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.

Friday, February 21, 2014

Denied as Admission date , ambulance drop off location required in claims

Admission Date REQUIRED


What this means: For the trading partner, Payer Path, this is a required field for ambulance claims.  This must be added in order for the claims to go through.

Provider action: Add the admission date

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing:Once this is corrected, you would want to re-file any claims that rejected for this reason


Ambulance Drop-Off Location is required for Ambulance Claims.


What this means: One of the requirements for ambulance claims is that a drop off city, state and zip code are required

Provider action: Add the drop off location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


Ambulance Pick-Up Location is required for Ambulance Claims.

What this means: One of the requirements for ambulance claims is that a pick up city, state and zip code are required

Provider action: Add the pick up location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.




Tuesday, May 22, 2012

When Tricare cover ambulance services

TRICARE covers ambulance services in the following circumstances:


•     Emergency transport to a hospital

•     Transfer from one hospital to another hospital more capable of providing the required care as ordered by a physician

•     Transfers between a hospital or SNF and another facility for outpatient therapy or diagnostic services ordered by a physician

•     Transfers to and from a SNF when medically indicated

Note: Payment of ambulance transfers to and from a SNF may be included in the SNF prospective payment system (PPS).

Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities, and the patient’s medical condition warrants speedy admission or is such
that transfer by other means is contraindicated. TRICARE does not cover ambulance services for these conditions:

•     Non-emergency ambulance services used instead of a taxi service or other normal transportation means when the patient’s condition would permit
use of regular transportation (Ambulance transportation is covered under the TRICARE Extended Care Health Option [ECHO] benefit when the beneficiary is being transported to and from institutions or facilities when the
beneficiary is receiving institutional care.)

•     Transport or tra nsfer of a patient primarily for the purpose of having the patient closer to home, family, friends, or a physician

•     Any type of medicabs or ambicabs that function as public passenger services transporting patients to and from medical appointments

Saturday, January 28, 2012

Ambulance billing - Denied and Non Covered Service

Denied Services
Program payment will not be made when other transportation could be utilized without endangering the patient’s health, whether such means of transportation is actually available.
A claim may be denied on the grounds that the use of an ambulance service was unreasonable in the treatment of the illness or injury involved.
Non-Covered Services
Medicare does not cover the following services:
 Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs or wheelchair vans.
 Parking fees.
  Tolls for bridges, tunnels and highways.

What are the documents required when you submit the claims to Medicare

Documentation Requirements for Ambulance Billing
The trip record documentation of each patient encounter should include the following:
 Complete and legible information.
 Reason for the transport.
 A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternate mode.
 Relevant history (when available).
  Observations and findings (patient’s condition at the time of transfer).
  A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.
 A detailed description of existing safety issues.
  A detailed description of special precautions taken (if any) and explanation of the need for such precautions.
 Assessment and clinical evaluations that should include:
oVital signs.
o Neurological assessment.
o Cardiac information.
                 Documentation of procedures and supplies provided such as:
O IV therapy.
o Respiratory therapy.
o Intubation.
o Cardiopulmonary Resuscitation (CPR).
o Oxygen administered.
o Drug therapy.
o Restraints. 
 A description of specific monitoring and treatments ordered and performed/ administered; that a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. 
 The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given).

· Point of pickup (identify place and complete address). 
 Number of loaded miles/cost per mile/mileage charge. For services rendered with dates of service on or after January 1, 2011, miles must be reported as fractional units. For instructions on fractional units refer to “Mileage” under the “Services and Procedure Codes” section in this manual. 
 Minimal or base charge and charge for special items or services with an explanation/itemization of the special items or services. 
 For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient. 
 Any additional available documentation that supports medical necessity of ambulance transport (e.g., emergency room report, Skilled Nursing Facility (SNF) record, End-Stage Renal Disease (ESRD) facility record, hospital record). 
 A separate run sheet for each transport (e.g., two run sheets for round trips).
 Date and legible identity of the observer. Note: Refer to Signature Guidelines for Medical Review Purposes in this section.

Note: The HCPCS codes and ICD-9-CM codes reported on the health insurance claim must be supported by the documentation on the run sheet

Sunday, January 22, 2012

Signature Guidelines for Medical Review Purposes in Ambulance billing

Medicare requires that services provided/ordered be authenticated by the author. The method used must be a handwritten or electronic signature. Stamped signatures are not acceptable. These guidelines impact the ambulance trip/run sheets and the Physician Certification Statements (PCSs). 
Run sheets must have legible signatures, including credentials, from the provider(s) who renders the services documented. 
The signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. 
Signature Authentication Process 
If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested by the reviewer before the claim is processed.

Signature Log

A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. The signature log may be submitted when records are requested. The signature log may be included on the actual page where the initials or illegible signatures are used or it may be a separate document. 

Attestation Statement
An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and date of service. An attestation is specific to the service documented.
Providers should not add late signatures to the medical record, but make use of the signature authentication process. When medical records are requested, you may notice changes within the request letter. To meet the requirements for signatures, additional documentation (attestation statement or signature log) may need to be submitted with your medical records.