MD AAHAMMedicare Part A Presents:

Manual Medical Review Therapy Exception Process and Therapy Coverage

November 16, 2012

Disclaimer All Current Procedural Terminology (CPT) codes and descriptors used in this presentation

are copyright© by the American Medical Association. All rights reserved.

The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Novitas Solutions does not permit videotaping or audio recording of training events.

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Agenda Change Requests 8036 and 7881

Frequently Asked Questions

Coverage and Documentation

Part A Claim Requirements

Comprehensive Error Rate Testing Program

Self Service Options

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Manual Medical Review of Therapy Services

Change Request 8036Change Request 7881 Expiration of 2012 Therapy Cap Revisions and User-Controlled Mechanism to

Identify Legislative Effective Dates

Middle Class Tax Relief and Job Creation Act of 2012 Section 3005 -Middle Class Tax Relief and

Job Creation Act of 2012

Effective October 1, 2012

All requests for therapy services above $3700 need to be pre approved

No automatic exception to this new process

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Manual Medical Review of Therapy Services Provider Bulletin Issued September 7, 2012

Outlines Novitas Solutions structure on how we are handing Manual Medical Review of Therapy

Coversheets for submitting a request included with the bulletin

For more information, please view the bulletin: https://www.novitas-solutions.com/bulletins/all/news-09072012.html

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Therapy Cap Certain providers are required to submit a

request for an exception in advance of furnishing therapy services above the threshold of $3,700.  

The request will be manually medically reviewed. 

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Provider Settings Part B Skilled Nursing Facilities Comprehensive Outpatient Rehabilitation

Facilities Outpatient Rehabilitation Facilities Private Practices Home Health Hospital Outpatient

◦ Except Critical Access Hospitals

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Caps/Threshold $3,700 for both Physical Therapy and

Speech Language Pathology◦ $1,880; -KX with automatic exception

$3,700 for Occupational Therapy◦ $1,880; -KX with automatic exception

Services on or after October 1 - December 31, 2012◦ Without automatic exception, continue reporting ◦ -KX

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Phases Phase I

◦ October 1, 2012 through December 31, 2012

Phase II◦ November 1, 2012 through December 31, 2012

Phase III◦ December 1, 2012 through December 31, 2012

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Knowing Your Phase Therapy Provider Phase Information

◦ https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t

◦ Listed by National Provider Identifier

◦ If not listed, placed in Phase III

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Submitting Pre-Claim Review

Submit pre-approval no sooner than the 15th of the month prior to assigned Phase

Request pre-approval for a specific number of days

Days should not exceed 20 per discipline Decision will be made within 10 business

days◦ By letter, phone, or fax

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Documentation Required for Pre-Approval Beneficiary Last Name Beneficiary First Name Beneficiary Middle Initial Beneficiary Medicare Claim Number (HICN) Beneficiary Date of Birth Beneficiary Address and Telephone Number Name and address of Provider Certifying

Plan of Care Telephone and Fax Number of Provider

Certifying Plan of Care

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Documentation Required for Pre-Approval continued National Provider Identifier (NPI) of Physician/Non-

Physician Practitioner Certifying Plan of Care Name of Performing Provider Address of Performing Provider NPI of the Performing Provider Telephone and Fax Number of Performing Provider Number of Treatment Days Requested Expected Date Range of Services Date of Submission

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Approvals Approvals

◦ Providers and Beneficiaries Notified within 10 business days by letter, phone or

fax

◦ Failure to make decision = automatic approval of request

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Denials Denials

◦ Providers and Beneficiaries Notified within 10 business days by letter, phone or

fax◦ Include detailed reason(s) for the determination

Unapproved services rendered will be denied◦ Submit an Appeal

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Unapproved Services Not Rendered

Send a new preapproval request only when◦ The original request was denied◦ Additional information is available

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Pre-Claim Review Requests All requests require the Therapy Cap Cover/

Transmittal Sheet

Can be requested by fax or mail

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Part A Therapy Cap Cover/ Transmittal Sheet To view the entire Part A form, refer to:

◦ https://www.novitas-solutions.com/claims/therapy-cap/pdf/ther-cap-a.pdf

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Part A Pre-Claim Review Requests Place the Therapy Cap Cover/Transmittal

Sheet on top of the Pre-authorization request

Submit request◦ By fax: 412-802-1833◦ By mail:

Novitas Solutions, Inc. Therapy Cap Part A Post Office Box 890365 Camp Hill, PA 17089-0365

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Beneficiary Liability When conditions for exception are not met

the beneficiary is financially responsible

There is no legal requirement to issue an Advanced Beneficiary Notice (ABN)◦ Voluntary ABNs are strongly recommended

For Additional information, refer to:◦ http://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medical-Review/TherapyCap.html

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Frequently Asked Questions

What Should I Expect? Upon receipt of the all requested records,

Novitas Solutions, Inc. will review the records and make a decision (number of days approved and/or denied).  

This determination will be made using the coverage and payment policy requirements contained within Pub.  100-02, Section 220 of the Medicare Benefit Policy Manual and any applicable local coverage decisions when making decisions as to whether a service shall be preapproved.

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How will I know if my Request is Approved? If Novitas Solutions, Inc. approves your request,

you will be notified of this decision within 10 business days via letter, telephone, or fax.   The beneficiary will also be notified of this approval via telephone, fax, or letter. 

If Novitas Solutions, Inc. fails to make a decision within 10 business days, this will lead to an automatic approval of the request.  The provider and beneficiary will be notified of this automatic approval via telephone, fax, or letter. 

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How will I know if my Request is Denied?

If the request for an exception is denied, Novitas Solutions will provide notification via telephone, fax, or letter of denial to the provider and beneficiary.  This notification will include detailed reason(s) for the determination.

If the provider furnishes the denied services and submits a claim, this claim would not be payable under Medicare. The claim will be denied and the beneficiary would be held liable.

A provider may render the services that are unapproved and submit the claim, which shall be denied by Novitas Solutions, Inc.  At that time, the provider may request an appeal.

If the provider chooses to not render the unapproved services, they may send in a new preapproval request only if they have additional information to supply and the original request was denied.

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What Does the $3,700 Threshold Represent? The threshold represents the total allowed

charges under Part B for services furnished by independent practitioners, and institutional services under Part B (hospital outpatient departments, skilled nursing facilities).

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Does Therapy Provided in a Critical Access Hospital (CAH) Count?

Services provided in a CAH are not counted, and CAHs are not subject to the manual medical review provision.

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How do I Determine if a Patient is close to the cap or $3700 threshold?

Total therapy dollars used is available in:

◦ Interactive Voice Response(IVR)

◦ Health Insurance Query Access (HIQA)

◦ The Common Working File (CWF)

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Reporting Requirements

New Part A Claim Reporting Requirements Effective 10/1/2012, for outpatient therapy

services, Report Name and NPI of the physician/NPP certifying the therapy plan of care in the Attending Physician field

◦ UB-04 Paper Claims: Field Locator 76

◦ Direct Data Entry: Bottom of Page 3 (MAP1713)

◦ Electronic Claims: Loop 2310A

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Existing Claim Reporting Requirements Continue to use therapy modifiers:

◦ Modifier GN: Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care

◦ Modifier GO: Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care

◦ Modifier GP: Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care

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KX Modifier on claims Reminder: Use of the KX Modifier is an

attestation from Provider or Supplier that:◦ The services are reasonable and necessary◦ There is documentation of medical necessity in

the patient’s medical record◦ Other requirements specified in Internet Only

Manuals are met Append KX Modifier to applicable claims for

services above:◦ The therapy caps of $1880◦ The therapy thresholds of $3700

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Claims Exceeding the $3700 Threshold All Claims for beneficiaries that meet or

exceed the $3700 threshold will suspend

◦ If provider is NOT in Phase, Novitas will process your claim regularly

◦ If provider IS in Phase, then we’ll check: If pre-approval was granted, claim will be processed If pre-approval was denied, claim will be denied If pre-approval request was not submitted, we will

request medical records

Comprehensive Error Rate Testing (CERT)

Comprehensive Error Rate Testing (CERT) National Claim Paid Error Rate

◦ Part A Institutional Facilities 7.9% Inpatient hospitals 4.4% Non-inpatient hospital facilities

◦ Part B Physician/Non-physician providers 9.2% Physician, lab and ambulance

Impacts all providers submitting Fee for Service claims

Limited random claim sample

Record requests must be received within 30 days from the initial CERT letter

Right to Appeal? Yes

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Common Part A Errors Insufficient documentation:

◦ Missing physician's orders for billed dialysis treatments and/or diagnostic laboratory tests associated with the dialysis treatments;

◦ Missing valid orders for Epogen or Venofer and/or insufficient documentation to support Epogen dosing per the submitted protocols and dosing algorithms;

◦ Missing physician's progress notes or occupational therapy notations to support severity of conditions, comorbidities, or other complexities necessitating the use of the KX modifier;

◦ Medical record did not contain a valid physician’s order, documented order intent or clinical indication for the service, e.g., laboratory testing, medications, inpatient admission;

◦ Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed; ◦ No documentation submitted to support prior conservative treatment for the patient; therefore subsequent procedures

were deemed not medically reasonable and necessary, e.g., inpatient admission, medications, supplies; and ◦ Lack of documentation (hospital inpatient discharge summary) to support 3 day qualifying stay prior to Skilled Nursing

Facility (SNF) admission.

Medical necessity errors:◦ Inpatient stays that were determined to not be medically reasonable and necessary based on the submitted

documentation.  The medical record documentation that was submitted did not substantiate the beneficiary’s need for an inpatient stay, but rather justified that the beneficiary’s condition could have been treated on an outpatient/observation basis;  and

◦ Related services that were required as a result of the primary service were denied because the medical necessity of the primary service was not justified, e.g. venipuncture, pathology services.

Incorrect coding errors:◦ Incorrect number of units of medications billed specifically the administration of Epogen related to chronic kidney

disease; ◦ Incorrect laboratory tests billed, e.g. Complete Blood Count (CBC) with automated differential was performed (85025)

and billed when the physician only ordered a CBC (85027).

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Comprehensive Error Rate Testing (CERT) Center Medical Record Requests

Common Errors

Articles and Frequently Asked Questions

References and Contact Information

https://www.novitas-solutions.com/cert/index.html

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Website Changes

New Medical Policy Center

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New Medical Policy Search

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Self Service Options

Customer Service Center

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Customer Service Center Some of the items you can find in this new center

◦ Single Toll Free Call Flow Step-by-Step guide to using the Interactive Voice Response (IVR)

◦ System Access Part A Fiscal Intermediary Standard System (FISS) User Guide Part B Professional Provider Telecommunication Network (PPTN) Guide

◦ Frequently Asked Questions (FAQs) Top Provider Inquiries

◦ References AB Reference Manual Part A Claims Issues Log

◦ Contact Information Inquiry Guide Contact Us

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Customer Contact Information

Provider◦ 1-877-235-8073◦ Hours of Operation

Monday: 8:00 am – 2:00 pm Tuesday – Friday: 8:00 am – 4:00 pm

◦ Call Flow Customer Service Center https://www.novitas-solutions.com/csc/index.html

Interactive Voice Response (IVR)◦ Hours of Operation

Monday: 6:00 am – 8:00 pm Tuesday - Friday: 4:00 am – 8:00 pm Saturday: 6:00 am – 4:00 pm

◦ Step-by-Step Guide Customer Service Center https://www.novitas-solutions.com/csc/index.html

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Beneficiary Contact Information Patient / Medicare Beneficiary

◦ 1-800-MEDICARE (1-800-633-4227) http://www.medicare.gov/default.aspx

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Part A Annual Recertification of Fiscal Intermediary Standard System Logon

Recertify active users with access to Direct Data Entry (DDE) and the Health Insurance Query Access (HIQA)◦ Initial letter

60 days to respond◦ Second letter

30 days to respond◦ No response will result in the deletion of the

Resource Access Control Facility (RACF) identification (ID) associated with the Provider Transaction Access Number (PTAN)

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Fax to Image Were you aware records for an Additional Development Request (ADR) can be faxed

directly to Novitas Solutions?

The fax to image option allows for documentation to be submitted directly to Novitas Solutions. ◦ Available 24 hours a day, 7 days a week◦ Fax ADR response to 1-877-439-5479

Faxes should not exceed 200 pages

The original ADR request must be submitted as the cover sheet to the records

Supporting documentation, or requested medical records, should follow the ADR letter

Each ADR request must be faxed separately

Additional Tips◦ https://www.novitas-solutions.com/bulletins/parta/newsletter/2012/jan.html ◦ https://www.novitas-solutions.com/bulletins/partb/med-reports/pdf/mr0312.pdf

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Medicare Insights Weekly Podcast Weekly podcast covering important

Medicare news and events

Automatically delivered

Easy to subscribe, just copy the link to your podcast software

https://www.novitas-solutions.com/podcasts/

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Medicare Part A & Part B Center Our website offers a wide variety of valuable

resources including: ◦ A/B Reference Manual◦ Appeals ◦ Cost Reporting & Reimbursement◦ Electronic Billing (EDI) ◦ Frequently Asked Questions◦ News and Bulletins◦ Self-Service Tools

For additional resources visit:◦ https://www.novitas-solutions.com/parta/index.html ◦ https://www.novitas-solutions.com/partb/index.html

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Mailing List Subscribe to our E-Mail Lists

◦ https://www.novitas-solutions.com/mailinglists.html

Available mailing lists◦ Jurisdiction 12 Part A or Part B General Education

Receives All Updates, except Electronic Data Interchange (EDI)

◦ Jurisdiction 12 Part A or Part B Electronic Billers (EDI)

◦ Part A & Part B PC-ACE Pro32 Users (EDI)

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Evaluation and Management (E/M) Center Evaluation and Management (E/M) Center

◦ Offers an array of educational resources which will assist you in coding E/M services

◦ The E/M Center allows you to access information from one convenient location

◦ https://www.novitas-solutions.com/em/index.html

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Part A Fiscal Intermediary Standard System Hours District of Columbia (DC), Maryland (MD),

New Jersey (NJ), Pennsylvania (PA)◦ Monday – Friday

6 am – 9 pm◦ Saturdays

6 am – 4 pm

Delaware (DE)◦ Monday – Friday

6 am – 6 pm◦ Saturdays

6 am – 4 pm

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Calendar of Events Our Training and Events Center offers a

wide variety of education

Join us for Workshops, Teleconferences, and Webinars

To view the most current calendar of events, visit:◦ https://www.novitas-solutions.com/training/index.

html

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Centers for Medicare & Medicaid Services (CMS) The CMS website offers valuable resources

such as: ◦ CMS Internet Only Manuals (IOMs)◦ Medicare Learning Network (MLN) Matters Articles◦ Open Door Forum

For additional resources visit:◦ http://www.cms.gov/

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Send In Your Survey Electronically and Thanks for Your Participation We value your feedback to measure the

effectiveness of this program and to prepare for future events

Send the survey electronically; it is easy, just click and submit◦ Webinars:

https://www.novitas-solutions.com/calendar/parta/webinar/index.html

https://www.novitas-solutions.com/calendar/partb/webinar/index.html

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