Knowledge Base Article
MAC Talk
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MAC Talk
Tuesday, March 17, 2020
Getting to Know the MACs
Welcome to the third edition of MMP’s MAC Talk article. Before jumping in to “The Local Scene” I wanted to provide general information about MACs in the form of questions and answers.
Question: What is a MAC?
Answer: A CMS contractor that processes Medicare Part A and Part B (A/B) benefit claims or Durable Medical Equipment (DME) claims for a designated jurisdiction. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare Fee-for-Service (FFS) program and the health care providers and suppliers enrolled in the FFS program.
Question: What types of claims does an A/B MAC process?
Answer: A/B MACs process claims for both institutional and non-institutional providers for a designated geographic jurisdiction. Currently, there are 12 A/B MACs that process about 95% of all FFS claims. Four of the twelve MACs also specialize in handling claims for home health and hospice providers. Seven different companies hold the prime contracts (CGS, FCSO, NGS, Noridian, Novitas, Palmetto and WPS).
Question: What are the primary functions of the MACs?
Answer: MACs perform the following functions:
- Process Medicare FFS claims,
- Enroll providers in the Medicare FFS program,
- Respond to provider inquiries,
- Handle Redetermination requests (1st stage of the appeals process),
- Review medical records for selected claims,
- Perform provider reimbursement services,
- Review and audit institutional provider cost reports,
- Educate providers about Medicare FFS billing requirements,
- Establish Local Coverage Determinations (LCDs) and Articles,
- Support CMS demonstration projects (e.g., prior authorization, new payment models), and
- Coordinate with CMS and other FFS contractors.
March MAC Talk: The Local Scene
February 18, 2020 Palmetto GBA Article for No Orders for Inpatient Admission (5J503)
In this article, Palmetto GBA offers tips to preventing a denial for lack of an inpatient order. The first tip in the article is as follows:
- “Physician’s order to admit to inpatient services should be clearly identified in the medical records. This order may be located within the history and physical, progress note, emergency room report and/or verbal order signed and dated by the physician.”
February 26th, 2020: Palmetto GBA Posts FAQs from February 13th Part A Ask the Contractor Teleconference
The transcript includes a welcome and brief discussion about Medicare Comprehensive Error Rate Testing (CERT) Program. Specific questions ranged from interrupted stays to waiving a Medicare patient’s coinsurance, deductible and copays to asking if Medicare Advantage Plans adhere to local and national coverage determinations.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BM5SZ43042?opendocument
February 26, 2020: National Government Services (NGS) Posts Guidance for Amending Medical Records
NGS reminds providers that “occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected or entered after rendering the service.” The post goes on to provide guidance on how to comply with amending a medical record as outlined in the Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.
March 2nd, 2020: NGS Posts News Alert about QIO Improvement Initiatives
In this Alert, NGS encourages providers to reach out to your Quality Improvement Networks – Quality Improvement Organization (QIN-QIO) to see if what resources may be available “to assist you with your local healthcare priorities and needs.”
March 4th, 2020: Palmetto GBA Posts JJ and JM Part B Ask the Contractor Teleconference Q&As
Even though in general MMP focuses on Part A Services, there were a couple of interesting Q&A’s in this release, for example:
- Question: If we have questions regarding a national coverage determination, is there anyone to contact for additional information and/or a better understanding of the criteria that is required?
- Answer: As a Medicare contractor, Palmetto GBA interprets national coverage determinations (NCD) as outlined by CMS. Your first call should be to the Palmetto GBA provider contact center for general information. If you disagree with the NCD and would like to request CMS to consider making changes, you should send your request to NCDrequest@CMS.hhs.gov.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B"BMDJKB7554?opendocument
March 9th, 2020: WPS Posts Notice about Expiring ABN Form CMS-R-131
“The Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 expiration date is March 2020. CMS has not notified us of a new form. In addition, CMS has not instructed us to assess errors for the current form during medical review. The form is still acceptable until CMS notifies us otherwise, even after March 2020. We will publish more information when it becomes available.”
https://www.wpsgha.com/wps/portal/mac/site/claims/news-and-updates/form-cms-r-131/
March 9th, 2020: WPS Post Notice about Procedure Code 94762 – Are You Billing Correctly?
Procedure code 94762 represents a continuous overnight pulse oximetry service. WPS GHA recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. We encourage all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) – Evaluate Use.
March 10th, 2020: Noridian Posts Notice Regarding Improper Payment for IMRT
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance. Use the following resources to bill correctly:
- IMRT Planning Services Editing MLN Matters Article
- July 2016 Update of the Hospital Outpatient Prospective Payment System MLN Matters Article
- Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services OIG Report
- Medicare Claims Processing Manual, Chapter 4 , Section 200.3.1
Source: CMS MLN Connects dated September 19, 2019
MMP Note: Palmetto GBA JM recently added a Review of Outpatient Claims for CPT Codes 77301 and 77338 IMRT Planning and MLC Devices to their TPE Medical Review list. You can view the entire Medical Review list at: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers"JM%20Part%20A"Medical%20Review"General"9NNJBX6701?open.
March 10th, 2020: NGS Posts their March 2020 Provider Education: Social Determinants of Health
This three page document defines Social Determinants of Health (SDOH), discusses effort within the government to increase the understanding and impact of SDOH on healthcare and healthcare outcomes, and provides resources for Provider to help identify and address gaps in SDOHs for Medicare beneficiaries.
March 16th, 2020: WPS Posts CERT Denials for Laboratory Services
Claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted error findings for insufficient documentation for laboratory services. Documentation to support medical necessity, a valid physician order (or note of intent), and laboratory report(s) were often missing.
The following will help providers responding to CERT claim reviews. Documentation should include:
- The ordering physician or non-physician (physician assistant, nurse practitioner, or clinical nurse specialist) progress note that documents the medical necessity for the laboratory services.
- A signed and dated physician or non-physician order (a registered nurse (RN) cannot sign an order) or progress notes documenting intent.
- All laboratory reports to support the procedure code(s) billed.
For more information, refer to the Medicare Learning Network (MLN) Fact Sheet, "Complying with Documentation Requirements for Laboratory Services."
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.
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