI Lookup inquiry is performed.

If the Medicare beneficiary information submitted in the MBI Lookup is valid, but the beneficiary's recorded date of death is more than 13 months prior to the date the MBI Lookup inquiry is performed, the user will receive a message advising that the date of death exceeds the timely claim filing requirement. The MBI will not be returned.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BJ9RJ40743?opendocument

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J5A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Inpatient Psychiatric Hospital Services (IPS):
• Reviews identify the psychiatric evaluations are incomplete. The CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 2, Section 30.2 lists the components of the psychiatric evaluation. These include the following:
• a medical history,
• record of mental status,
• onset of illness and circumstances leading to admission,
• description of attitudes and behaviors, intellectual functioning, memory functioning and orientation, and
• an inventory of the patient's assets.
• Reviews continue to identify errors related to certification requirements. For more information related to certification requirements review our Inpatient Psychiatric Facility (IPF) Certification/Recertification Review Results resource.
• Wound Care: Reviews identify the documentation is incomplete and not meeting the requirements of WPS Local Coverage Determination (LCD) L37228. The documentation should support evidence of improvement, which includes measurable changes. Measurable changes include the amount of drainage, inflammation, swelling, pain, wound dimensions, and necrotic tissue. If there is no wound improvement the documentation should support a modification to the treatment plan.
• Inpatient Rehabilitation Facilities (IRF): The results of the Round 2 reviews support improvement of the documentation on the pre-admission screening and post admission evaluation. Five providers completed Round 2 and are no longer undergoing review.

January 13, 2020: WPS GHA Medicare Review (MR) Targeted Probe & Educate (TPE) Quarterly Update – J8A

Throughout quarter four of 2019, the MR clinical staff identified the following common errors:

• Malnutrition: Twelve providers completed Round 1 of TPE and were successful in their reviews. The diagnosis of severe malnutrition was evident in the documentation.  
• Outpatient Hyperbaric Oxygen Therapy (HBO-T): Reviews identify incomplete documentation to support the HBO-T condition. When providers treat a patient for multiple diagnoses, it is important to state clearly which diagnosis necessitated the need for HBO-T, and to include the prior history and treatment for support. The CMS National Coverage Determination (NCD) 20.29 outlines the covered conditions.

January 13, 2020: Palmetto GBA Daily Newsletter: Medical Necessity of Therapeutic Exercise

In this edition of their Daily Newsletter, Palmetto GBA posted a module focused on the medical necessity of therapeutic exercises. The following topics are covered in this module:

• Therapeutic Exercise Overview,
• Therapy Billing,
• Requirements for Medical Necessity,
• Documentation Requirements, and
• Reminders.
• At the top of the list of reminders list is the reminder that beginning January 1, 2020 a new modifier is required on claims for physical and occupational therapy services provided in whole or in part by a therapy assistant.

Palmetto advises you to share this with appropriate staff.

https://www.palmettogba.com/internet/eLearn3.nsf/MedicalNecessityPartB/story_html5.html

January 14, 2020: Palmetto GBA Daily Newsletter: Intensity-Modulated Radiation Therapy Module

Just a day after the Therapeutic Exercise Module, Palmetto posted an Intensity-Modulated Radiation Therapy (IMRT) Module which includes information about covered conditions, billing and coding guidelines, multileaf collimator and medical necessity.

https://palmettogba.com/internet/eLearn3.nsf/IntensityModulatedRadiationTherapy/story_html5.html