a day with medicare · 2015. 3. 4. · process, cert review results, cms goals and potential...

A Day with

Medicare

An educational event focusing on the

Comprehensive Error Rate Testing (CERT) Program

6/11/2015

Overland Park Convention Center

6000 College Blvd

Overland Park, KS 66211

(913) 339-3000

7/22/2015

St Charles Convention Center

1 Convention Center Plaza

St Charles, MO 63303

(636) 669-3000

2 | P a g e

Table of Contents

Please write to us at [email protected] if you have questions or

concerns

Continuing Education Credits (CEUs)…… 3

Responding to Coding Questions……….. 3

Disclaimers………………………………... 3

Daily Schedule……………………………... 4

Registration………………………………… 4

Breakfast……………………………………. 4

Lunch……………………………………...... 4

Materials…………………………………..... 4

Breakout Sessions………………………… 5

Session Descriptions…………………….. 6

WPS Medicare Staff Bios…………………. 13

3 | P a g e

Continuing Education Credits (CEUs)

CEUs for CMS-sponsored webinars and workshops are accepted by the American Academy of

Professional Coders (AAPC) at a rate of one CEU per hour. These CEUs may come from CMS or

Medicare Administrative Contractor (MAC) offices. A certificate of attendance or completion with the

CMS logo is necessary to show participation.

To claim CEUs, attendees will enter certificate information onto their CEU Tracker using the “No

Index Number” option. A copy of the certificate does not need to be provided to AAPC unless the

member is selected for verification purposes.

Responding to Coding Questions

Contractors are prohibited from providing coding advice. Based on CMS’ Medicare Contractor

Beneficiary and Provider Communications Manual, Publication 100-09, Chapter 6, Section 30.1.1,

providers are responsible for determining the correct diagnostic and procedural coding for the

services they furnish to Medicare beneficiaries. For details, please refer to:

http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

Disclaimers

These presentations are a tool to assist providers. Every reasonable effort has been made to ensure

the accuracy of the information; however, the provider has the ultimate responsibility for correct

submission of claims. WPS Medicare bears no liability for the results or consequences of the misuse

of this information. The official Medicare Program provisions are contained in the relevant laws,

regulations, and rulings.

We will not be able to answer specific claims questions as no system access will be available.

We reserve the right to change a participant’s sessions (only if necessary).

Recording or videotaping these educational presentations is prohibited.

Thank you for silencing your cell phone during all sessions.

4 | P a g e

Daily Schedule

8:30 – 9:00 AM Registration and Breakfast

9:00 – 9:20 AM Welcome and General Session

9:30 – 10:30 AM Breakout Session 1 (5 concurrent sessions)

10:30 – 10:40 AM Break

10:40 – 11:40 AM Breakout Session 2 (5 concurrent sessions)

11:40 – 1:00 PM Complimentary Lunch/Keynote Speaker

1:10 – 2:10 PM Breakout Session 3 (5 concurrent sessions)

2:10 – 2:20 PM Break

2:20 – 3:20 PM Breakout Session 4 (5 concurrent sessions)

3:20 – 3:30 PM Refreshments

3:30 – 4:30 PM Questions and Answers with WPS Medicare Staff

Registration

Staff at the registration table will be available all day to answer questions and assist with locating

sessions.

Breaks

Morning and afternoon breaks will consist of a beverage service.

Light refreshments will be offered prior to and during the Question and Answer session.

Breakfast

A Continental breakfast will be available beginning at 8:30 AM.

Lunch

Please join us for lunch following Session 2.

Materials

All materials and handouts will be provided at the event.

5 | P a g e

Breakout Sessions

Event Title Provider Type

Session 1

Physician Inpatient Hospital Services - The Good, the Bad and the Ugly A/B

The Comprehensive Error Rate Testing Program - Get the Scoop! A/B

Signed, Sealed and Delivered - Ensuring Orders, Signatures and Notes Support

What is Billed

A/B

The CERT Forecast - If It Gets Stormy, Will You Be Ready? A

Documenting Medical Necessity for Major Joint Replacements (Hip and Knee) A/B

Session 2

Moving to the Next Level - Using the Medicare Appeals Process to Your Advantage A/B

Part B CERT Errors - All Hands on Deck! B

No Denials, No Recoupments, No Errors! A

Avoiding Recoupment and Retaining Dollars - SNF Certification/Recertification

Statements

A

Hospital Admission Criteria A/B

Session 3

SNF Consolidated Billing - To Bill, or Not to Bill, That is the Question A/B

Evaluation and Management (E/M) Services - Reducing Errors Through Education

(Part 1)

A/B

Increase Your Inpatient Psychiatric Facility (IPF) Revenue by Decreasing Your

Errors

A

Take Aim at Reducing Part B Claim Errors B

The Do’s and Don’ts of Diagnostic Laboratory Tests A/B

Session 4

Avoid Payment Errors – Present on Admission (POA) Indicators and Patient

Discharge Status Codes

A

Documentation Through the Eyes of Medicare Reviewers A/B

Who’s Reviewing Your Claims? A/B

The ABC’s of the Initial Preventive Physical Exam & Annual Wellness Visit A/B

Evaluation and Management (E/M) Services - Reducing Errors Through Education

(Part 2)

A/B

You will select the sessions you wish to attend during the online registration process.

If a topic does not appear, that session is full. Note: If you are selecting Evaluation and

Management two sequential sessions are offered and you are required to register for

and attend both.

6 | P a g e

General Categories and Session Descriptions

Appeals

Moving to the Next Level – Using the Medicare Appeals Process to Your Advantage

Janet Mateo, Analyst, Provider Outreach & Education

Thom Ryan, Senior Analyst, Provider Outreach & Education

What does a provider do if they disagree with an initial determination? Do you know how the claim

reopening process differs from the appeals process? Learn about the Medicare Appeals process, the

new coding requirements for reopening a claim, the difference between the claim reopening and the

appeals process, and receive guidance on filing both actions correctly. Also, learn what happens

when a change or addition to a claim is discovered beyond the timely filing limits.

Target Audience: Part A & B, Coders, Billers, Office Staff

Comprehensive Error Rate Testing (CERT)

Part B CERT Errors – All Hands on Deck!

Sue Brewer, Analyst, Provider Outreach & Education

Mary Muchow, Senior Analyst, Provider Outreach & Education

Denise Stanley, Supervisor, MR CERT

Join us for an interactive experience where you will review examples of actual documentation

reviewed by the CERT contractor and test your knowledge of Medicare Part B regulations! After a

short overview of the most common Part B CERT error findings, all participants will dive into the

documentation. You will then bring to the surface your decision of whether a CERT error was

assessed for each case. Providers, clinicians, coders, billers, and compliance staff should consider

attending this informative session to learn more about how to avoid denials with proper

documentation of Medicare claims.

Target Audience: Part B, Coders, Billers, Office Staff

No Denials, No Recoupments, No Errors! Aileen Sigler, Analyst, Provider Outreach & Education Karen Kroupa, Analyst, Provider Outreach & Education Tanya Hardiman, Analyst, Provider Outreach & Education Stay on top of your game and don’t get struck out by denials on your Part A claims. In this session,

we’ll examine some of the latest errors found by the CERT contractor. Join your Part A teammates

and develop a game plan for hitting a home run on every claim by avoiding denials.

Target Audience: Part A, Administrators, Billers, Office Staff, Clinicians, Coders

7 | P a g e

Take Aim at Reducing Part B Claim Errors



With the implementation of CMS medical review initiatives, comes the likelihood that your Part B

Medicare claim may be selected for medical review by one of CMS’ contractors. Based on historical

data, the error categories and types of errors have remained quite consistent. Providers, clinicians,

coders, billers, office staff, and compliance staff should consider attending this informative session to

learn the most common Part B claim errors, and how to avoid them. In addition to the identification of

historical and forecasted Part B claim errors, we will demonstrate, through the use of the WPS

Medicare website, the multitude of educational resources created to prevent and avoid the same

errors in the future.

Target Audience: Part B, Coders, Billers, Office Staff

The CERT Forecast – If It Gets Stormy, Will You Be Ready?

Jan Ervin, Analyst, Provider Outreach & Education

This session will focus on the services CERT is projecting to look at when conducting reviews. We’ll

look at reasons why CERT is forecasting these services and what they’ll be looking for. Don’t miss

this opportunity to prepare your facility to weather the storm.

Target Audience: Part A, Coders, Billers, Office Staff, Administrators

The Comprehensive Error Rate Testing Program – Get the Scoop!


You may have seen CERT in the headlines, but do you have all of the information you need to fully

understand why it was implemented, how it works and what your role is in the process? This

informative session will help you better understand the fine print about the CERT contractors, the

process, CERT review results, CMS goals and potential outcomes. Designed for practitioners,

coders, billers, office staff, and compliance staff, participants will benefit from gaining a better

understanding of the CERT program and its importance to all Medicare contractors and providers

alike.

Target Audience: Part A & B, Coders, Billers, Office Staff, Administrators

8 | P a g e

Claim Review

Who’s Reviewing Your Claims?




CMS has implemented a multitude of program integrity and medical review initiatives, each with a

slightly different focus, but all with an eye toward the goal of detecting and correcting improper

payments to and from Medicare. These efforts are an important step toward the prevention of waste,

fraud and abuse in the Medicare program. Join us to better understand how the role of the Medicare

Administrative Contractor medical review staff and CMS medical review contractors differ, what

contractors are reviewing, and the potential outcomes of all respective medical review activities.

Designed for practitioners, clinicians, coders, billers, office staff, and compliance staff, participants will

recognize the importance of complete and correct documentation, preparation and submission of

Medicare claims and the impact of those claims on the national paid claims error rate.

Target Audience: Part A & B, Coders, Billers, Office Staff, Compliance Staff

Documentation

Documenting Medical Necessity for Major Joint Replacements (Hip and Knee)

Mary Sue Gardner, RN/BSN, Senior Nurse Analyst, Provider Outreach & Education

Cheyenne Santiago, RN, Senior Nurse Analyst, Provider Outreach & Education

Please join us for a discussion on documenting medical necessity for major joint replacements (hips

and knees). This educational event is intended to improve compliance with documentation

requirements for major joint replacement surgery.

Target Audience: Part A & B, Utilization Review Staff, Admitting Personnel, Physicians, Practitioners

Documentation Through the Eyes of Medicare Reviewers



What do claim review contractors look for? What are the top errors and how can these be avoided?

What needs to be included in the documentation? Find out the answers to these questions and more

in this session that will focus on reviews performed by various Medicare contractors. Based on

historical data, we will share information on the most common error findings and will provide tips and

resources to prevent future documentation and coding issues.

Target Audience: Part A & B, Coders, Billers, Practitioners, Compliance Staff

9 | P a g e

Signed, Sealed and Delivered – Ensuring Orders, Signatures and Notes Support What is Billed Aileen Sigler, Analyst, Provider Outreach & Education

Would your claim get a stamp of approval? Are all the components of your documentation in place,

complete and accurate to support payment for the services you’ve billed? In this session, we will

review orders and signature requirements and how any missing pieces can affect receiving proper

reimbursement from Medicare.

Target Audience: Part A & B, Administrators, Billers, Clinicians, Coders The Do’s and Don’ts of Diagnostic Lab Tests



Laboratory denials continue to be a growing error across all review entities. Join us as we discuss:

• Beneficiary information required to be submitted with each claim or order for laboratory services

• The medical condition for which a laboratory test is reasonable and necessary

• The medical documentation that is required by a Medicare contractor at the time a claim is submitted for a laboratory test

• Record keeping requirements in addition to any information required to be submitted with a claim, including physicians’ obligations regarding these requirements.

Target Audience: Part A & B, Coders, Billers, Practitioners, Compliance Staff

Evaluation and Management Services (E/M)

Evaluation and Management (E/M) Services – Reducing Errors Through Education – Parts 1

and 2

Ellen Berra, Senior Analyst, Provider Outreach & Education

PLEASE NOTE – THIS BREAKOUT CONSISTS OF 2 PARTS – Those choosing this breakout

must register for both sessions.

In this session, you will be provided information on the CMS guidelines for choosing an E/M

procedure code based on the documentation. We will discuss the three key components used in

choosing a procedure code and when an alternative method may be used. We will have examples of

recent CERT results on actual documentation submitted. This will be a lively discussion on one of the

areas of concern in the CERT program!

Target Audience: Part A & B, Practitioners, Compliance Staff, Coders, Billers, Office Staff

10 | P a g e

Physician Inpatient Hospital Services – The Good, the Bad and the Ugly

Ellen Berra, Senior Analyst, Provider Outreach & Education

Karen Kroupa, Analyst, Provider Outreach & Education

Tanya Hardiman, Analyst, Provider Outreach & Education

Medicare has identified inpatient hospital visits as an area of concern. Come join us to discuss the

documentation requirements for these services. We will discuss the E/M components and what we

and other reviewers are expecting to see in the documentation. We will provide documentation

examples of the good, the bad and the ugly and discuss the concerns of the reviewers along with

additional helpful hints.

Target Audience: Part A & B, Administrators, Billers, Clinicians, Coders

Facility Based Services

Avoid Payment Errors – Present on Admission (POA) Indicators and Patient Discharge Status Codes Janet Mateo, Analyst, Provider Outreach & Education

Are you reporting Present on Admission indicators correctly? Did you know that inaccurate reporting

of a patient discharge status code can lead to an underpayment or overpayment? During this session,

we will review the POA reporting guidelines and discuss common miscoded POAs. We will also

review common patient discharge code errors and look at how incorrect coding leads to claim errors.

Target Audience: Part A, Coders, Billers, Office Staff

Avoiding Recoupment and Retaining Dollars - SNF Certification/Recertification Statements


The CERT Contractor has been recouping dollars from Skilled Nursing Facilities due to their failure to

obtain proper certification or recertification statements. Don’t let this happen to you! During this

session, we will discuss common medical practices and how to properly document acceptable

certification and recertification statements.

Target Audience: Part A, Skilled Nursing Facilities – All Staff

11 | P a g e

Hospital Admission Criteria



CMS has fundamentally altered the manner in which hospitals define how inpatient status and

outpatient observation is determined. It is critically important for physicians and hospitals to work

together to apply the correct payment policy for Medicare patients. Join us for this session on

hospital admission criteria and learn what you need to know when requesting a hospital bed.

Target Audience: Part A & B, Utilization Review Staff, Admitting Personnel, Physicians, Practitioners

Increase Your Inpatient Psychiatric Facility (IPF) Revenue by Decreasing Your Errors

Janet Mateo, Analyst, Provider Outreach & Education


Is your facility losing money on denials resulting from insufficient documentation errors, medically

unnecessary services, or treatment errors? In this session we will review the IPF CERT errors,

provide examples of IPF improper payments and provide guidance to avoid errors.

Target Audience: Part A, Billers, Office Staff

Preventive Services

The ABC’s of the Initial Preventive Physical Exam (IPPE) & Annual Wellness Visit (AWV)


Aileen Sigler, Analyst, Provider Outreach & Education

The IPPE and AWV focus on disease detection, prevention and lifestyle modifications that can help

beneficiaries live longer, healthier lives. Many providers still have questions and struggle with

completing all the elements to make it a covered service. Join us as we explore the fundamentals of

these important benefits. Topics include: the components of the IPPE and AWV, who can perform the

service, how to correctly bill for them and so much more!

Target Audience: Part A & B, Coders, Billers, Office Managers, Compliance Staff

12 | P a g e

Skilled Nursing Facility Consolidated Billing

SNF Consolidated Billing – To Bill, or Not to Bill, That is the Question

Karen Kroupa, Analyst, Provider Outreach & Education

Tanya Hardiman, Analyst, Provider Outreach & Education


Join us in this audience participation session to get your SNF Consolidated Billing questions

answered. This unique breakout session brings Part A SNFs and all other providers together for an

interactive discussion on when to bill the SNF or Medicare program for services rendered. Learn how

to use best practices to bill correctly the first time. We’ll show you resources recommended by CMS

to add to your own best practices to make SNF CB easier.

Target Audience: Part A & B, Coders, Billers, Office Staff, Compliance Staff

13 | P a g e

WPS Medicare Staff Bios

Bringing you over 200 years of Medicare experience!

Ellen Berra, POE Senior Analyst, has over 25 years of experience in the Medicare program and

joined Provider Outreach and Education in 1996. Ellen’s experience in Medicare includes Claims,

Appeals, Congressional Inquiries, and Fair Hearings. She has led many teams in creating Medicare

educational material for standard educational topics and specific material for specialty societies and

associations. She contributes educational articles on many different subjects to the website, e-News

and Communiqué.

Sue Brewer, POE Analyst, has 25 years of Medicare experience. Her responsibilities include

presenting seminars on a variety of topics. Previous positions held include Supervisor of Claims

Development and Medicare Secondary Payer (MSP) units, Training Specialist and Fair Hearing

Officer. Sue graduated from the University of Wisconsin at Madison.

Maria Diaz, POE Customer Service Specialist, has over 13 years of Medicare experience and has

been in her current position for the last 5 years. She is responsible for reporting, assisting with

educational material, and working with the provider community. Prior to this, Maria held positions as

a Medicare Customer Service Representative, assisting providers with billing questions; as an

internal trainer, teaching staff all aspects of Medicare billing, system usage and regulations; and in

the technical department testing new implementations and solving technical issues with claims.

Jan Ervin, POE Analyst, has over 9 years of Medicare experience and has been in her current

position since 2008. Her Medicare background began with Mutual of Omaha Medicare in 2006 as a

Cost Report Auditor. Her primary job responsibilities involve facilitating educational seminars,

webinars and teleconferences for various facilities throughout the United States. Jan earned her

BSBA in accounting at University of Nebraska at Omaha.

Mary Sue Gardner, RN/BSN, POE Senior Nurse Analyst, brings over 13 years of Medicare

experience the POE team. She has a Bachelor of Science in Nursing (RN/BSN) from Methodist

College of Nursing, in Omaha, Nebraska. Prior to working in Medicare, Mary Sue spent many years

practicing clinically in various inpatient and outpatient settings. She has worked in the Medical Review

department as well as POE. Mary Sue provides clinical education in all WPS contracts of work

throughout the United States.

Tanya Hardiman, POE Analyst, brings 11 years of Medicare experience to her current position. She

spent three years as a Customer Service Representative before joining the POE team. Her duties

include conducting Medicare seminars, teleconferences, and webinars as well as developing “self-

service” educational tools on various Medicare topics. Tanya is a graduate of Southwest Minnesota

State University with a degree in Sociology.

14 | P a g e

Karen Kroupa, POE Analyst, has over 11 years of experience in various Medicare departments. She

started as a Claims Examiner, then as a Customer Service Representative before joining POE. Prior

to working for Medicare, she worked in Mutual of Omaha Insurance Company’s Large Group Health

Plan department. Karen has a BA in English, Art and Art History from the University of Nebraska at

Omaha.

Janet Mateo, POE Analyst, has over 16 years of Medicare experience. Janet’s primary job

responsibilities include education and training for Medicare providers in various states. Before joining

Mutual of Omaha in 1999, Janet was employed by the National Multiple Sclerosis Society for 10

years at local chapters in New Jersey and Illinois. Janet possesses a Masters in Social Work

Administration and a Bachelor of Science degree from Rutgers University in New Brunswick, New

Jersey. Janet also received training from the Center for Postgraduate Studies in Psychotherapy in

Red Bank, New Jersey.

Mary E. Muchow, POE Senior Analyst, has over 34 years of Medicare experience. Mary held

previous positions in Claims Examination/Entry, Medical Review, and Training. Prior to joining the

POE team, Mary worked in the Benefit Integrity Unit as an investigator and trainer. Later, as the

Medicare Fraud Information Specialist (MFIS), Mary represented multiple contractors as a liaison

between federal investigators, prosecutors, CMS, and other agencies. In this role, Mary often

presented relevant Medicare fraud and abuse topics to law enforcement and audiences on a national

level. Mary joined POE in 2003 where she provides outreach activities, provider education and the

development of partnerships with various societies and associations.

Thom Ryan, POE Senior Analyst, has over 10 years of Medicare experience. He began his career

with WPS in the Tricare division. In 2005, he joined POE where his primary focus is technology and

face-to-face education. Thom holds a bachelor degree in Social Work from Winona State University.

K. Cheyenne Santiago, RN, POE Senior Nurse Analyst, brings over 8 years of experience to the

POE team. She is responsible for clinical education for the provider community including training on

Medicare rules, regulations and clinical coverage criteria, as well as current health care practice

trends. She holds an Associate of Science in Nursing (RN/ASN) from Excelsior College School of

Nursing, in Albany, New York.

Aileen Sigler, Outreach Analyst, has over 17 years of Medicare experience. Her primary job

responsibilities include developing and facilitating seminars, teleconferences and webinars for the

provider community. She held prior positions in the Claims, Customer Service and internal Training

departments before joining Provider Outreach & Education in June of 2005.

15 | P a g e

Denise Stanley, Supervisor, has 17 years of experience in the Medicare program, including 5 years

in the Benefit Integrity Unit investigating potential fraud and abuse. Denise is currently the CERT

Supervisor in the Medical Review department. In this role, she serves as a liaison between the CERT

contractors and the provider community. Her responsibilities include analysis of CERT review

findings, providing current content for the WPS Medicare CERT web page, responding to provider

inquiries for CERT review results and collaboration with POE for educational events.

Sheryl Torres, Manager, has 20 years of experience in the Medicare program. In this role, she

oversees the day to day operations of Provider Outreach and Education activities. In addition to her

current role, Sheryl has held various positions in Customer Service, Quality Assurance and prior POE

responsibilities.

Thank you for joining us today!

16 | P a g e

a day with medicare · 2015. 3. 4. · process, cert review results, cms goals and potential...

Documents