Western Michigan HFMA Meeting September 16 2015 Presented

Western Michigan HFMA Meeting September 16, 2015 Presented by Janet Mateo Provider Outreach & Education 9/29/2020 1

Agenda • • • Probe and Educate Updates IPPS Updates Avoiding Payment Errors OPPS Updates What’s New with WPS Medicare 9/29/2020 2

Probe Results PROBE AND EDUCATE UPDATES 9/29/2020 3

April 30, 2015 Updates • Probe and educate will continue with Probe 3 until September 30, 2015 • Continue to prohibit Recovery Auditors to review • CMS believes process has improved understandig 9/29/2020 4

Probe 3 • Probe 3 will mirror Probes 1 and 2 by sampling of 10 claims – (25 for large providers) • Will include claims with dates of service through July 31, 2015. 9/29/2020 5

August 12, 2013 Update • On July 1, 2015, CMS released proposed updates to the 2 -Midnight Rule regarding when inpatient admissions are appropriate for payment under Medicare Part A – Updates included in the calendar year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) proposed rule 9/29/2020 6

2 -Midnight Benchmark • The 2 -Midnight Policy remains unchanged for hospital stays expected to be two midnights or longer 9/29/2020 7

Quality Improvement Organization (QIO) Role • Beginning on October 1, 2015, QIOs will assume responsibility for conducting initial patient status reviews – To determine the appropriateness of Part A payment for short stay inpatient hospital claims • Reviews are currently conducted by the MACs 9/29/2020 8

Medicare Administrative Contractor (MAC) Role • MACs currently conducting the third round of Inpatient Probe and Educate reviews – Anticipated completed date of September 30, 2015 • Some provider education may continue beyond this date 9/29/2020 9

MAC Role • After October 1, 2015, MACs may continue to conduct CMS-approved claim reviews unrelated to patient status – (e. g. , coding reviews, reviews to determine the medical necessity of the procedure conducted, etc. ). 9/29/2020 10

Recovery Auditor (RA) Role • The moratorium on Recovery Auditor patient status reviews expires on • October 1, 2015 9/29/2020 11

Recovery Auditor (RA) Role • May conduct patient status reviews only for providers that have been referred by the QIO – Beginning January, 2016 • Recovery Auditors may continue to conduct CMS-approved claim reviews unrelated to the appropriateness of the inpatient admission 9/29/2020 12

Patient Notice of Observation Status • On August 6, 2015, President Obama signed into law a bill that might impact providers’ bottom line – The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) 9/29/2020 13

NOTICE Act • The NOTICE Act will require a hospital or critical access hospital to provide the beneficiary with a new written notice – If the patient receives more than 24 hours of outpatient observation services • Effective August 5, 2016 9/29/2020 14

What the Notification Should Include • Under the NOTICE Act, the hospital notification must: – – – 9/29/2020 Explain the individual’s status as an outpatient Explain the implications of the outpatient status Include appropriate additional information Written and formatted using plain language Be signed by the individual or person acting on the individual’s behalf 15

What’s New INPATIENT PPS 9/29/2020 16

Quality Based Payment Adjustments • Hospital Value-Based Purchasing • Hospital Readmissions Reduction • Hospital Acquired Condition Reduction 9/29/2020 17

Hospital Value-Based Purchasing Program (HVBP) • Incentive payments based on Total Performance Score • Funding from payment reductions – Increase to 1. 75% for 2016 • Estimated $1. 4 billion available 9/29/2020 18

Hospital Readmissions Reduction Program (HRRP) • Payment reduced for certain readmissions • Conditions expanded for 2015 – Chronic Obstructive Pulmonary Disease – Total Hip and Total Knee Arthroplasty • Maximum reduction increased to 3% • Estimated savings of $424 million 9/29/2020 19

Hospital Acquired Condition Program (HAC) • 1% payment reduction to hospitals with high HACs • Estimated savings of $369 million 9/29/2020 20

Avoiding Payment Errors PRESENT ON ADMISSION (POA) INDICATORS 9/29/2020 21

Defining HACs • CMS identified conditions that are: – High in cost and/or volume – Result in a higher paying MS-DRG – Could reasonably have been prevented 9/29/2020 22

Examples of HACs • Foreign object left in the body after surgery • Infections or injuries acquired after admission • Blood incompatibility FYs 2014 -2015 HAC Categories 9/29/2020 23

HAC Diagnosis Codes • The specific ICD-9 diagnosis codes associated with the HAC categories are available at: – http: //www. cms. gov/Medicare-Fee-for. Service-Payment/Hospital. Acq. Cond/Hospital. Acquired_Conditions. html 9/29/2020 24

HAC Diagnosis Codes • The specific ICD-10 diagnosis codes associated with the HAC categories will be available at: – http: //www. cms. gov/Medicare-Feefor-Service. Payment/Hospital. Acq. Cond/icd 10_hacs. html 9/29/2020 25

Present on Admission • Conditions present at the time the order for inpatient admission occurs • Conditions that develop during an outpatient encounter – Emergency department – Observation – Outpatient surgery 9/29/2020 26

General Reporting Requirements • POA indicator is assigned to the principal and all secondary diagnoses • Providers must resolve issues related to inconsistent, missing, conflicting or unclear documentation • POA indicator not required for the external cause of injury code 9/29/2020 27

POA Indicator Options Code Reason for Code Y Diagnosis present on admission N Diagnosis not present at time of admission U Documentation insufficient to determine if condition was present W Clinically undetermined 9/29/2020 28

Reporting POA Indicator • Reported in the eighth position of the – Principle diagnosis field – Secondary diagnosis field – Other diagnosis fields • Example – 12345 --Y 9/29/2020 29

Diagnosis Codes Exempt from POA Reporting • List of ICD-9 -CM codes on the POA exempt list can be accessed at: – http: //www. cdc. gov/nchs/data/icd 9 cm_guid elines_2011. pdf • List of ICD-10 -CM codes on the POA exempt list can be accessed at: – http: //www. cdc. gov/nchs/data/icd/10 cmguideli nes_2016_Final. pdf 9/29/2020 30

POA Reporting Guidelines • Additional information on POA Reporting Guidelines can be accessed at the: – ICD-9 -CM Coding Guidelines, Appendix 1 – ICD-10 -CM Coding Guidelines, Appendix 1 9/29/2020 31

Misreported POA Indicators • Misreported POA indicators can be found on the CERT Error Summary at: – http: //www. wpsmedicare. com/j 8 macparta/dep artments/cert/2014 -4 th-qtr-errorsummary. shtml 9/29/2020 32

Claim Processing Issue • Reason code 34931 – Claims returned to provider (RTP) for missing POA indicator • Categories & Codes Exempt From Diagnosis Present on Admission Requirement can be accessed at: – http: //www. cdc. gov/nchs/data/icd 9 cm_guidelines_201 1. pdf 9/29/2020 33

Avoiding Payment Errors DISCHARGE STATUS CODING ERRORS 9/29/2020 34

Discharge Status Codes • Two digit code • Identifies where the patient is at conclusion of encounter – Visit – Inpatient stay – End of billing cycle (through date) 9/29/2020 35

Discharge Status Codes • Used to receive timely payment • Helps avoid claim errors • Omitting a code or incorrectly coding can cause: – Claim rejection – Cancellation or – Incorrect payment 9/29/2020 36

Common Discharge Codes Code Description 02 Discharge to Inpatient Prospective Payment System hospital 03 Discharge to Skilled Nursing Facility in anticipation of skilled care 06 Discharge to Home Health 62 Discharge to Inpatient Rehabilitation Facility (IRF) 63 Discharge to Long Term Care Facility (LTC) 65 Discharge to Psychiatric Facility 9/29/2020 37

Post-Acute Care Transfer Policy • Applies when discharge is assigned to one of the post-acute DRGs or Special Pay DRGs – Table 5 of the IPPS Final Rule 9/29/2020 38

Post-Acute Transfer DRGs 9/29/2020 39

Post-Acute Care Transfer Policy • Patient discharged to one of the following: – Facility excluded from IPPS – Skilled Nursing Facility – Home Health within 3 days of discharge from acute care stay 9/29/2020 40

Transfers Between IPPS Hospitals • Payment is made to the receiving hospital at the full IPPS rate • Payment to the transferring hospital is based on a per diem rate 9/29/2020 41

Transfers to Hospitals Excluded From IPPS • Facilities excluded from IPPS – IRFs – LTCHs – Psychiatric Hospitals – Children’s Hospitals and Cancer Hospitals • Full PPS rate paid to the transferring hospital 9/29/2020 42

Transfers to Hospitals Excluded From IPPS • Payment to receiving hospital – Basis for reasonable cost – Rate of its respective payment system • IRF • LTCH PPS 9/29/2020 43

Wrong Discharge Status Code Reporting • Wrong discharge status codes represented 4% of the total CERT error findings for the 1 st Quarter 2015 CERT Error Summary report at: – http: //www. wpsmedicare. com/j 8 macparta/dep artments/cert/2015 -1 st-qtr-errorsummary. shtml 9/29/2020 44

CERT Error Summary 9/29/2020 45

Bundled Payments for Care Improvement Initiative (BPCI) • Composed of four related payment models that link payments for multiple services during an episode of care into a bundled payment – Focus on outcomes for an episode of care, rather than procedures 9/29/2020 46

What’s New OUTPATIENT PPS 9/29/2020 47

Clarification to Inpatient-Only Services CR 9097 • Not appropriate when furnished as an outpatient service • Service designated as inpatient-only – Receives no payment under OPPS • Services furnished on same day as inpatient-only procedures – Receives no payment 9/29/2020 48

Exceptions to Inpatient-Only Policy 1) Inpatient-only defined as a “separate procedure” • 9/29/2020 Other service (s) billed can be paid under OPPS if they have a status indicator of “T” 49

Exceptions to Inpatient-Only Policy 2) Patient dies or is transferred to another hospital before admission • Report inpatient-only service with modifier CA • 9/29/2020 CMS makes single payment for all services provided 50

Revision to Inpatient-Only Procedure Policy CR 9097 • Inpatient-only procedures provided to patient in the outpatient setting will be covered by CMS – Effective April 1, 2015 9/29/2020 51

Use of HCPCS Modifier PO CR 9025 • Data collection requirement – Reporting is voluntary in 2015; • Mandatory January 1, 2016 • Report new modifier with every HCPCS code – Outpatient hospital services furnished in offcampus provider-based department 9/29/2020 52

Changes to Device Offset From Payment • Device offset payment reduction will not be applied to HCPCS C 2623 • (Biopsy, lung or mediastinum, percutaneous needle) – Retroactive to April 1, 2015 • Device offset is a reduction from passthrough payments for C 2623 9/29/2020 53

Billing for Diagnostic Digital Breast Tomosynthesis CR 9191 • Payment for HCPCS code G 0279 permitted only when billed in conjunction with HCPCS code G 0204 or G 0206 – HCPCS Code G 0279 • 9/29/2020 “Diagnostic digital breast tomosynthesis, unilateral or bilateral 54

Billing for Diagnostic Digital Breast Tomosynthesis CR 9191 • Report revenue code 401 • Applies to TOBs 12 X, 13 X, 22 X and 23 X and – TOB 85 X with revenue code other than 096 X, 097 X or 098 X 9/29/2020 55

Claim Processing Issue • HCPCS G 0279 – Some claims with HCPCS G 0279 are not paying correctly • Issue is tentatively scheduled for fixed on 01/04/16 • Claims with dates of services 01/01/2015 – 01/03/2016 will be mass adjusted 9/29/2020 56

Hyperbaric Oxygen Therapy (HBO) • Hospitals providing HBO therapy should report HCPCS code G 0277 – Effective January 1, 2015 • HCPCS Code C 1300 discontinued 9/29/2020 57

Submitting Request for HBO Prior Authorization • J 8 Michigan providers can submit electronic prior authorization (PA) requests for HBO services via C-SNAP – Decision letter will be issued by Medical Review via C-SNAP 9/29/2020 58

Lung Cancer Screening • Lung cancer screening added as a new preventive service – February 5, 2015 • Additional information can be accessed at: – https: //www. cms. gov/Newsroom/Media. Releas e. Database/Press-releases/2015 -Pressreleases-items/2015 -02 -05. html 9/29/2020 59

Lung Cancer Screening • Medicare will cover annual screening for lung cancer for beneficiaries who meet the eligibility criteria 9/29/2020 60

Screening for Cervical Cancer With Human Papillomavirus Testing • Human papillomavirus testing added as a preventive service – For asymptomatic beneficiaries aged 30 – 65 years • In conjunction with a Pap Smear Test – https: //www. cms. gov/medicare-coveragedatabase/details/nca-decisionmemo. aspx? NCAId=278&Time. Frame=7&Doc Type=All&bc=Ag. AAYAAAAg. AAAA%3 d%3 d 9/29/2020 61

What’s New? WPS MEDICARE UPDATES 9/29/2020 62

Claim Edits for Chemotherapy Drugs • Claim processing edits implemented to prevent future improper payments – Claims submitted with non-covered diagnosis or condition will deny 9/29/2020 63

Claim Edits for Chemotherapy Drugs • Providers are responsible for refunding money for non-covered diagnosis and/or non-covered conditions • Self-audits should be performed 9/29/2020 64

Check out these new features C-SNAP 9/29/2020 65

C-SNAP Enhancements • Submit medical records for post-payment medical reviews and Additional Documentation Requests (ADRs) • Ability to track current status of documentation from submission to completion 9/29/2020 66

Update to e. News Profile • To ensure that we are providing the most useful information, please update your e. News profile by: – Adding contact information and – Answering a few simple questions on the e. News profile webpage at: • http: //www. wpsmedicare. com/j 8 macparta/news/e. N ews/update-your-e. News-profile. shtml 9/29/2020 67

Are You Ready? COUNTDOWN TO ICD-10 9/29/2020 68

ICD-10 Implementation • Claims with date of service 10/01/15 or after – Must contain a valid ICD-10 code • Claim processing system will not process claims with ICD-9 or a combination of ICD-9 and ICD-10 codes 9/29/2020 69

Submitting Claims that Span the ICD -10 Implementation Date SE 1408 • Article provides guidance for submitting claims that span the ICD-10 implementation date at: – https: //www. cms. gov/Outreach-and. Education/Medicare-Learning-Network. MLN/MLNMatters. Articles/Downloads/SE 1408. pdf 9/29/2020 70

Ways to Check Claim Status After ICD-10 Implementation • • • Interactive Voice Response (IVR) Customer Service Representative (CSR) C-SNAP Direct Data Entry (DDE) ASC X 12 9/29/2020 71

ICD-10 Flexibilities • CMS/AMA announce ICD-10 flexibilities – The list of clarifying questions and answers related to CMS/AMA Joint announcement and guidance, can be accessed at: • https: //www. cms. gov/Medicare/Coding/ICD 10/Dow nloads/ICD-10 -guidance. pdf 9/29/2020 72

ICD-10 Flexibilities • ICD-10 Ombudsman – Receive and triage physician and provider issues • Review Contractors will not deny claims due solely to ICD-10 specificity – For 12 months after implementation • Quality Reporting for 2015 – Penalties not assessed for specificity if ICD-10 code is from the correct family of codes 9/29/2020 73

Disclaimer WPS Medicare has produced this material as an informational reference. Every reasonable effort has been made to ensure the accuracy of this information at the time of publication, however, WPS Medicare makes no guarantee that this information is error-free and bears no liability for the results or consequences of the misuse of this information. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at www. cms. gov. 9/29/2020 74