Novitas Solutions Medicare Update NJSOM 2013 Annual Conference

Novitas Solutions Medicare Update NJSOM 2013 Annual Conference October 10, 2013

Disclaimer • All Current Procedural Terminology (CPT) codes and descriptors used in this presentation are copyright© by the American Medical Association. All rights reserved. • 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.

Agenda • • Medicare Updates Medicare Review Programs ICD-10 Update Local Coverage Determinations Related to Oncology • Local Coverage Articles Related to Oncology • Contractor Initiatives

Medicare Updates

MLN Connects™ Provider e. News 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 follows: § CMS Medicare Fee-for-Service Provider e-News is now the MLN Connects Provider e. News § 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-and. Education/Outreach/FFSProv. Part. Prog/Downloads/2013 -06 -27 Enews. pdf

Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years • Change Request 8165 • Effective: 10/1/2013, Implementation: 10/7/2013 • Key Points o Recovery Auditor identified claims for new patient visits paid more than once in three year period by same physician or physician group o Contractor will be prompted to validate new patient claims when more than one service is identified in a three year period o The "Medicare Claims Processing Manual, " Chapter 12, Section 30. 6. 7 provides that Medicare interprets the phrase “new patient” to mean a patient who has not received any professional services, i. e. , evaluation and management service or other face-to-face service (e. g. , surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. • For more information o http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/MM 8165. pdf

Detailed Written Orders and Face-to-Face Encounters • Change Request 8304 • Effective/Implementation : July 1, 2013 • Key Points o Documentation must show the physician, Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) had a face-to-face encounter examination with a beneficiary in the six months prior to the written order for certain items of Durable Medical Equipment (DME) o DME ordered by a PA, NP, or CNS or a physician must document the occurrence of a face-to-face encounter by signing/co-signing and dating the pertinent portion of the medical record • For more information o http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNMatters. Articles/Downloads/MM 8304. pdf

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: – MLN Matters® Number: MM 8039 • http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/downloads/MM 8039. pdf

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R -131 • Change Request 8404 • Effective/ Implementation: December 9, 2013 • Key Points: – This article provides: • Instructions for Home Health Agency (HHA) use of the Advance Beneficiary Notice of Noncoverage (ABN) to replace the outgoing Home Health Advance Beneficiary Notice (HHABN), Form CMS-R-296, Option Box 1; • ABN issuance guidelines for therapy services and therapy specific examples; and • Minor editorial changes to clarify existing manual instructions regarding ABN issuance • For more information: – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/MM 8404. pdf

Revised CMS 1500 Paper Claim Form: Version 2/12 • OMB approved revised CMS 1500 claim form, version 02/12, OMB control number, 0938 -1197 • Changed the form to adequately accommodate and implement ICD-10 -CM diagnosis codes • Revisions add the following functionality: – Indicators for differentiating between ICD-9 -CM and ICD-10 -CM diagnosis codes. – Expansion of the number of possible diagnosis codes to 12. – Qualifiers to identify the ordering, referring and supervising provider roles (on item 17) • Tentative timeline for implementation (subject to change) – January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12) – January 6 - March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05) – April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12) • For more information: – http: //www. cms. gov/Outreach-and-Education/Outreach/FFSProv. Part. Prog/Downloads/201306 -27 Enews. pdf

HIPAA Eligibility Transaction System (HETS) • Allows providers or clearinghouses to submit eligibility request files over a secure connection • Real-time transactions only • For more information, refer to Special Edition Article SE 1249 at: – http: //www. cms. gov/Research-Statistics-Data-and. Systems/CMS-Information. Technology/HETSHelp/Downloads/MLN-Matters. Article-SE 1249. pdf

Place of Service Coding for Physician Services in an Outpatient Setting • SE 1313 • Key Points: – Recovery Auditors identified physicians incorrectly reporting the place of service as office (11) when the services were provided in an outpatient hospital (22) setting – Improper payment exists when billed with an incorrect place of service based on the setting where the services were rendered • For more information: – MLN Matters® Number: SE 1313 – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1313. pdf

Additional/Subsequent Procedures Performed During 90 Day Global Period • SE 1323 • Key Points: – Recovery Auditors identified providers incorrectly billing E/M services provided by the surgeon the day before major surgery, the day of minor surgery, 0 -10 days after minor surgery, and up to 90 days after major surgery – Global Surgical Package was established by CMS to ensure all components of surgery are bundled into one payment – Ensure billing staff are not billing E/M services that are already included in payment for global surgery • For more information: – MLN Matters® Number: SE 1323 – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1323. pdf

Add-on HCPCS/CPT Codes Without Primary Codes • SE 1320 • Key Points: – Recovery Auditors identified providers billing only add-on codes without respective primary codes – Add-on codes is a code that describes a service, that is performed in conjunction with another primary service • For more information: – MLN Matters® Number: SE 1323 – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1320. pdf

Hospice Related Services – Part B • SE 1321 • Key Points: – Providers need to identify if a beneficiary is enrolled in hospice – Beneficiary should contact the Hospice provider to arrange for care they need – Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment – Contractors will deny services submitted without GV or GW modifiers • GV - Attending physician not employed or paid under arrangement by the patients hospice provider • GW – Service not related to terminal condition – Add-on codes is a code that describes a service, that is performed in conjunction with another primary service • For more information: – MLN Matters® Number: SE 1323 – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNMatters. Articles/Downloads/SE 1320. pdf

Special Edition Articles • Guidance to Reduce Mohs Surgery Reimbursement Issues: – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1318. pdf • Co-Surgery Not Billed with Modifier 62: – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1322. pdf • Revision to Common Working File Edit for Technical Component of Pathology Services Occurring on the Same Day as an Outpatient Hospital Visit: – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/SE 1322. pdf • Mandatory Reporting of an 8 -Digit Clinical Trail Number on Claims – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/Downloads/MM 8401. pdf

Medicare Review Programs Overview

Background • The Centers for Medicare & Medicaid Services (CMS) is required to protect the Medicare Trust Fund • CMS contracts with various contractors to perform prepayment and post payment reviews of claims through various claims review programs – Medical Review through the Medicare Administrative Contractors (MACs) – National Correct Coding Initiative (NCCI) Edits – Medically Unlikely Edits (MUE) – Comprehensive Error Rate Testing (Cert) Program – Recovery Audit (RA) Program – Program Safeguard Contractors (PSC) and Zone Program Integrity Contractors (ZPICs) – Office of Inspector General (OIG)

Medical Review (MR) • Novitas Solutions’ MR Department is one component of the overall Medicare Integrity Program (MIP) • MR works in collaboration with other MIP Contractors to minimize potential future losses to the Medicare Trust Fund • MR activities support the primary goal of the MIP – Pay claims correctly – Reduce the claims payment error rate • MR aggressively pursues every opportunity, through Progressive Corrective Action (PCA), to process claims in the right amount for covered, medically necessary, and correctly coded services rendered to eligible beneficiaries by legitimate providers

Medical Review Activity • Typically, MR conducts the following review types – Probe (pre or post payment) • Service-wide – Typically 50 -100 claims • Provider-specific – Typically 20 -40 claims – Audit/Edit (pre or post payment) • Service-wide • Provider-specific • • Data analysis performed – Verified and context provided Claim review performed – Prepayment or post payment PCA determined Referral to appropriate entity when fraud detected

Comprehensive Error Rate Testing (CERT) • 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 B Common Errors • Insufficient documentation: – – Procedure/service billed Missing or illegible documentation and/or physician signature No valid physician’s order No physical therapy certified plan of care/treatment plan • Incorrect coding errors: – – Evaluation and Management (E/M) codes Critical care, discharge day management, physical therapy Units of medication/infusion services Laboratory services

JL Part A Common Errors • Insufficient documentation: – – – • No valid physician’s order Inpatient stay Missing or illegible documentation and/or physician signature Procedure/service performed No valid certification for therapy services Skilled Nursing Facility (SNF) 3 day qualifying stay Medical necessity errors: – Need for an inpatient stay – Related services • Other errors: – – – Diagnosis Related Group (DRG) Discharge disposition code Resource Utilization Group (RUG) Laboratory services and Debridement code

Comprehensive Error Rate Testing (CERT) Center

Recovery Audit (RA) Program • RA review claims on a post-payment basis • There is a three (3) year time limit for the RA to review services. – This time frame is based on the date of service • Issues reviewed by the RA are approved by the Centers for Medicare & Medicaid Services (CMS) prior to widespread review • Approved issues are posted to the RA website before the widespread review • RA utilizes the same medical policies and CMS manuals as contractors

PSC and ZPIC • Program Safeguard Contractor (PSC) and Zone Program Integrity Contractors (ZPIC) Major Responsibilities are: – Indentify and deter Medicare fraud and abuse – Develop fraud cases to refer to OIG – Support law enforcement – Identify and report program vulnerabilities to CMS – Recommendations for provider education, overpayment recovery, corrective actions, and licensure considerations

OIG • Office Inspector General (OIG) Work Plan outlines their current focus areas and states the primary objectives of each project • Specific Items Include: – Inpatient Billing for Medicare Beneficiary – Same Day Readmission – Compliance with Medicare Transfer Policy – Place of Service • https: //oig. hhs. gov/reports-andpublications/workplan/index. asp

Medicare Quarterly Provider Compliance Newsletter • The “Medicare Quarterly Provider Compliance Newsletter [Volume 3, Issue 4]” Educational Tool (ICN 908625) was revised. Designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. Includes information on corrective actions that health care professionals can use to address and avoid the top issues of the particular Quarter. – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/Med. Qtrly. Comp-Newsletter-ICN 908787. pdf • Index of Recovery Audit and Comprehensive Error Rate Testing (CERT) findings from current and previous newsletters is available. Customized by provider type to identify those findings that impact specific providers. o http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/Med. Qtrly. Comp. NL_Archive. pdf

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 setting • 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 reporting • Ambulatory and physician services provided on or after October 1, 2013 will use ICD-10 -CM diagnosis codes – Date of discharge for hospital claims for inpatient settings • Inpatient discharges occurring on or after October 1, 2013 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 date • Inpatient claims – Use ONLY THROUGH date/DISCHARGE date – use ICD-10 codes • http: //www. cms. gov/Outreach-and. Education/Medicare-Learning-Network. MLN/MLNMatters. Articles/Downloads/SE 1325. pdf

CPT and HCPCS • No impact on Current Procedure Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes • CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients

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 CR 8109 and 8197. • For more information: – MLN Matters® Number: MM 8109 and MM 8197 – http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network -MLN/MLNMatters. Articles/index. html

ICD-10 Resources • Keep Up to Date o http: //www. cms. gov/Medicare/Coding/ICD 10/index. ht ml o Sign up for the Centers for Medicare & Medicaid Services (CMS) ICD-10 Industry Email Updates- http: //www. cms. gov/Medicare/Coding/ICD 10/CMS_IC D-10_Industry_Email_Updates. html o Follow @CMSGov on Twitter o Subscribe to Latest News Page Watch - https: //public. govdelivery. com/accounts/USCMS/subs criber/new? topic_id=USCMS_609

ICD-10 MLN Resources • MLN Matters Articles: – Special Edition Article SE 1239 – Updated ICD-10 Implementation Information – Special Edition Article SE 1240 – Partial Code Freeze Prior to ICD-10 Implementation – Special Edition Article SE 1325 – Institutional Services Split Claims Billing Instructions for Medicare FFS Claims that Span the ICD-10 Implementation Date – MLN Article MM 7492 – Medicare FFS Claims Processing Guidance for Implementing ICD-10 • MLN Products – – ICD-10 -CM/PCS Myths and Facts ICD-10 -CM/PCS The Next Generation of Coding ICD-10 -CM Classification Enhancements General Equivalence Mappings Frequently Asked Questions

Local Coverage Determinations (LCD’s) Related to Oncology

Local Coverage Determinations (LCD’s) Effective August 1, 2013 • Biomarkers for Oncology (L 33142) • Multitude of testing options which can more precisely pinpoint management needs of individual patients • Implantable Infusion Pump (L 33115) • Provides continuous controlled infusion of a drug to a select body site and can be refilled by percutaneous injection

Local Coverage Determination (LCD) DL 33640 • LCD DL 33640 - Biomarkers Overview • Comments received are being reviewed by our Contractor Medical Directors.

Local Coverage Determination (LCD) L 27515 • Radiation Therapy Services (L 27515) • • The role of the Radiation Oncologist Intensity Modulated Radiation Therapy (IMRT) IMRT Treatment Planning IMRT Treatment Delivery

Local Coverage Determination (LCD) L 27515 • INDICATIONS OF COVERAGE – – – – Tumor Mapping and Clinical Treatment Planning Therapeutic Radiology Simulation – Aided Field Setting 3 -D Field Setting Basic Radiation Dosimetry Calculation Teletherapy Isodose Plan Special Teletherapy Port Plan Special Dosimetry Treatment Devices, Design, and Construction Medical Radiation Physics Consultation Radiation Treatment Delivery Portal Verification Film Radiation Treatment Management Radiation Therapy Management Neutron Beam Treatment Delivery

Indications of Coverage Continued • Special Treatment Procedures • Intensity Modulated Radiation Therapy (IMRT) • Image Guided Radiation Therapy (IGRT)

Limitations of Coverage – No Separate Payment • • • • Anesthesia Care of infected skin Checking of treatment charts, verification of dosage, as needed Continued patient evaluation, examination, written progress notes, as needed Final physical examination Medical prescription writing Nutritional counseling Pain management Review and revision of treatment plan Routine medical management of unrelated problem Special care of ostomy Written reports, progress note Follow-up examination and care for 90 days after last treatment

Coding Information • • Bill Type Codes Revenue Codes Current Procedural Terminology (CPT) Codes International Classification of Disease-9 th Edition (ICD-9) Codes that do and do not support medical necessity • Documentation Requirements

Local Coverage Articles Related to Oncology

Coding Article A 49325 • The following Jurisdiction L MAC Article has been revised: • NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions (A 49325)

Local Coverage Article A 52316 • The following Jurisdiction L MAC Article has been added: – Biomarkers for Oncology (A 52316)

Contractor Initiatives

Website Improvements • Novitas Solutions Web site improvements implemented September 29, 2013 • New features include: – Separate Website for Jurisdiction H and Jurisdiction L – Improved Search Functionality – Navigation Enhancements • Webinars are scheduled in October – register now at: –https: //www. novitas-solutions. com

Novitas Home Page

JL Navigation

JL Part B Home Page

JL Outreach and Education

Novitasphere • • Coming Soon Part B Provider Portal Connect via internet to Novitas Available options include: – Claim submission; – Claim status; and – Eligibility

Jurisdiction L Customer Contact Information • Provider – 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 – 24 Hours a day 7 Days a week • Full IVR Options – – Mon- Fri 6: 00 am – 9: 00 pm ET Saturday 6: 00 am - 4: 00 pm ET • Step-by-Step Guide • http: //www. novitassolutions. com/webcenter/spaces/Medicare. JL/pagebyid? content. Id=00004402

Stay Up-to-Date • Weekly Podcast – Weekly podcast of the latest Medicare Updates and other informative topics – Subscribe under the Outreach and Education Center • Web Updates – Daily E-mail of the latest Medicare Updates • http: //www. novitassolutions. com/webcenter/spaces/Medicare. JL/page/pag ebyid? content. Id=00007968

Thank You Janice Mumma 717 -526 -3645 Janice. mumma@novitas-solutions. com