Medicare Part B Updates Changes and Whats Trending

Medicare Part B Updates, Changes and What’s Trending May 3, 2019

Disclaimer § § § All Current Procedural Terminology (CPT) only are copyright 2018 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.

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Agenda § Agenda: Medicare Updates and Changes • Keeping Your Patients Healthy • Novitas Initiatives • § Objectives: Provide the latest news and updates • Stay updated on Medicare changes • Take advantage of the various self-service options available to the provider community •

Acronym List Acronym Definition ADR Additional Documentation Request AWV Annual Wellness Visit CDC Centers for Disease Control and Prevention CERT Comprehensive Error Rate Testing CMS Centers for Medicare & Medicaid Services CR Change Request HCPCS Healthcare Common Procedure Coding System ICD-10 International Classification of Diseases, Tenth Revision IPPE Initial Preventive Physical Examination IVR Interactive Voice Response Unit LCD Local Coverage Determination

Acronym List Two Acronym Definition MAC Medicare Administrative Contractor MBI Medicare Beneficiary Identifier MDPP Medicare Diabetes Prevention Program MLN Medicare Learning Network NPI National Provider Identifier TPE Targeted Probe and Educate

Medicare Updates/Changes

JH Customer Contact Center Update § Training closure dates: • Thursdays: ü May 2, 9, 16, and 23, 2019: Ø 1: 00 – 3: 00 PM CT § Holiday: • Memorial Day: ü Monday, May 27, 2019 § Contact Us web page § Customer Contact Phone Number: • 1 -855 -252 -8782 § Provider Teletypewriter (TTY): • 1 -855 -498 -2447

New Instructions for Local Coverage Determinations (LCDs) § MM 10901: • Implementation: January 8, 2019 § Key Points: • New LCDs: ü Informal meetings are optional for customers to request information on how to submit valid new LCD request: Ø Will be conducted via teleconference ü New LCD requests have specific requirements to be valid ü Comment period and notice period will not change for new LCDs • Contractor Advisory Committee (CAC): ü Will now be open to interested parties to observe: Ø Locations and times will be posted to our website ü CAC members will also include non-physician healthcare professionals such as Dentist, Certified Registered Nurse Anesthetist (CRNA), Physical Therapist (PT) and Licensed Clinical Social Worker (LCSW)

New LCD Process § LCD reconsideration request: ü Coding updates only, such as adding diagnosis code, will be handled through revision to companion local coverage article: Ø No longer appropriate to include CPT or ICD-10 codes in LCDs instead they will be placed in billing and coding articles linked to LCD (process could take up to 1 year to complete) ü Change in coverage will require a comment and notice period: Ø This change may delay LCD revisions for a reconsideration request

Revised LCDs and Articles § The list of revised LCDs and Articles are on our website under April 11, 2019 § Revised LCDs and Articles will be published to the Medicare Coverage Database and on our Website in February

New Physician Specialty Code for Undersea and Hyperbaric Medicine § MM 10666: Effective: January 1, 2019 • Implementation: January 7, 2019 • § Key Points: A new provider specialty code D 4 is now recognized for Undersea and Hyperbaric Medicine • The CMS-855 I and CMS-855 O paper applications will be updated to reflect the new specialty codes in the future: • ü Providers should select the “undefined physician option” and indicate Undersea and Hyperbaric Medicine in the space provided • Undersea and Hyperbaric Medicine will apply for following edits: ü Ordering/Referring ü Critical Access Hospital (CAH) Method II Attending and Rendering ü Attending, operating, or other physician or non-physician practitioner listed on a CAH claim

Summary of Policies in the Calendar Year 2019 Medicare Physician Fee Schedule Final Rule § MM 11063: Effective: January 1, 2019 • Implementation: January 7, 2019 • § Key Points: • • • Streamlining Evaluation and Management Payment and Reducing Clinician Burden Modernizing Medicare Physician Payment by Recognizing Communication Technology Based Services Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders Providing Practice Flexibility for Radiologist Assistants Discontinue Functional Status Reporting Requirements for Outpatient Therapy Outpatient Physical Therapy and Occupational Therapy Services Furnished by Therapy Assistants

Additional Summary of Policies in the Calendar Year 2019 Medicare Physician Fee Schedule Final Rule § Practice Expense (PE): Market-Based Supply and Equipment Pricing Update § Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the Physician Fee Schedule § Medicare Telehealth Services: • Telehealth origination site facility fee payment amount update

Update to Medicare Deductible, Coinsurance and Premium Rates for 2019 § MM 11025: Effective Date: January 1, 2019 • Implementation Date: January 7, 2019 • § Key Points: • 2019 Part A – Hospital Insurance: ü Deductible: $1, 364. 00 ü Coinsurance: Ø $341. 00 a day for 61 st-90 th day Ø $682. 00 a day for 91 st-150 th day (lifetime reserve days) Ø $170. 50 a day for 21 st-100 th day (Skilled Nursing Facility coinsurance) • 2019 Part B –Medical Insurance: ü Deductible: $185. 00 a year ü Coinsurance: 20 percent § Additional Reference: • 2019 Medicare Parts A & B Premiums and Deductibles Fact Sheet

Therapy Cap Values for Calendar Year (CY) 2019 § MM 11055: Effective: January 1, 2019 • Implementation: January 7, 2019 • § Key Points: • Outpatient therapy limits (KX modifier threshold) for: ü Physical Therapy (PT) and Speech-Language Pathology (SLP) combined is $2, 040 ü Occupational Therapy (OT) is $2, 040 • Medical Review (MR) threshold amount : ü PT and SLP services combined is $3, 000 ü OT services is $3, 000 § Provider Specialty: Therapy (JH)

National Coverage Determination (NCD) 90. 2 – Next Generation Sequencing (NGS) § MM 10878: Effective: March 16, 2018 • Implementation: March 8, 2019 • § Key Points: • Beginning date of service March 16, 2018 Medicare will cover certain diagnostic laboratory tests using NGS under certain conditions: ü Patients with recurrent, relapsed, refractory, metastic cancer, or advanced stages III or IV cancer ü Patient has either not been previously tested using same NGS test for same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by treating physician ü Decision to seek further cancer treatment ü Must be ordered by treating physician ü Must be performed in a Clinical Laboratory Improvement Amendments (CLIA) – certified laboratory ü Must have Food & Drug Administration (FDA) approval or cleared indication for use in that patient’s cancer

Clarification of Diabetes Self. Management Training (DSMT) Telehealth Services § MM 11043: Effective – January 1, 2019 • Implementation- January 2, 2019 • § Key Points: • CMS is clarifying DSMT policy to specify that all 10 hours of the initial DSMT training and the two (2) hours of annual follow-up DSMT training may be furnished via telehealth in cases when injection training is not applicable

Revision of Definition of the Physician Supervision of Diagnostic Procedures § MM 11043: Effective - January 1, 2019 • Implementation - January 2, 2019 • § Key Points: • CMS is revising its policy to specify that beginning with dates of services on or after January 1, 2019, diagnostic procedures that are furnished by a Radiologist Assistant (RRAs), who are certified by The American Registry of Radiologic Technologists, and RPAs, who are certified by the Certification Board for Radiology Practitioner Assistants, require only a direct level of physician supervision, when permitted by state law and state scope of practice regulations

Revised Definition of the Physician Supervision of Diagnostic Procedures § Beginning with dates of services on or after January 1, 2019, the description for Physician Supervision of Diagnostic Procedures indicator "03" on the Medicare Physician Fee Schedule is revised to say the following: • "03 = Procedure must be performed under the personal supervision of a physician. (Diagnostic imaging procedures performed by a Registered Radiologist Assistant (RRA) who is certified and registered by The American Registry of Radiologic Technologists (ARRT) or a Radiology Practitioner Assistant (RPA) who is certified by the Certification Board for Radiology Practitioner Assistants (CBRPA) and is authorized to furnish the procedure under state law, may be performed under direct supervision

Fee Schedule Look-up Tool

Medicare Physician's Fee Schedule (MPFSDB) Indicator Descriptions § MPFSDB Indicator Descriptions

New Modifier for Expanding the Use of Telehealth for Individuals with Stroke § MM 10883: Effective: January 1, 2019 • Implementation: January 7, 2019 • § Key Points: New HCPCS informational Modifier G 0 (G zero) • For telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke: • ü Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals, CAH method II (revenue codes 096 X, 097 X, or 098 X); or ü Telehealth originating site facility fee, billed with HCPCS code Q 3014 § Telehealth Service Modifiers (JH)

Changes to Amount in Controversy (AIC) for Appeals in 2019 § The AIC for appeals filed on or after January 1, 2019: Administrative Law Judge (ALJ) hearing will remain at $160 • Federal District Court will increase from $1, 600 to $1, 630 • § The amount in controversy is calculated in the following manner: Amount Charged minus Medicare payments already made or awarded = Subtotal Balance • Subtotal Balance minus any applicable Deductible/Coinsurance = Amount in Controversy •

2019 Amounts in Controversy Appeal Level Time Limit for Filing Appeal Amount in Controversy Redetermination 120 days $0. 00 Reconsideration 180 days $0. 00 Administrative Law Judge (ALJ) Hearing 60 days $160. 00 for 2018 $160. 00 for 2019 Medicare Appeals Council of the Departmental Appeals Board (DAB) 60 days $0. 00 Judicial Review in Federal District Court 60 days $1600. 00 for 2018 $1, 630. 00 for 2019 § Appeals (JH)

New Medicare Card Mailing Waves Complete Wave States Included Newly Eligible All – Nationwide People with Medicare Cards Mailing April 2018 - ongoing 1 Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia Beginning May 2018 COMPLETE 2 Alaska, American Samoa, California, Guam, Hawaii, Northern Mariana Islands, Oregon Beginning May 2018 COMPLETE 3 Arkansas, Illinois, Indiana, Iowa, Kansas, Minnesota, Nebraska, North Dakota, Oklahoma, South Dakota, Wisconsin Beginning June 2018 COMPLETE 4 Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Vermont Beginning July 2018 COMPLETE 5 Alabama, Florida, Georgia, North Carolina, South Carolina Beginning August 2018 COMPLETE 6 Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Texas, Utah, Washington, Wyoming Beginning September 2018 COMPLETE 7 Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Puerto Rico, Tennessee, Virgin Islands Beginning October 2018 COMPLETE

New Medicare Card § New Medicare card: Health and Human Services (HHS) logo • Gender and signature line removed •

How You Can Help Your Patients • Patients may not receive a new card if their address on file with the Social Security Administration is not correct • Verify your patient’s address: • If the address you have on file is different than the address you view in electronic eligibility transaction responses, ask your patients to contact Social Security and update their Medicare records § Beneficiaries contact: • Social Security Administrative: ü 1 -800 -772 -1213 ü www. ssa. gov/myaccount • Railroad Retirement Board: ü 1 -877 -772 -5772 § CMS Product Ordering: • Still Waiting for Your New Medicare Card?

Patients Can Print New Card § Beneficiaries in previously implemented waves that did not receive their card can: • Sign into My. Medicare. gov to see if their card was mailed: ü If so, they can print an official card ü They need to create an account if they do not have one • Call 1 -800 -MEDICARE (1 -800 -633 -4227) ü They may need to correct something, such as their mailing address • Use their current card to get health care services

Important Dates For The New Medicare Card Date Action April 2018 Begin mailing cards to Newly Eligible People with Medicare May 2018 Begin mailing new Medicare cards to people with Medicare June 2018 Launch provider MBI look-up tool October 2018 Return MBI on Remittance Advice April 16, 2019 Statutory deadline for issuing new Medicare cards January 2020 Transition Period Ends: Must use the MBI on data exchanges (some exceptions)

Keeping Your Patients Healthy

Discuss Preventive Services With Your Patient § Definition: • Preventive services can be defined as patient counseling and screenings to prevent illness, disease, and other health-related problems § Purpose: • Providers play a crucial role in promoting, providing, and educating Medicare patients about potentially life-saving preventive services and screenings: ü Encourage your Medicare patients to take advantage of covered preventive services ü Medicare covers many preventive services at little or no cost to your patients § Resources: • • • CMS Preventive Services Page CMS Preventive Services Video Medicare Claim Processing Manual, Pub. 100 -04, Chapter 18 – Preventive and Screening Services Provider Resources on Preventive Services Your Guide to Medicare’s Preventive Services: ü A guide for beneficiaries

Preventive Services and Screenings Covered by Medicare § § § § Alcohol Misuse Screening & Counseling Annual Wellness Visit Bone Mass Measurements Cardiovascular Disease Screening Tests Colorectal Cancer Screening Counseling to Prevent Tobacco Use Depression Screening Diabetes Screening Diabetes Self-Management Training Glaucoma Screening Hepatitis B Vaccine & Administration Hepatitis C Virus Screening HIV Screening Influenza Virus Vaccine & Administration § § § § Initial Preventive Physical Examination Intensive Behavioral Therapy (IBT) for Cardiovascular Disease Intensive Behavioral Therapy (IBT) for Obesity Lung Cancer Screening Medical Nutrition Therapy Pneumococcal Vaccine & Administration Prostate Cancer Screening for Cervical Cancer Screening for STIs and HIBC to Prevent STIs Screening Mammography Screening Pap Tests Screening Pelvic Examinations Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Interactive Preventive Services Tool § Preventive Services Tool

Protect Your Patients from Influenza this Season § Influenza is a serious health threat, especially to vulnerable populations like people 65 and older, who are at high risk for hospitalization, complications, and even death from flu § CDC recommends everyone six months of age and older receive a flu vaccine each year § Typical flu season: • Late fall through early spring § Medicare coverage: • One flu vaccine and its administration each flu season: ü Additional flu vaccines if medically necessary • Coinsurance and deductible waived § References: • • • Centers for Disease Control and Prevention (CDC): Influenza (Flu) CMS Influenza Virus Vaccine and Administration Quick Reference MLN Matters Article MM 10871 - Quarterly Influenza Virus Vaccine Code Update – January 2019

Novitas Initiatives

New Novitas Learning Center (NLC) § New NLC effective January 2019! Improved look and feel and streamlined navigation • More sophisticated design: • ü Intuitive dashboard provides quick view of learning customized for the learner ü Learn anywhere, anytime on any device ü Improved content library • Take the lead in your own professional development when seeking and accessing Medicare training opportunities

New NLC Changes § Novitas strives to continually improve the services and resources provided to our customers. Our most recent innovation is the redesign of the NLC. Effective January 1, 2019, NLC users will observe a few changes • • • The username previously established to access a NLC account will be replaced by the user’s email address Existing users will log into their account using the email address associated with the user account in the NLC All users will be prompted to reset their passwords after the January 1, 2019, transition ü Users will only need to reset their password one time. • Historical learning information associated with the NLC account will be migrated to the new system for all completed courses. ü If a course is still in progress at the time of the transition, it will not be moved to the new system § Contact the novitascenterlearninghelpdesk@novitas-solutions. com for assistance

Upcoming Live Medicare Events § Join us at an upcoming Novitas Explore Medicare Education Symposium (JH)

Targeted Probe and Educate

Targeted Probe and Educate (TPE) § Definition: • To review a sample of claims with education to help reduce errors in the claims submission process § Purpose: • To provide opportunity to educate before, during and after the probe: ü Pre-education will begin before ADRs are sent. Providers will be notified of the review ü Intra-education will continue during the probe if easily resolvable issues are found and can be corrected eliminating the need for appeal ü Post-education will be provided once the probe has been completed: Ø A results letter will be mailed to the provider with a detail report Ø An educational teleconference will be provided to any providers receiving a moderate or major error classification § Change Request (CR) 10249 – Targeted Probe and Educate

TPE Rounds of Review Process TPE Process Round 1 Initial Probe Round 2 Round 3 CMS Corrective Actions After Round 3 Provider Notification X X X N/A Pre-Probe Education X X X N/A ADR request X X X N/A Medical Review (education if necessary) X X X N/A Results letter X X X N/A Post-Probe Education X X X N/A Referral (if applicable) N/A X X Extrapolation, referral to UPIC or RA or 100% prepay review

TPE Process § Includes three rounds of a prepayment probe review with education § Once a provider reaches a minor error classification, they will be removed from review of that service and Novitas will continue to monitor their claims data on a proactive, routine basis § If the error rate remains at a moderate or major error classification, the provider will be moved to another round of review § Providers will have 45 days after the education before the next round of records will be requested § During a 1 -on-1 education session Medical Review staff will walk through any errors in the provider/supplier’s 20 -40 reviewed claims: • Providers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed

TPE Process - Continued § If there are continued high denials after three rounds: The provider/supplier will be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, etc. • Note, discontinuation of review may occur at any time if appropriate improvement is achieved during the review process. • § Minor, Moderate or Major Classification rates: Rates varies based on the service/item/topic under review • Determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round: • ü Education will be provided during and after each round in order to help the provider/supplier throughout the process § Reference: • Targeted Probe and Educate Questions and Answers

TPE Topics For Review § All topics for review are published on the Novitas Solutions’ website with a link to education that will assist in ensuring a successful review § These lists will be continually updated as new topics are added § Not all providers will be subject to review: • Targeted Probe and Educate Topics and Schedule of Review

TPE Schedule of Review Topic Type Round 1 Start Date Drug Injections J 2778, J 2505, J 0897, J 0178, J 1745, Pre and Post Payment TPE May/June 2018 TBD Drug and Biologicals J 7192, J 7189 Drug and Biologicals Herceptin Round 2 Start Date Round 3 Start Date TBD February 2019 Prepayment TPE February 2019 TBD Current Procedural Terminology (CPT) only copyright 2018 American Medical Association. All rights reserved.

What is Novitasphere? § Definition: • Free, secured web-based Portal which allows enrolled users access to time-saving features § Purpose: Allows enrolled users access to Eligibility, MBI Lookup, Claim Information, Remittance Advice, Appeal Requests, Medical Review Records and more • Available to JH and JL Part A/B providers, billing services and clearinghouses • Live Chat • § For demonstrations and more information on Novitasphere visit: • (JH)

Part B Navigation Bar

Keep Your Novitasphere Access Active § All users must log in at least once every 30 days, or their Novitasphere access will be removed § If your office is already enrolled, please share this reminder with users in your organization

Trending Inquiries Received in the Customer Contact Center § Trouble using IVR to obtain beneficiary eligibility or claim status using an MBI? When speaking an MBI in the IVR be sure to speak naturally, including normal pauses every few characters • Convert a MBI to a number that can be keyed into the IVR using the IVR Alphanumeric Conversion Tool (JH): • ü Example: Ø MBI number EG-4 TE-5 MK-72 converted 1*32*414*81*325*61*5272 § Consider using the Novitasphere for most self service inquiries

Summary § Provided the latest news and updates § Stay up to date with the latest Medicare changes by visiting the Novitas Solutions website § Take advantage of the various self-service options available to the provider community

Customer Contact Information § Providers are required to use the IVR unit to obtain: Claim Status • Patient Eligibility • Check/Earning • Remittance inquiries • § Jurisdiction H: Customer Contact Center- 1 -855 -252 -8782 • Provider Teletypewriter- 1 -855 -498 -2447 • § Patient / Medicare Beneficiary: 1 -800 -MEDICARE (1 -800 -633 -4227) • http: //www. medicare. gov •

Thank You § Liz Henry Education Specialist, Provider Outreach and Education Liz. henry@novitas-solutions. com 717 -526 -6359 § Janice Mumma Supervisor, Provider Outreach and Education janice. mumma@novitas-solutions. com 717 -526 -6406 § Stephanie Portzline Manager, Provider Engagement Stephanie. Portzline@novitas-solutions. com 717 -526 -6317