Thursday, June 25, 2015

Ambulance Service - Part B - Medicare basic guidelines

Ambulance Service - Part B

Ambulance services are separately payable only under Part B. There are certain
circumstances in which the service is covered and payable as a beneficiary transportation service under Part A; however in this case the service cannot be classified and paid for as an ambulance service under Part B. Payment may be made for expenses incurred for ambulance service provided the conditions specified in the following subsections are met.

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.

Vehicle and Crew Requirement
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting beneficiaries with acute medical conditions. The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. This should include, at a minimum, one 2-way voice radio or wireless telephone.

Vehicle Requirements for Basic Life Support and Advanced
Life Support
Basic Life Support ambulances must be staffed by at least two people, at least one of
whom must be certified as an emergency medical technician (EMT) by the State or local
authority where the services are being furnished and be legally authorized to operate all
lifesaving and life-sustaining equipment on board the vehicle. Advanced Life Support
(ALS) vehicles must be staffed by at least two people, at least one of whom must be
certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic.

Verification of Compliance

In determining whether the vehicles and personnel of each supplier meet all of the above requirements, carriers may accept the supplier’s statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if:
1. The statement describes the first aid, safety, and other patient care items with
which the vehicles are equipped;
2. The statement shows the extent of first aid training acquired by the personnel
assigned to those vehicles;
3. The statement contains the supplier’s agreement to notify the carrier of any
change in operation which could affect the coverage of ambulance services; and
4. The information provided indicates that the requirements are met.

The statement must be accompanied by documentary evidence that the ambulance has the equipment required by State and local authorities. Documentary evidence could include a letter from such authorities, a copy of a license, permit, certificate, etc., issued by the authorities. The carrier will keep the statement and supporting documentation on file.

When a supplier does not submit such a statement or whenever there is a question about a supplier’s compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), carriers will take appropriate action including, where necessary, on-site inspection of the vehicles and verification of the qualifications of personnel to determine whether the ambulance service qualifies for reimbursement under Medicare. Since the requirements described above for coverage of ambulance services are applicable to the overall operation of the ambulance supplier’s service, information regarding personnel and vehicles need not be obtained on an individual trip basis.

Friday, June 19, 2015

New HCPCS Codes Subject to CLIA Edits for 2015



HCPCSCode Descriptor
G0464Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)
G6030Amitriptyline
G6031Benzodiazepines
G6032Desipramine
G6034Doxepin
G6035Gold
G6036Assay of imipramine
G6037Nortriptyline
G6038Salicylate
G6039Acetaminophen
G6040Alcohol (ethanol) any specimen except breath
G6041Alkaloids, urine, quantitative
G6042Amphetamine or methamphetamine
G6043Barbiturates, not elsewhere specified
G6044Cocaine or metabolite
G6045Dihydrocodeinone
G6046Dihydromorphinone
G6047Dihydrotestosterone
G6048Dimethadione
G6049Epiandrosterone
G6050Ethchlorvynol
G6051Flurazepam
G6052Meprobamate
G6053Methadone
G6054Methsuximide
G6055Nicotine
G6056Opiate(s), drug and metabolites, each procedure
G6057Phenothiazine
G6058Drug confirmation, each procedure
80163Digoxin level
80165Valproic acid level
80300-80304Drug screen
80320-80377Alcohols levels
81246Test for detecting genes associated with blood cancer
81288Test for detecting genes associated with colon cancer
81313Test for detecting genes associated with prostate cancer
81410Test for detecting genes associated with heart disease
81411Test for detecting genes associated with heart disease
81415Test for detecting genes associated with diseases
81416Test for detecting genes associated with disease
81417Reevaluation test for detecting genes associated with disease
81420Test for detecting genes associated with fetal disease
81425Test for detecting genes associated with disease
81426Test for detecting genes associated with disease
81427Reevaluation test for detecting genes associated with disease
81430Test for detecting genes causing hearing loss
81431Test for detecting genes causing hearing loss
81435Test for detecting genes associated with colon cancer
81436Test for detecting genes associated with colon cancer
81440Test for detecting genes associated with cancer of body organ
81445Test for detecting genes associated with cancer of body organ
81450Test for detecting genes associated with blood related cancer
81455Test for detecting genes associated with cancer
81460Test for detecting genes associated with disease
81465Test for detecting genes associated with disease
81470-81471Test for detecting genes associated with intellectual   disability
81519Test for detecting genes associated with breast cancer
87505-87507Detection test for digestive tract pathogen;
83006Test for detecting genes associated with growth stimulation
87623-87625Detection test for human papillomavirus (hpv)
87806Detection test for HIV1
88341Special stained specimen slides to examine tissue
88344Special stained specimen slides to examine tissue
88364Cell examination
88366Cell examination
88369Microscopic genetic examination manual
88373Microscopic genetic examination using computerassisted technology
88374Microscopic genetic examination using computerassisted technology
88377Microscopic genetic examination manual.

Monday, June 15, 2015

Advance Beneficiary Notice of Nonc overage: When Should You Sign an ABN?


Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:
•    Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
•    Services paid for by a government entity other than Medicare
•    Personal comfort items
•    Routine eye care
•    Dental care
•    Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.
CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:
•    Give the name or description of the service they are providing
•    Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'
•    Give you the estimated cost of the service or procedure
•    Provide you with three options, worded in the following ways:
o    Option 1. 'I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.'
o    Option 2. 'I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.'
o    Option 3. 'I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.'
The ABN will also have a place for additional information, such as a dated witness signature.
There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.

Some points to remember:
•    Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.
•    Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.
•    If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurances may cover services that Railroad Medicare does not.

Wednesday, May 13, 2015

Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport

Fact sheets: Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport


OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid. 

BACKGROUND
In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas).  Since implementing the demonstration, CMS has observed a decrease in expenditures for power mobility devices.  CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary repetitive scheduled non-emergent ambulance transport services. New Jersey, Pennsylvania, and South Carolina were selected for initial implementation of this process because of their high utilization and improper payment rates for these services.

Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.

Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process.  Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. 

PRIOR AUTHORIZATION PROCESS
The model will establish a prior authorization process for repetitive scheduled non-emergent ambulance transport services. This process will allow all relevant documentation to be submitted for review prior to rendering services.  CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied.  Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without prior authorization decision, that claim shall undergo pre-payment review.

CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days.  A provisional affirmative prior authorization decision will affirm a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 trips) per prior authorization request in a 60-day period. 

To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS will include an expedited review process.  The request for an expedited review must provide rationale supporting the expedited review request.  Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary.  In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation. 

Under this model, if a prior authorization has not been requested before the fourth round trip in a 30-day period, claims will be subject to pre-payment medical review. CMS believes that the repetitive scheduled non-emergent ambulance transport trips for a beneficiary will generally be scheduled through one provider or supplier at the beginning of the authorization period. CMS will allow one ambulance provider or supplier to request prior authorization per beneficiary per time period. Any provider or supplier submitting claims for which no prior authorization request is recorded will be subject to 100 percent medical review.

Tuesday, April 14, 2015

Physician Signature Requirements for Diagnostic Testing


Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An 'order' is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;

A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.    Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment.   Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation.   Therefore, Novitas recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation.   Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation.   Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Novitas Solutions, it is critical that the signed physician order for all diagnostic tests be included.   Without the order, the services could be determined to be medically unnecessary and the claim will be denied.

Tuesday, March 10, 2015

Implementing new policies related to Medicare Part B inpatient services


Effective date October 1, 2014
Implementation date: February 10, 2015

Summary
The Centers for Medicare & Medicaid Services (CMS) recently announced changes to the Medicare Claims Processing Manual related to payment policies regarding payment of Medicare Part B inpatient services.

When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient. All hospitals billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the inpatient prospective payment system (IPPS), hospitals paid under the outpatient prospective payment system (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.
Implementing the Payment Policies Related to Patient Status from the CMS-1599-F

Provider Type Affected
This MLN Matters Article is intended for hospital submitting claims to Medicare Administrative Contrators (MACs) for services provided to Medicare beneficiaries.

What You Need to Know
Change Request (CR)959 incorporates changes to the "Medicare Claims Processing Manual" related to the payment policies regarding Patient Status from final rule CMS-1599-F. This includes payment of Medicare Part B inpatient services, and admission and medical review criteria for payment of hospital inpatient services under Medicare Part A.

Background
When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, provided the allowed timeframe for submitting claims is not expired. Medicare will not allowed timeframe for submitting claims is not expired. Medicare will not allow payment for services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services that are, by definition, provided to hospital outpatients and not inpatients.

Specific changes to the "Medicare Claims Processing Manual" as a result of CR8959 involve Chapter 240 of that manual. Specifically, inpatient routine services in a hospital generally are those services included by the provider in a daily service charge--sometimes referred to as the "Room and Board" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A. Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification of an item or service as routine or ancillary among providers of the same class in the same State. Some providers established customary charging practice resulting in separate charges for these services following the "Provider Reimbursement Manual" )PRM-1) instructions. However, in order for a provider's customary charging practice to be recognized it must consistently follow those instructions for all patients and this must not result in as inequitable apportionment of cost to the program. If the PRM-1 instructions have not been followed, a provider cannot bill these services as separate charges. Additionally, it is important that the charges for services rendered and documentation meet the definition of the Healthcare Common Procedure Coding System (HCPCS) in order to separately bill.

All hospital billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), hospital paid under the Outpatient Prospective Payment System (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.

Hospitals paid under the OPS would continue billing the OPPS for Part B inpatient services. Hospitals that are excluded from payment under the OPPS in 42 Codes of Federal Regulations (CFR) 419.20 (b) would be eligible to bill Part B inpatient services under their non-OPPS Part B payment methodologies.

Beneficiaries are liable for their usual Part B financial liability. Beneficiaries would be liable for Part B copayments for each hospital Part B inpatient service and for the full cost of drugs that are usually self-administered. If the beneficiary's liability under Part A for the initial claim submitted for inpatient services they received, the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts. Conversely, if the beneficiary's liability under Part A is less than the beneficiary's liability under Part B for the inpatient services they received, the beneficiary may face greater cost sharing.

Timely filing restrictions will apply for Part B inpatient services. Claims that are filed beyond one (1) calendar year from the date of service will be rejected as untimely and will not be paid.

Wednesday, February 25, 2015

EHR Incentive Program: How to Report Once in 2014 for Medicare Quality Reporting Programs


Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:
•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once

Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:
•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.

•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.

•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.

2014 QRDA III SEVT Testing Available

The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.