Agenda/Objectives. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 1

Transcription

1 Agenda/Objectives Medicare Program Changes Discuss Changes in the FY 2015 Hospice Final Rule Principal Diagnosis Coding Explain Principal Diagnosis coding Manifestation vs. Etiology Diagnosis Coding Data Analysis Discuss Data Analysis Reports and Top Reason Codes and Resolutions Steps for: Appeals Provider Contact Center (PCC) Claims Tying it all Together Define and Discuss Solid Performance focusing on the DMAIC Methodology to Identify Areas for Improvement Resources Identify and Review Web Resources January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 1

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3 What Changes Are in FY 2015 Hospice Final Rule? The Centers for Medicare & Medicaid Services (CMS) issued the FY 2015 Hospice Final Rule on August 4, The Final Rule (CMS-1609-F) updates the Medicare hospice wage index and Medicare hospice payment rates for fiscal year (FY) These regulations became effective on October 1, Continues the phase-out of the wage index budget neutrality adjustment factor (BNAF). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 3

4 What Other Changes Are in the Final Rule? The Final Rule also provides updates on: Hospice payment reform analyses. potential definitions of terminal illness and related conditions. Information on potential processes and appeals for Part D payment for drugs while beneficiaries are under a hospice election. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 4

5 Additional Changes The Final Rule also: Specifies timeframes for filing the notice of election and the notice of termination/revocation. Adds the attending physician to the hospice election form, and requires hospices to document changes to the attending physician. Requires hospices to complete their hospice aggregate cap determinations within five (5) months after the cap year ends, and remit any overpayments. Updates the hospice quality reporting program. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 5

6 Winding It Up The Last of the Changes Lastly, the Final Rule: Provides guidance on determining hospice eligibility. Provides information on the delay in the implementation of the International Classification of Diseases, 10th Revision Clinical Modification (ICD-10-CM). Further clarifies how hospices are to report diagnoses on hospice claims. Makes technical regulations text change. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 6

7 Where Do I Go If I Need More Information? Palmetto GBA hosts Quarterly Updates Webcast in March, June, October and December. Check the calendar on Palmetto GBA s Event Registration Portal. The requirements in the Final Rule are implemented at the Medicare contractor level when CMS issues one or more Change Requests (CRs). Until CMS issues the CR(s), Medicare contractors have limited information for educational purposes. Register for Palmetto GBA s and CMS updates to keep abreast of program changes, updates, and scheduled events. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 7

8 Changes Implemented with Change Request (CR) 8877 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 8

9 Principal Diagnosis Coding January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 9

10 Principal Diagnosis Coding Instructions International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Coding Guidelines require you to report diagnosis coding on your hospice claim. The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 10

11 Principal Diagnosis Coding Instructions The coding guidelines state that when the provider has established, or confirmed, a related definitive diagnosis, codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 11

12 Principal Diagnosis Coding Instructions Hospice providers may not report diagnoses codes that cannot be used as the principal diagnosis according to ICD-9-CM/ICD-10-CM Coding Guidelines and that require further compliance with various ICD-9-CM/ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 12

13 Principal Diagnosis Coding Instructions According to the ICD-9CM/ICD-10-CM Coding Guidelines both debility and adult failure to thrive are considered nonspecific, symptom diagnoses. Specifically, you should not use these ICD-9-CM codes as principal hospice diagnoses on a hospice claim form (Debility, unspecified) (Other malaise and fatigue) (adult failure to thrive) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 13

14 Principal Diagnosis Coding Instructions When any of these diagnoses are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice diagnosis based on ICD-9-CM/ICD- 10-CM Coding Guidelines. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 14

15 Principal Diagnosis Coding Instructions Additionally, there are several dementia diagnosis codes that cannot be used as the principal diagnosis, and require further compliance with various ICD-9-CM/ICD-10-CM coding conventions, such as those that are classified as unspecified or which have principal diagnosis code sequencing guidelines. These dementia codes (most of which are those found under the ICD-9-CM/ICD-10-CM classification, Mental, Behavioral, and Neurodevelopmental Disorders ) are typically manifestations from an underlying physiological condition; and are not appropriate as principal diagnoses because of etiology. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 15

16 CR 8877 Attachment A Codes Not Allowed as Principal Senile Dementia Uncomplicated Presenile Dementia Uncomplicated Presenile Dementia with Delirium Presenile Dementia with Delusional Feat Presenile Dementia w/depressive Feat Senile Dementia with Delusional Feat Senile Dementia with Depressive Feat Senile Dementia with Delirium Vascular Dementia Uncomplicated Vascular Dementia with Delirium Vascular Dementia with Delusions Vascular Dementia w/depressed Mood Other Specified Senile Psychotic Conditions Unspecified Senile Psychotic Condition January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 16

17 CR 8877 Attachment A Codes Not Allowed as Principal Delirium Due to Conditions Classified Elsewhere Subacute Delirium Psychotic Disorder with Delusions in Conditions Classified Elsewhere Psychotic Disorder with Hallucinations in Conditions Classified Elsewhere Mood Disorder in Conditions Classified Elsewhere Other Specified Transient Organic Mental Disorders Due to Conditions Classified Elsewhere Dementia, Unspecified, Without Behavioral Disturbance Dementia, Unspecified, With Behavioral Disturbance Other Persistent Mental Disorders Due to Conditions Frontal Lobe Syndrome Personality Change Due to Conditions Classified Elsewhere Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 17

18 Manifestation Codes January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 18

19 Format of ICD-9-CM Manual Volume 1 Tabular list of diseases and injuries. Volume 2 Alphabetic index of diseases and injuries. Volume 3 Tabular and Alphabetic. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 19

20 Coding Conventions In Alpha Index List underlying code first Manifestation code in brackets [ ] In Tabular Listing Instructional information Code underlying condition first Sequencing rule January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 20

21 Used in Tabular Listing Instructional information. Code underlying condition first. Sequencing rule. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 21

22 Manifestation Code vs Etiology Code Etiology is telling you what the patient has wrong with him/her. Manifestation tells you how the etiology is presenting. Manifestation codes describe the manifestation of an underlying disease, not the disease itself, and therefore should not be used as a principal diagnosis. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 22

23 ICD-9-CM vs ICD-10-CM Slanted brackets, [ ], are used in the ICD-9-CM Index to Diseases to identify manifestation codes. In the ICD-10-CM Index to Diseases and Injuries, square brackets, [ ], are used to identify manifestation codes. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 23

24 Example: Index to Diseases Neuritis, amyloid, any site is the primary code Polyneuropathy in other diseases classified elsewhere, appears in slanted brackets and is reported as a secondary code. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 24

25 ICD-9 Index to Diseases January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 25

26 Example: Tabular List Verify codes and in the Tabular List of Diseases. Note the description for code does not instruct you to assign code Description for code is italicized and states, Code first underlying disease, as with a listing that includes Amyloidosis ( ). Report code followed by code on the claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 26

27 Always verify code in tabular list. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 27

28 ICD-9 Tabular List January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 28

29 Notice of Election (NOE) Exception Submission Review The Good, The Bad, and The Ugly January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 29

30 NOE Exception Submission Review The Good:. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 30

31 NOE Exceptions Submissions Example One: The Good (Approved) Admission Date: 10/16 Actual Provider Remarks: We are requesting an exception for payment on this claim. Our 81A was originally submitted on 10/06 and went to RTP because of a previous provider that had not completed their billing. On 10/18, CWF had a revocation posted and we released our NOE from RTP getting a new receipt date. Occurrence Span Code: 77 with dates 10/16 to 10/21 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 31

32 NOE Exceptions Submissions Example Two: The Good (Approved) Admission Date: 10/08 Actual Provider Remarks: We newly certified hospice did not receive ID from MAC until 10/14 NOE keyed on 10/14. Occurrence Span Code: 77 with dates 10/08 to 10/13 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 32

33 NOE Exception Submission Review The Bad:. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 33

34 NOE Exceptions Submissions Example Three: The Bad (Denied) Admission Date: 10/07 Actual Provider Remarks: Our 81A was originally submitted on 10/10 and went to RTP because of a previous provider that had not completed their billing. On 10/18, CWF had a revocation posted and we released our NOE from RTP getting a new receipt date of 10/18. Occurrence Span Code: 77 with dates 10/07 to 10/17 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 34

35 NOE Exceptions Submissions Example Three: Denial Continued This exception was denied because the discharging hospice was the same as the admitting hospice and they did not file a discharge claim or Notice of Termination/Revocation of Election (NOTR) timely. Discharge was 10/3. NOTR (81B) received on 10/15 (late) and approved 10/20. How to avoid this exception denial: If there will be a delay in submitting the discharge claim, submit the NOTR immediately after discharge. The system does accept a discharge claim after a NOTR has processed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 35

36 NOE Exceptions Submissions Example Four: The Bad (Denied) Admission Date: 10/13 Actual Provider Remarks: Patients SOC date was entered incorrectly on the NOE. It should have been 10/3 not 10/10. I canceled the NOE and resubmitted the correct start of care (SOC) date when the 81D paid. Occurrence Span Code: 77 with dates 10/13 to 10/21 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 36

37 NOE Exceptions Submissions Example Four: Denial Continued This exception was denied because it was provider error. How to avoid this exception denial: Ensure correct information is submitted on the NOE. Setup audits to catch this information. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 37

38 NOE Exception Submission Review The Ugly:. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 38

39 NOE Exceptions Submissions Example Five: The Ugly(Denied) Admission Date: 10/23. This patient was discharged on 10/30. The exception was submitted for the entire dates of service. Actual Provider Remarks: 77 Code added for reconsideration. Patient was currently in an inpatient hospice unit with xxxxxx hospice in Dade City. (this provider also copied and pasted a screen shot of a HIQA screen in the remarks screen. It did not format well enough to read). Occurrence Span Code: 77 with dates 10/23 to 10/30 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 39

40 NOE Exceptions Submissions Example Five: Denial Continued This exception was denied because the provider did not give a specific reason and/or evidence to approve an exception. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 40

41 NOE Exceptions Submissions Example Five: Denial Continued How to avoid this exception denial: Be specific in your remarks (In this specific case, an exception may have been granted if the provider did this. The NOE was timely but returned). Note: It was never stated that the change of hospices could not have been a transfer situation since the discharge and admission were on the same date. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 41

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43 Hospice Appeals Data January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 43

44 Top Denial Reason Codes (RC) Appealed Reason Code 5T009 5CFNP 5Z5MI Description This claim has been fully denied by medical review for more than one reason Hospice Plan of Care does not meet requirements Program Integrity/Utilization Review Decision (ZPIC) Total Processed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 44

45 Redetermination Decisions 5T CFNP Z5MI % Unfavorable 44% Unfavorable 76% Unfavorable 17% Favorable 43% Favorable 17% Favorable 6% Dismissed 12% Dismissed 7% Dismissed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 45

46 How Do I Appeal A Denial? When appealing, ensure that the request includes all denial reasons applied to the claim. Some claims will contain line item specific denials and others will contain one reason code for the entire claim. Documentation submitted with the appeal should: Support the patient s need for services rendered. Contain information that addresses all reasons for denial. Include all required admission and continuing care documents (e.g., election statement, plan of care, physician narrative statement, certification of terminal illness, etc.). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 46

47 Medical Review Claim Denial Letters Under Palmetto GBA s medical review process: The documentation submitted in response to the Additional Documentation Request (ADR) is reviewed in its entirety. For provider-specific and service-specific medical review edits, a Claim Review Decision and Education letter is mailed to the provider. Letter includes Redetermination: 1st Level Appeal form, which is prepopulated with: Provider Name Provider Address Patient Name Health Insurance Claim (HIC) Number Claim Number Claim Date(s) of Service January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 47

48 Sample Letter January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 48

49 Medical Review Claim Denial Details Claim Page Four (4) In Direct Data Entry (DDE) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 49

50 Why Was My Claim Denied With RC 5T009? This claim has been fully denied by medical review for more than one reason. Each line item will have a the same or a different denial reason code. Claim and line level denial codes can be viewed in DDE by pressing the F2 key to get to the Additional Details (MAP171D) screen. The REJ CD field displays the claim level denial reason code. The Denial Reason field at the bottom of the page contains the line item denial code. To view each line item denial code, press F6 to move forward. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 50

51 DDE Additional Details Blank Claim Screen January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 51

52 RC 5T009 Favorable Example Initial Denial Information Denial reason code 5CFNP applied to revenue code 0651 line item. The hospice plan of care does not meet the requirements set forth in the Code of Federal Regulations (CFR). Comments on claim page 4 state, No plan of care (POC) submitted to cover dates of service billed. Denial reason code 5T009 was applied to all discipline revenue code (0551 and 0571) lines. Discipline data is billed for reporting purposes only and is not part of the decision to pay or deny the claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 52

53 RC 5T009 Favorable Example Redetermination Decision Received POC for dates of service submitted and all other documentation requirements were met. Claim was adjusted for payment. No further action required by provider. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 53

54 RC5T009 Unfavorable Example Initial Denial Details Denial reason code 5CFH9 applied to Routine Home Care (RHC) revenue code (0651) line item. The physician narrative statement was not present or was not valid. Claim page 4 of DDE. The documentation submitted in response to the ADR included the Certification of Terminal Illness, but does not include a physician narrative statement with attestation statement. No POC for Dates of Service (DOS) 07/25 07/31 Remember that the POC must be reviewed every 15 days and updated as appropriate. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 54

55 RC5T009 Unfavorable Example Redetermination Decision Valid election statement, certification, POC, and other documentation submitted. No physician narrative submitted. Remember that the physician narrative is a requirement and must be submitted with all other required documentation. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 55

56 RC5T009 Unfavorable Example What To Do Now If a signed and dated physician narrative existed prior to billing the claim. Proceed to the next step in the appeals process, which is a Reconsideration by the Qualified Independent Contractor (QIC). Submit all required documentation with the request, especially the physician narrative. This is a new and independent review, and Palmetto GBA does not forward the medical records to the QIC. If a signed and dated physician narrative did not exist prior to billing, it cannot be added and backdated. No payment can be made on the claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 56

57 RC 5T009 Dismissed Example Initial Denial Details Reason code 5CF36 applied to RHC revenue code line. According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less. Remarks on claim page 4 state, Lack of Clinical documentation and/or other information to support a prognosis of 6 months or less. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 57

58 RC 5T009 Dismissed Example Reason for Dismissal Redetermination request received but was not signed and dated. When submitting a request for a redetermination by Fax or Mail, providers may use the Redetermination Request Form found on Palmetto GBA s website or provide a cover letter that contains all of the elements on the form. The form or letter must be signed and dated by the individual in the agency who is authorized to submit the request. If the request form or letter is not signed, the request will be dismissed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 58

59 Save Time Submit Appeals Electronically Providers also have the option to submit their appeals through the Online Provider Services (OPS) application. Use the secure message option to select the Redetermination Request Form. The form is pre-populated with the provider information. Complete the other fields. Documentation is submitted using the attachment feature. Unlimited attachments can be submitted. Attachments must be a pdf document. Each attachment can be up to 40 megabytes. Maximum of 150 megabytes. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 59

60 Explain Why My Claim Denied With RC 5CFNP POC submitted with the documentation, but it did not meet all requirements as set forth in Medicare regulations. The POC is required for all hospice patients. Specific requirements are outlined in the CMS IOM, Pub , Chapter 9. POC is required to be reviewed at least once every 15 days and updated as appropriate. If dates of service on claim span from one 15-day period of time to another, then the initial plus any updated/revised/reviewed POCs must also be submitted for review. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 60

61 RC 5CFNP Favorable Example Initial Denial Information Dates of Service = 10/01 10/31 Denied six (6) days of RHC No POC review or IDG review submitted for first six days of the month (10/01 10/06). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 61

62 RC 5CFNP Favorable Example Redetermination Decision Redetermination Request received that included POC from 09/23 10/07. All other required documentation also received. Denial was reversed and claim was adjusted to pay for days initially denied during the medical review process. No further action needed from provider. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 62

63 RC 5CFNP Unfavorable Example Initial Denial Information Dates of service = 07/01 07/31. Denied 10 days (07/01 07/10) of RHC. No documentation submitted with POC to support requirement for review/update every 15 days. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 63

64 RC 5CFNP Unfavorable Example Redetermination Decision Documentation received included: All other required information. Initial POC (patient enrolled in hospice on 06/02). IDG meeting notes from 07/11 and 07/25. POC review notes for 07/22 and 07/24. No documentation received to support that POC was reviewed/updated every 15 days for period of time between patient enrollment date and start date of the claim (07/01). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 64

65 RC 5CFNP Unfavorable Example What To Do Now? If required POC review/update documentation existed before claim was billed. Proceed to the next step in the appeals process, which is a Reconsideration by the Qualified Independent Contractor (QIC). Submit all documentation for payment of services with the request, especially the POC review/update notes. This is a new and independent review, and Palmetto GBA does not forward the medical records to the QIC. If required POC review/update documentation did not exist prior to billing, it cannot be added and backdated. No payment can be made on the claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 65

66 RC 5CFNP Dismissed Example Initial Denial Information Dates of Service = 11/01 11/30. Denied 13 days (11/01 11/13) of RHC. No POC review other documentation submitted to show POC was reviewed/updated every 15 days. Patient enrolled in hospice 09/27. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 66

67 5CFNP Dismissed Example Redetermination Decision Initial denial decision issued 02/21. Redetermination requests must be submitted within 120 days of the date of the remittance advice (RA). For this example, the request should have been submitted no later than 06/21. The request was not received until 08/25. Request dismissed due to late filing. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 67

68 RC 5CFNP Dismissed Example What Happens Now? Timely filing requirements can be extended if good cause is established. Examples of good cause are: Incorrect or incomplete information about claim or subject was furnished to provider by official sources (CMS, the contractor, or the Social Security Administration). Unavoidable circumstances that prevented the provider, from timely filing a request. Ex: Major floods, fires, tornados, and other natural catastrophes. NOTE: Failure of a billing company or other entity retained by the provider to submit a request on time does not constitute good cause. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 68

69 RC 5CFNP Dismissed Example What Happens Now? If good cause exists, the request must include documentation to support the provider s position as to why the request is being submitted late. Any State of Disaster proclamations made by the president or state governors are automatically established as good cause (e.g., areas where hurricanes or tornados, etc.). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 69

70 Why Was My Claim Denied With RC 5Z5MI? Denial codes with Z in the second position are used specifically when Palmetto GBA receives a directive from the Zoned Program Integrity Contractor (ZPIC) to deny a claim. 5Z5MI is specifically based on a program integrity/utilization review decision. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 70

71 RC 5Z5MI Favorable Example Initial Denial Decision Claim initially received on 10/05. Payment made on 10/21. ZPIC performed a utilization review in the subsequent year and determined payment on the claim should be denied. The claim was adjusted according to ZPIC request and denial code 5Z5MI was appended to the adjusted claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 71

72 RC 5Z5MI Favorable Example Redetermination Decision Redetermination Request received that included all required documentation to support the services billed and patient s eligibility for hospice care. Denial was reversed and claim was adjusted to reflect all charges as covered. No further action needed from provider. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 72

73 RC 5Z5MI Unfavorable Example Initial Denial Decision Claim received on 02/17. ZPIC utilization review of claim on a pre-payment basis and payment denied on 05/14. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 73

74 RC 5Z5MI Unfavorable Example Redetermination Decision Provider requested a redetermination of the claim. Documentation submitted with the appeal supported patient s chronic conditions, but did not support beneficiary s terminal prognosis. Denial was affirmed on 10/01 and decision letter mailed to provider. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 74

75 RC 5Z5MI Unfavorable Example What To Do Now? Next step in the appeals process is a reconsideration by the QIC. If a Reconsideration will be filed, it must be submitted to the QIC within 180 days of the redetermination decision. Before submitting a request for a reconsideration, review all documentation submitted with the redetermination request. If documentation existed in the patient s file that was not submitted with the redetermination request, be sure to include it in the reconsideration request. Documentation that was submitted with the redetermination request does not need to be resubmitted; the QIC will request the documentation from the MAC. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 75

76 Hospice PCC Data January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 76

77 Top RC s For PCC Inquiries Reason Code Description Total Claim Not Filed on Time 2, Claim approved for payment (partial or full) 1, Previously processed bill is being canceled 1,608 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 77

78 Total Inquiries How Many Inquiries Did The PCC Receive? 2,500 2,000 1,500 2,018 1,749 1,608 1, Reason Codes January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 78

79 What Does RC Mean? Timely filing requirements not met Claims filed on the CMS 1450 (UB-04) claim form, must be filed within 12 calendar months from the Through date on the claim. Timely filing requirements may be extended if good cause exists. Examples of good cause are: Administrative error (error or misrepresentation of an employee, Medicare contractor). Retroactive Medicare entitlement: this applies only if patient signed election statement and all other hospice admission requirements were completed. Resources: CMS IOM, Publication , Chapter 1, Section 70.7 Palmetto GBA s Timely Filing Job Aid January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 79

80 Can I Appeal A Timely Filing Denial? Timely filing rejections are not considered a denial and cannot be appealed. If provider disagrees with the timely filing rejection, a written request may be submitted for review to determine if the time limit can be extended. Request must include: Patient name, address, Medicare Number Provider, name and address as it is in the provider enrollment file. Provider Transaction Access Number (PTAN), which is the six-digit number assigned to the provider for billing privileges. Provider NPI, and A detailed explanation as to why the timely filing requirement should be extended. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 80

81 Where Do I Send My Request To Extend the Timely Filing Requirement? Providers that submit claims to Palmetto GBA should send their written inquiries for an extension of the timely filing requirements either: By Mail: Palmetto GBA J11 HHH PCC Mail Code: AG-840 P. O. Box Columbia, SC OR By Fax: January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 81

82 Inquiry Example: Inquiry received on 12/18/14 (more than one year after the end of the billing period). Dates of Service on Claim 08/05/13 through 08/31/13 of the previous year. Provider stated that billing dispute was submitted requested that the timely filing requirement be extended. Research revealed: A billing dispute request was received on 08/05/2014 but did not process because it was missing the provider s name, NPI, PTAN, and last five digits of the Tax Identification Number. The Billing Dispute request was resubmitted and received on 10/03/2014. Provider was contacted for additional information, and request was processed in December January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 82

83 What Did the Research Show? Patient s Medicare entitlement records showed: Enrollment with Hospice A from 06/15/12 through 10/07/12. Patient changed (transferred) to Hospice B on 10/07/12. Patient discharged from Hospice B and was readmitted to Hospice C on 08/05/13. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 83

84 What Other Information Do The Records Show? Hospice B submitted the Notice of Transfer (81C) on time as well as all claims for subsequent benefit periods through 07/31/13. Hospice B submitted the final claim two times with incorrect dates of 08/09/13 08/13/2013. Both claims RTPd for sequential billing. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 84

85 Tell Me More Hospice C attempted to submit their first claim on 10/03/13. The claim RTPd RC U5181, which means that the claim submitted has Occurrence Code (OC) 27 and a date that should establish a new benefit period. The admit date, OC 27 date and From date on the claim was 08/05/13. Hospice C attempted to submit a NOE on 03/20/14, but it RTPd because Hospice B had not yet submitted their final claim to update the revocation indicator on the previous benefit period. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 85

86 There s More! Hospice B successfully submitted final claim in April 2014 but with dates of service 08/01/13 08/13/13, which overlap the start date with Hospice C. On June 24, 2014, Hospice B canceled their claim (818), which finished processing on July 2, Cancel claim removed the claim from the Common Working File (CWF), but not the new benefit period that was set up beginning 08/09/13. Hospice B was contacted by Palmetto GBA in December 2014 to submit an 81D to cancel the benefit period. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 86

87 Wait! There s More! Hospice B submitted the cancel notice (81D) on 12/01/2014; it finalized on 12/08/14. Hospice C resubmitted their NOE on 12/02/14, and it also finalized on 12/08/14 and subsequently submitted their claim. After reviewing the case history files, a request was submitted to the appropriate functional area to extend the timely filing requirement for Hospice C s claim. The request was granted on 12/19/14, and the claim was adjusted for payment. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 87

88 Could This Have Been Resolved Sooner? The answer to the question is YES! Hospice B should have verified that the dates submitted on their final claim were correct. The claim could have been adjusted instead of canceled (cancelling a claim suggests that the claim should never have been submitted). Many providers do not understand that when a claim is canceled, the benefit period does not automatically get removed from the CWF when the cancellation claim is processed. Always monitor the CWF records and the claim status to ensure that the claim processed to completion (P B9997) and submit the 81D to remove the benefit period if necessary (See Palmetto GBA s Canceling a Hospice Notice of Election (NOE) or Benefit Period job aid for detailed instructions). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 88

89 What Else Could Have Been Done To Resolve This Sooner? Hospice C should have verified the patient s eligibility records before admitting the patient. Since Hospice B still had an open benefit period, Hospice C should have contacted the other agency to verify the patient s discharge date before completing the admission process. If Hospice B failed to or refused to cooperate, a billing dispute resolution request should have been submitted several months before it was. Hospice C should have ensured that the information submitted with the billing dispute resolution request was complete and accurate. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 89

90 When Should I File A Billing Dispute Resolution Request? The agency identifying the issue must contact the other agency to attempt to resolve the matter. If the situation is not resolved within a reasonable amount of time, the agency may submit a billing dispute resolution request. Billing dispute requests must be received prior to the end of the timely filing period for the claim(s) in question. The request must contain all the required information or it will be returned to you. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 90

91 How Do I Submit A Billing Dispute Resolution Request? The request must be submitted in writing and include the following: Provider Name, address, Provider Transaction Access Number (PTAN), National Provider Identifier (NIP) number, and the last five digits of the provider s Tax Identification (ID) number. Beneficiary s name, Medicare number and date of birth. Dates of Service. Name of the agency that was contacted to attempt a resolution. The date the contact was made with the other agency. How the contact was made. Name of the individual contacted at the other agency. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 91

92 Resources To Assist Providers Palmetto GBA s job aid for Billing Disputes Resolution Requests Billing Dispute Resolution Request Form The form is not required If sending a letter, all elements outlined on the form must be included in the letter The request can be mailed or faxed By Mail: Palmetto GBA Attn: Provider Contact Center - AG-840 P. O. Box Columbia, SC OR By Fax: January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 92

93 What Does RC Mean? The claim was approved for either a partial or a full payment. Partial payment means certain line items on the claim were denied. Denied line items can be appealed if provider disagrees with denial. When full payment is made, all line items are listed on the claim as covered unless the provider submitted some of the line items as non-covered charges. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 93

94 RC Example Inquiry Inquiry received regarding reduction applied to overall payment on the claim. Question why a letter from CMS states that a reduction of 2% was applied to the overall payment. Provider stated that other information given indicated that the payment was reduced by 4% and wanted clarification. Further research on previous inquiry showed provider questioned 2015 Pricer. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 94

95 What Really Happened? Claim Dates of Service 10/11 10/11 Revenue Code 0656 Total Submitted Charges $1, Total Not Allowed Exceeds Medicare allowable $ Total Allowed Amount Actual allowable - 2% reduction No Quality Data $ Payment Reduction 2% Sequestration $14.32 Total Paid $ January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 95

96 What Could Have Been Done To Resolve This? The Remittance Advice (RA) is the first source of payment information. DDE claim status can be checked and it will show the total covered charges or any denied charges. DDE does not show the actual payment amounts. Electronic Remittance Advices (ERAs) are transmitted to the provider s GPNET mail box and are available on OPS. Standard Paper Remits (SPRs) are mailed to the provider. The remit will show the actual amount allowed less any sequestration reduction displaying the total amount paid. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 96

97 What If I Disagree With The Amount Paid? Check the claim to ensure it was submitted correctly. If so, then review the total allowed amount and compare it to the pricer. Remember that hospices that fail to submit their quality data are subject to 2% reduction in payment. CMS sends a list of providers subject to the 2% quality reduction at the beginning of each year. Palmetto GBA mails letters to all impacted providers as soon as we receive the list from CMS. The 2% reduction for failure to submit quality data is already included in the pricer software for hospice providers. Palmetto GBA s Hospice Rate Calculator is a valuable resource. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 97

98 Understanding RC A previously processed bill is being canceled. Either the provider submitted a cancel bill (8X8) or Palmetto GBA has initiated a cancelation claim (8XI). Cancel claims are generated for multiple reasons. The most common reason is due to sequential billing. If a hospice refuses to cooperate with another hospice when a billing dispute arises, Palmetto GBA will intervene and cancel the claims. Automated cancel claims will be generated if the patient s eligibility records are updated with a date of death that precedes the through date on a claim. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 98

99 RC Example Inquiry Provider inquiry questioning why claim for 11/01 11/08 was being canceled (TOB 81I). Research revealed that the through date on the claim exceeded the patient s eligibility records showed that the date of death was prior to 11/08. Automated adjustment was made on claim because payment cannot be made after the patient dies. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 99

100 Verifying Why A Claim Is Being Canceled Review claim page 4 in DDE. In most cases, when an automated cancel claim is generated, remarks will be present on the claim to explain why the claim is being canceled. Ensure that the dates of service on the claim are correct. Verify the patient s eligibility information in the CWF. If a date of death is present and is incorrect, the only way to get it corrected is through the Social Security Administration (SSA). After the patient s eligibility records are updated with the correct date of death, a new claim can be submitted. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 100

101 Hospice Claims Data January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 101

102 Top RC s On Claims That RTP d Reason Code Description Total Count Sequential Billing U Hospice NOE received falls within a previously established election period. Hospice claim reporting HCPCS Code Q5003, Q5004, Q5005, Q5007, or Q5008, and the service facility location NPI is blank or invalid. 21,776 21,021 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 102

103 Total Count Total Number Of Claims RTP d 50,000 40,000 47,425 30,000 20,000 21,776 21,021 10, U Reason codes January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 103

104 RC Details And Description This reason code is appended to the claim when it is filed out of sequence. Hospice claims must be filed in sequential order. Previous claim(s) either not filed or RTP d and not corrected before the subsequent claim. Always check the status of a previous claim and ensure it is fully processed (P B9997, D B9997 and sometimes R B9997). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 104

105 DDE Status/Location Codes Status P D R S T I Explanation The claim is completely processed (either fully or partially paid). The claim is completely processed and was denied. The claim is completely processed and was rejected. The claim is still in process. Note: [no provider intervention can be made other than responding to Additional Documentation Request (ADR) if applicable.] The claim has been returned to provider (RTP) for correction. The Intermediary has either inactivated OR specially processed your claim. *RTPs more than 60 days old and suppressed claims are moved to an I B9997 status for 3 years then purged. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 105

106 37402 Examples Example 1: Patient enrolled in hospice February /18 02/28 P B /01 03/31 P B /01 04/30 T B9997 Reason Code U /01 05/31 T B9997 Reason Code /01 06/30 T B9997 Reason Code January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 106

107 Steps To Resolve RC Check claim status in DDE, OPS, or if vendor software (if applicable). Ensure that all claims for prior billing periods have been fully processed. Correct RTPd claims through DDE as multiple submissions of the same claim can cause other issues such as duplicate errors and incorrect data to be transmitted, which will cause the claim to return again. After all claims for previous billing periods, F9 the claims that edited for sequential billing, one at a time. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 107

108 RC U5106 Details and Descriptions The admission date on the NOE submitted falls within an established benefit period. A new NOE will not process if the revocation indicator on the existing benefit period in the patient s eligibility record has not been updated. Look for a 1 or a 2. If the revocation indicator is 0, the previous hospice has not completed their billing, or you should handle the change as a transfer. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 108

109 RC U5106 Claim Example NOE submitted with admission date of 05/27. Patient s eligibility record shows an existing benefit period beginning with 05/12 07/10. The revocation indicator is 0. The latest billing shows 05/22. To resolve: 1. Contact the other hospice to verify the discharge/revocation date. 2. The previous hospice has to finalize their billing first. 3. After the previous hospice finalizes their billing, resubmit your NOE and then any subsequent claims. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 109

110 RC Details and Description Type of Bill 81X or 82X with dates of service on or after 04/01/2014 and the HCPC code Q5003, Q5004, Q5005, Q5007, or Q5008 is present on the claim and service facility location NPI is blank or invalid. CR 8358, effective date April 1, 2014, requires Hospices to report the National Provider Identifier (NPI) of any nursing facility, hospital, or hospice inpatient facility where the patient is receiving hospice services, regardless of the level of care provided, when the site of service is not the billing hospice. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 110

111 How To Resolve RC Ensure the facility NPI is reported on the claim. Ensure you report the NPI, facility name, and address of any SNF, NF, hospital, or hospice inpatient facility where the patient is receiving services when the service is not performed at the same location as the billing hospice s location (i.e., your own hospice-inpatient facility). See additional information in Palmetto GBA s Hospice Change Request (CR) 8358 Questions and Answers. Note: When the patient has received care in more than one facility during the billing month, the hospice shall report the NPI of the facility where the patient was last treated. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 111

112 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 112

113 DMAIC Define; clearly articulating the business problem, goal, potential resources, project scope and high-level project timeline. Measure; documenting the current process, validating how it is measured, and assessing baseline performance. Analyze: isolate the top causes, list and prioritize potential causes of the problem, and prioritize classes and subclasses of errors, and target interventions. Improve: fully understanding the top causes identified in the Analyze phase, with the intent of either controlling or eliminating those causes to achieve breakthrough performance. Control; Sustaining the changes made to guarantee lasting results. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 113

114 Palmetto GBA Actions Define Research the CMS design requirements for addressing the potential or observed vulnerabilities. Design requirements are typically contained in Medicare statute, regulation, manual/ncd instruction, or LCD. Communicate them to providers. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 114

115 Palmetto GBA Actions Measure Determine the relevant metrics that will be used to track improvement for providers selected for medical review. All error classes undergoing medical record audits will have impact severity risk maps constructed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 115

116 Communicating Risk Palmetto GBA uses a procedure that determines the inherent level of risk of an error-class based on a combination of financial risk and National or local audit experience. Dollars at risk. Estimated error dollars the product of dollars at risk and either the locally corresponding Charge Denial Rate (CDR) measured by Palmetto GBA s PCA process or the corresponding Claims Payment Error Rate (CPER) measured and reported Nationally by the CERT Contractor are subjected to a weighting procedure that determines an a priori risk score. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 116

117 Palmetto GBA Actions Analyze Conduct medical review to validate problem(s). Prioritize classes and subclasses of errors, and target interventions. Notify providers of results. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 117

118 Palmetto GBA Actions Improve Continued medical review One-on-one education via telephone conferences Educational articles Webcasts LCDs January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 118

119 Palmetto GBA Actions - Control Utilize statistical process control methods to identify recurrent problems with providers that have experienced denials via the Progressive Corrective Action (PCA) process. Prevent new problems by systematically sampling new providers for known error-classes within their specialty/service type. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 119

120 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 120

121 Online Provider Services (OPS) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 121

122 Secure Forms and Messaging January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 122

123 Secure Forms and Messaging January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 123

124 Owe Medicare Money? Request an immediate offset to repay your overpayment or request a that all future demanded overpayments are set for immediate offset. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 124

125 Owe Medicare Money? Make electronic check payments, for demanded or voluntary payments with no additional processing or transaction fees. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 125

126 Other eservices in OPS January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 126

127 How Do I Access Palmetto GBA s Website? Palmetto GBA s Home Health and Hospice Website URL Is: January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 127

128 How Do I Contact Palmetto GBA? Register For Updates Us Questions Contact Us By Telephone January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 128

129 What Social Media Does Palmetto GBA Have? Try Our Blog Face Book Twitter LinkedIn YouTube January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 129

130 Palmetto GBA Website Self Service Tools & Left Navigation From Acronym/Terminology Index to Tools and Calculators, find the resources that will assist you with your needs. Direct link to ICD-10 information. This option provides educational resources such as the Event Registration Portal that houses Palmetto GBA s event schedule. Claims Processing Issues Log Forms ICD-10 Website Job Aids Workshops Self Service Tools Learning and Education Most Frequently Viewed Topics January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 130

131 What Can I Find on CMS Website? CMS Website Medicare This section provides information specific to the Medicare Program from General Information to Special Topics. Each section on this page has options to select that will take you to the information you need. Regulations & Guidance The CMS Internet Only Manuals (IOMs), Paper-Based Manuals, and Transmittals, MLN Matters Articles as well as a number of other resources are available in this section. Outreach & Education This section has a number of options that will assist you with educational needs. Earn continuing education credits for completing certain educational sessions, or find tools that you can use to help your agency/facility or others. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 131