Top 10 Medicare Denials for CPT Codes: What Providers Need to Know

Navigating Medicare’s denial landscape can be challenging for healthcare providers, as denied claims lead to lost revenue and increased administrative costs. Understanding the most frequently denied CPT (Current Procedural Terminology) codes and the reasons behind these denials can help healthcare organizations improve reimbursement rates and avoid costly errors. Here’s an in-depth look at the top 10 Medicare-denied CPT codes, along with best practices for reducing these denials.

1. CPT 99214 - Established Patient Office Visit (Moderate Complexity)

• Common Denial Reasons: Documentation insufficiency, lack of medical necessity, and coding errors.
• Tips to Avoid Denial: Ensure that the complexity level matches the documentation. Include all necessary elements, such as patient history, exam, and medical decision-making, to support the coding level.

2. CPT 99396 - Preventive Medicine Visit (Established Patient, 40-64 Years)

• Common Denial Reasons: Medicare often denies this as “not medically necessary,” as it does not cover preventive services under certain plans.
• Tips to Avoid Denial: Confirm Medicare coverage eligibility and verify if the patient’s plan includes preventive services or if an Advance Beneficiary Notice (ABN) is required.

3. CPT 36415 - Collection of Venous Blood by Venipuncture

• Common Denial Reasons: Service duplication, medical necessity, and bundling issues.
• Tips to Avoid Denial: Confirm that the service is separately payable under the patient’s plan and avoid double-billing when venipuncture is performed with other services.

4. CPT 99203 - New Patient Office Visit (Low Complexity)

• Common Denial Reasons: Incomplete documentation, coding errors, and new patient criteria not met.
• Tips to Avoid Denial: Make sure all required documentation is included, and confirm the patient qualifies as “new” under Medicare guidelines (no professional services provided by the same provider within the last three years).

5. CPT 99308 - Subsequent Nursing Facility Care (Low Complexity)

• Common Denial Reasons: Missing medical necessity and documentation inadequacies.
• Tips to Avoid Denial: Properly document the patient’s condition, services rendered, and reasons for continued nursing facility care to demonstrate medical necessity.

6. CPT 97110 - Therapeutic Exercises (Per 15 Minutes)

• Common Denial Reasons: Lack of documentation to support skilled therapy, exceeding therapy limits, and bundling issues.
• Tips to Avoid Denial: Include detailed notes about therapy goals, progress, and the medical need for ongoing therapy sessions.

7. CPT 99233 - Subsequent Hospital Care (High Complexity)

• Common Denial Reasons: Documentation not supporting complexity, duplication with other codes, and lack of medical necessity.
• Tips to Avoid Denial: Ensure that documentation reflects the high complexity required for this code. Include all elements that substantiate the need for a high-complexity visit.

8. CPT 97010 - Application of a Modality to 1 or More Areas; Hot or Cold Packs

• Common Denial Reasons: Bundling with other services, and Medicare’s non-coverage policy on certain modalities.
• Tips to Avoid Denial: Review Medicare’s bundling policies to determine if the service is covered when provided alongside other therapy services.

9. CPT 80050 - General Health Panel

• Common Denial Reasons: Medicare often does not consider this medically necessary or denies it for exceeding frequency limits.
• Tips to Avoid Denial: Verify if specific components of the panel are covered individually rather than billing the panel as a whole, and confirm the medical necessity before billing.

10. CPT 85025 - Complete Blood Count (CBC) with Automated Differential

• Common Denial Reasons: Medical necessity and frequency limitations.
• Tips to Avoid Denial: Confirm Medicare’s coverage guidelines on frequency and ensure a documented medical reason that justifies ordering the test.

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Key Takeaways for Reducing Medicare Denials

While the reasons for denial vary by code, there are general steps providers can take to minimize the risk:

• Prior Authorization and Coverage Checks: Verify whether the service is covered under the patient’s specific Medicare plan before providing it.
• Proper Documentation: Ensure that medical records comprehensively support the coding level and medical necessity for the service rendered.
• Staff Training: Educate billing and coding staff on Medicare’s policies, including frequent updates to covered services and CPT code guidelines.
• Advance Beneficiary Notices (ABNs): For services with unclear coverage, obtain ABNs from patients to ensure transparency and reduce the likelihood of unexpected denials.

Final Thoughts

By proactively addressing the most commonly denied CPT codes, healthcare providers can reduce administrative burdens, speed up reimbursement, and maintain financial stability. Addressing the underlying causes of denials—whether they involve coding accuracy, documentation, or policy awareness—is essential to a smooth and efficient revenue cycle.

What the Healthcare Industry Can Learn from the Change Healthcare Security Breach

Introduction

In today's digital age, the healthcare industry stands at the intersection of cutting-edge technology and sensitive patient data management. As healthcare organizations increasingly rely on electronic health records (EHRs), telemedicine, and data analytics, the importance of robust cybersecurity measures cannot be overstated. The recent Change Healthcare security breach serves as a stark reminder of the vulnerabilities that exist within healthcare systems and underscores the critical need for comprehensive security strategies. This article explores the details of the breach, its implications, and the essential lessons that the healthcare industry must embrace to prevent future incidents.

Understanding the Change Healthcare Security Breach

Change Healthcare, a prominent provider of data and analytics-driven solutions to the healthcare sector, experienced a significant security breach that compromised sensitive patient information. While the specific details of the breach may vary based on the latest reports, such incidents typically involve unauthorized access to databases containing Protected Health Information (PHI), financial records, and other confidential data. Common features of such breaches include:

• Unauthorized Access: Hackers or malicious insiders gaining entry to secure systems.
• Data Exfiltration: Extraction of sensitive information, which can be used for fraudulent activities or sold on the dark web.
• Service Disruption: Temporary shutdowns or disruptions in service delivery, affecting both patients and healthcare providers.

Implications of the Breach

The ramifications of a security breach in the healthcare industry are profound and multifaceted:

1. Erosion of Patient Trust: Patients entrust healthcare providers with their most sensitive information. A breach can severely damage this trust, leading to decreased patient engagement and loyalty.
2. Financial Losses: The costs associated with data breaches are substantial, encompassing regulatory fines, legal fees, and expenses related to remediation efforts.
3. Reputation Damage: A compromised reputation can hinder an organization's ability to attract and retain clients, partners, and top-tier talent.
4. Operational Disruptions: Breaches can interrupt essential services, impacting patient care and overall operational efficiency.

Key Lessons for the Healthcare Industry

The Change Healthcare security breach highlights several critical areas where the healthcare industry must focus to bolster its defenses against future cyber threats. Here are the top ten lessons:

1. Strengthen Cybersecurity Frameworks

Adopt Comprehensive Security Protocols: Implementing robust firewalls, intrusion detection systems, and encryption methods is essential to protect data both at rest and in transit. Regularly updating these protocols to address emerging threats is equally important.

Regular Security Audits: Conducting frequent assessments helps identify and mitigate vulnerabilities within the IT infrastructure. These audits should evaluate both hardware and software components, ensuring that all potential entry points are secured.

2. Enhance Employee Training and Awareness

Continuous Education: Employees are often the first line of defense against cyber threats. Regular training sessions on the latest cybersecurity threats, safe handling of PHI, and best practices for data protection are crucial.

Phishing Simulations: Implementing simulated phishing attacks can educate employees on recognizing and responding to suspicious activities, reducing the risk of successful phishing attempts.

3. Implement Multi-Factor Authentication (MFA)

Layered Security: MFA adds an extra layer of security by requiring multiple forms of verification before granting access to sensitive systems. This significantly reduces the risk of unauthorized access, even if passwords are compromised.

4. Ensure Compliance with Regulatory Standards

HIPAA Compliance: Adhering strictly to the Health Insurance Portability and Accountability Act (HIPAA) guidelines is non-negotiable. Compliance ensures that patient information is adequately protected and that organizations are prepared for potential audits.

Regular Updates: Staying informed about changes in regulations and ensuring that security measures are updated accordingly is vital for maintaining compliance and protecting data.

5. Develop a Robust Incident Response Plan

Preparedness: Having a clear, actionable plan in place allows organizations to respond swiftly and effectively to security breaches, minimizing damage and restoring operations promptly.

Communication Strategy: Establishing protocols for communicating with stakeholders, including patients, regulators, and the public, is essential during and after a breach to maintain transparency and trust.

6. Invest in Advanced Threat Detection Technologies

AI and Machine Learning: Leveraging advanced technologies can help detect unusual patterns and potential threats in real-time, enabling proactive measures to prevent breaches.

Behavioral Analytics: Monitoring user behavior can identify and mitigate insider threats and compromised accounts, adding an additional layer of security.

7. Secure Third-Party Vendors

Vendor Assessments: Conducting thorough security assessments of third-party partners ensures that they adhere to stringent security standards, reducing the risk of breaches through external channels.

Contractual Obligations: Including security requirements and breach notification clauses in vendor contracts ensures accountability and timely communication in the event of a security incident.

8. Regular Data Backups and Recovery Testing

Backup Strategies: Implementing regular data backup routines ensures that data can be restored in the event of a breach, minimizing downtime and data loss.

Disaster Recovery Testing: Periodically testing recovery procedures ensures that they are effective and efficient, allowing for swift restoration of operations when needed.

9. Promote a Culture of Security

Leadership Commitment: Organizational leadership must prioritize cybersecurity and allocate necessary resources to maintain robust security measures.

Employee Engagement: Fostering an environment where every employee feels responsible for maintaining data security encourages proactive behavior and vigilance against potential threats.

10. Monitor and Limit Data Access

Least Privilege Principle: Granting employees access only to the data necessary for their roles reduces the risk of internal breaches and limits the potential impact of unauthorized access.

Access Controls: Implementing stringent access controls and regularly reviewing permissions helps prevent unauthorized access and ensures that only authorized personnel can access sensitive information.

Conclusion

The Change Healthcare security breach underscores the critical need for the healthcare industry to prioritize cybersecurity. As healthcare organizations continue to embrace digital transformation, the importance of protecting sensitive patient information becomes increasingly paramount. By learning from such incidents and proactively implementing the strategies outlined above, healthcare providers can significantly reduce the risk of future breaches. This not only ensures the security and privacy of patient data but also maintains the trust and confidence that are essential for delivering quality care.

Final Thoughts

Cybersecurity is not a one-time effort but an ongoing commitment that requires continuous evaluation and adaptation. Healthcare organizations must remain vigilant, investing in the latest technologies, fostering a culture of security, and staying informed about evolving threats and regulatory changes. By doing so, the industry can safeguard its most valuable asset—patient trust—and ensure the continued delivery of exceptional healthcare services.

Call to Action

How is your organization enhancing its cybersecurity measures in response to recent breaches? Share your experiences, challenges, and strategies below! Let’s collaborate to build a more secure healthcare environment.

Services Offered by Medicare SPOT

Discover what you can do on the SPOT

First Coast’s Secure Provider Online Tool (SPOT) is a free Web-based application hosted through the Centers for Medicare & Medicaid Services’ Enterprise Identity Management (EIDM) portal external link.

The SPOT: User Guide pdf file and the On-the-SPOT FAQs will show you everything you want to know about:
http://medicare.fcso.com/Help/256025.pdf

*** Benefits/Eligibility Data
*** Claim Data
*** Claim Status
*** Part B Claim Reopening
*** Payment Data
*** Secure Mail (electronic form submission)
*** Part A/B Claim Redetermination Requests
*** Part A Claim Reopening Request
*** Part B MSP and Non-MSP Overpayment Forms
*** Part B Overpayment Redetermination Request
*** Part A/B General Inquiry Requests
*** Data Reports
*** Part A/B Provider Data Summary (PDS)
*** Part B Comparative Billing Report (CBR)


SPOT new account registration will temporarily close March 1 - 15

First Coast Service Options Inc. has suspended processing of new SPOT (Secure Provider Online Tool) account applications and new profile requests through March 15, 2016 due to system updates associated with the annual recertification process.

Providers seeking new SPOT accounts or additional profiles before March 15 may complete the application step and submit it for review. However, new account and additional profile requests will not be reviewed/approved until after processing resumes March 16.

Active SPOT account holders will still enjoy the benefits of its functionality, including the ability to view claims status and patient eligibility information, and to submit redeterminations and additional development responses (ADRs) online. Providers will also have full access to other SPOT features such as detailed data analysis at the claim and provider levels, and the ability reopen claims to make clerical corrections at multiple lines.

If your SPOT password expires during this period, you will still be able to access your account by following these steps to unlock your account and reset your password.

First Coast provides a step-by-step guide to assist you in establishing a new SPOT account. Most providers are able to complete the application and begin using SPOT to streamline their Medicare billing within 48 hours.

How to change password in Medicare CMS SPOT

Q: How often do I need to change my password, and how do I change it?

A: You must log in to the EIDM portal external link once every 60 days to change your password. You may change your Password as well as personal information associated with your Enterprise
Identity Management (EIDM) account through the My Profile menu on the EIDM website.


Change Password

1. Navigate to CMS’ EIDM portal: https://portal.cms.gov

5. Select My Profile from the My Portal menu
6. The View My Profile page will appear
7. Select Change Password from the Change My Profile left-navigation menu

8. Enter appropriate values in the following fields:

a. Old Password

b. New Password

c. Confirm New Password

9. Click the Next button, and the confirmation page will appear

Medicare part A & part B - Deductibel and coin 2016 - Announced

The Centers for Medicare & Medicaid Services (CMS) issued the 2016 deductibles, coinsurance, and premium rates for beneficiaries covered through the Medicare fee for service program. The 2016 deductible, coinsurance and base premium rates are:

2016 Part A - Hospital insurance

Deductible: $1,288.00

Coinsurance
• $322 a day for 61st-90th day
• $644 a day for 91st-150th day (lifetime reserve days)
• $161 a day for 21st-100th day (skilled nursing facility coinsurance)


2016 Part B - Supplementary medical insurance (SMI)

Under Part B of the Medicare supplementary medical insurance (SMI) program, enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute.

Deductible: $166 a year
Coinsurance: 20 percent

Medicaid Services (CMS) 855R Application - Reassignment of Medicare Benefits

Provider Types Affected
This MLN Matters Special Edition (SE) is intended for physicians, non-physician practitioners, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) and who choose to reassign their benefits or accept reassigned benefits of those claims.

Provider Action Needed
STOP - Impact to You
Physicians, non-physician practitioners, providers, and suppliers must use the revised CMS 855R (Reassignment of Benefits) application beginning June 1,2015.

CAUTION - What You Need to Know

The revised CMS 855R application will be available for use on the CMS.gov website as of December 29, 2014. MACs may accept both the current and revised versions of the CMS 855R through MAy 31, 2015, after which the revised CMS 855R application will be required to be submitted.
After May 31, 2015, MACs will return any newly submitted CMS 855R applications on the previous version (07/11) to the provider/supplier with a letter explaining that the CMS 855R has been updated and the current version of the CMS 855R (11/12) must be submitted.

GO-What You Need to Do
Make sure that your billing staffs are aware of these changes.

Background
Physician, non-physician practitioners, providers, and suppliers must use the revised CMS 855R application starting June 1, 2015. The revised CMS 855R has been stream lined and some sections have been re-ordered for clarity. The revised form includes an optional section for Physician Compare to help beneficiaries identify where their physicians are primarily practicing. This address must be one that is affiliated with the individual/organization where the benefits are being reassigned.

Billing and coverage for drug wastage

Can I bill for drug wastage from a multi-dose/multiuse vial or package of drug or biological?

Answer:

Providers may not bill for drug wastage for multi-does/multiuse vials or packages from which an amount is administered to one patient

Even if a provider is unable to store unused doses for later use because the pharmacy incorrectly reconstituted the drug using sterile water instead of bacteriostatic water, a provider may not bill for drug wastage in a multi-dose/multiuse vial or package

Tips for Submitting Accurate Claims:

Each HCPCS code is associated with a specific number of units and type of units may be described by various units of measure

Verify the number and type of units associated with the HCPCS code before calculating the quantity on your claim

Verify calculations with the physician if needed

Submit the number of units (based on the HCPCS code) for the amount actually administered and not the number of units in the entire multi dose/multiuse vial or package

First Coast Service Options Inc. (First Coast) will consider payment for the unused and discarded portion of a single-use drug/biological product after administration of the appropriate (reasonable and necessary) dosage for the patient’s condition. This applies to drugs priced through the Average Sales Price (ASP) drug/biological program. The Centers for Medicare & Medicaid Services (CMS) encourages physicians, hospitals, and other providers to provide injectable drug therapy incident to a physician’s services in a fashion that maximizes efficiency of therapy in a clinically appropriate manner. If a physician, hospital, or other provider must discard the unused portion of a single-use vial or other single-use package after administering a dose/quantity appropriate to the clinical context for a Medicare beneficiary, the program provides payment for the entire portion of drug or biological indicated on the vial or package label.

If less than a complete vial is administered at the time of service, and the unused portion is discarded, drug wastage must be documented in the patient’s medical record with the date, time, and quantity wasted. Upon review, any discrepancy between amount administered to the patient and the billed amount will be denied, unless wastage is clearly documented. The amount billed as “wastage” must not be administered to another patient or billed again to Medicare. All procedures for drug storage, reconstitution and administration should conform to applicable Federal Drug Administration (FDA) guidelines and provider scope of practice.

Note: For billing purposes, First Coast does not require the use of modifier JW. Drug wastage is billed by combining on a single line the wastage and administered dosage amount.

New or modified Remittance Advice Remark and Claims Adjustment Reason Code

New Codes – RARC Code Modified Narrative         Effective Date

N753  Missing/Incomplete/Invalid Attachment Control Number. 07/01/2015
N754 Missing/Incomplete/Invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form. 07/01/2015
N755 Missing/Incomplete/Invalid ICD Indicator on the 1500 Claim Form. 07/01/2015
N756 Missing/Incomplete/Invalid point of drop-off address, 07/01/2015
N757 Adjusted based on the Federal Indian Fees schedule (MLR). 07/01/2015
N758 Adjusted based on the prior authorization decision. 07/01/2015
N759 Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. 07/01/2015
M47 Missing/Incomplete/Invalid Payer Claim Control Number. Other terms exist for this element including, but not limited to, Internal Control Number (ICN), Claim Control Number (CCN), Document Control Number (DCN). 07/01/2015
MA74 ALERT: This payment replaces an earlier payment for this claim that was either lost, damaged or returned. 07/01/2015
N432 ALERT: Adjustment based on a Recovery Audit. 07/01/2015
N22 ALERT: This procedure code was added/changed because it more accurately describes the services rendered. 07/01/2015
M39 ALERT: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. 07/01/2015
M109 ALERT: This claim/service was chosen for complex review. 07/01/2015
M38 ALERT: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges. 07/01/2015
N381 ALERT: Consult our contractual agreement for restrictions/billing/payment information related to these charges. 07/01/2015
MA91 ALERT: This determination is the result of the appeal you filed. 07/01/2015
270 Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration. 07/01/2015
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability.) 11/01/15

Medicaid increases the payment of Pediatric

Pediatric Physician Rate Increase

Effective January 1, 2015, Current Procedural Terminology (CPT®) codes 99201 through 99496 will be reimbursed with an enhanced rate to pediatric physicians billing fee-for-service with one of the following specialty codes: 001, 019, 023 035, 036, 037, 038, 039, 043, 049, 059, 101,102.  The Physician Evaluation and Management Fee Schedule will be amended to reflect this change. 

Providers receiving reimbursement through a Medicaid managed care plan should refer to their contract with each plan to determine whether this change will impact their reimbursement from the plan.

How to fill/completing the PWK fax/mail coversheet

First Coast Service Options' (First Coast's) claims department is receiving a high volume of invalid or unnecessary PWK (5010 paperwork segment) fax/mail coversheets. If a coversheet is received containing inaccurate, incomplete, or invalid information, the coversheet will be either faxed or mailed back to the originating source, but without the documentation. Coversheets returned in this manner should not be resent; instead, the provider should await an additional documentation request (ADR) before submitting the documentation again to First Coast.

PWK issues

In other cases, the coversheets and additional documentation are not able to be appropriately attached to a claim due to several reasons. The following list has been developed to assist you in avoiding these situations.

1. PWK coversheet is received, completed accurately with documentation, but the claim was submitted without the indicators in the PWK loop.

• This will not allow us to assign the documentation in the system to the appropriate claim. If the claim requires documentation, an ADR letter will be sent and providers will need to respond to the letter.

2. PWK coversheet is received with the related documentation attached and a copy of our additional documentation request (ADR) letter. Again, the PWK loop indicators are not on the claim.

• There are two issues here: 1) without the PWK loop completed, the claim will not suspend to look for any anticipated documentation. Most importantly 2) the claim has already suspended for additional documentation; therefore, providers only need to respond to the ADR letter with appropriate documentation.

3. PWK coversheet is received with a request for an appeal/redetermination in the information box.

• The PWK process may only be used on initial claim submission. PWK cannot be used to bypass the standard appeals process. Please use the appropriate level of the appeals process if your claim has been denied or you need to make adjustments/corrections. Appeal requests submitted via the PWK fax/mail process will not be acknowledged.

4. In all of these instances, since the PWK fax/mail coversheet and/or claim is not being submitted correctly or with the correct information, the supporting documentation submitted to us is not being utilized to adjudicate the claim. Also, since in most cases this is outside of the standards for PWK, providers affected by these scenarios will not receive a response concerning the outcome or lack thereof.

5. Our internal claims area is being negatively impacted as well as our electronic storage capacity is being overwhelmed by unneeded, unusable documentation. Providers affected by this will more than likely never receive any indication of the negative impacts this is having on their claims.

Reminders

Here are some items to verify before faxing or mailing your form:

• Verify you have indicated the ACN (attachment control number [submitted in the PWK06 segment]), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, billing provider's name and NPI (national provider identifier) on the fax/mail coversheet.

• Include an address to mail the coversheet to, in case we are unable to fax it back to the originating number.

• Fax users: ensure to send your PWK fax coversheet and documentation to the appropriate locality fax line. Example: claims for providers in Puerto Rico should be faxed to the Puerto Rico fax line; claims for Florida providers to the Florida fax line; etc. If a coversheet is received into the incorrect faxination account, we will be unable to locate the claim.

• Do not send in documentation without the completed fax/mail coversheet.

• Do not use the PWK coversheet for any reason other than the PWK process.

How to submit document during first claim submission - detailed review - PWK segment

PWK allows documentation to be submitted with an initial claim

Effective October 1, 2012, First Coast Service Options Inc. (First Coast) implemented the PWK (paperwork) segment of the X12N version 5010. PWK allows for voluntary submission of supporting documentation with a 5010 version electronic claim.

PWK is a segment within the 2300/2400 Loop of the 837 Professional and Institutional electronic transactions that provides the link between electronic claims and additional documentation. PWK allows providers to submit electronic claims that require additional documentation and, through the dedicated PWK process, have the documentation imaged to be available during the claims adjudication. Eliminating the need for costly development and allowing providers and Medicare contractors to utilize efficient, cost-effective Electronic Data Interchange or EDI technology will create a significant cost savings.

Although PWK ultimately will allow electronic submission of additional documentation, the October implementation only allows for submission of additional documentation via mail and fax (PWK 02 segment, BM [by mail] and FX [by fax] qualifier, respectively).

First Coast has made available a fax/mail coversheet that providers or trading partners shall use to submit the unsolicited additional documentation. The First Coast fax/mail coversheet is an interactive form posted to our website. Providers or trading partners may complete required data elements and are then able to print a hardcopy of the form to mail or fax with their documentation. Modifications to the fax/mail coversheet are not permitted. Separate forms are provided for Part A and B for Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast has also provided secure faxination numbers for those providers or trading partners who elect to fax the additional documentation.

PWK Fax/mail coversheets

First Coast is requiring the following section of the form to be completed with valid information to ensure the paperwork documentation is appended to the pending claim in our system: ACN (Attachment Control Number (submitted in the PWK06 segment)), DCN (document control number [Part A]), ICN (internal control number [Part B]), the beneficiary's health insurance claim number (HICN)/Medicare number, Billing provider's name and NPI (national provider identifier).

First Coast will return PWK coversheets with missing or inaccurate data. The coversheet will be returned based on how it was received (fax or mail).

• Note: First Coast will not return any paperwork documentation that accompanies a rejected PWK coversheet; nor will the documentation be used for adjudication of the claim.

PWK documentation may not be submitted prior to submission of a claim. Submitters must send all relevant PWK data at the same time for the same claim. Thus, if the claim was submitted with multiple PWK iterations, all PWK data for the claim must be submitted together under one coversheet.

If the PWK segment is completed and additional documentation is needed for adjudication, First Coast will allow seven calendar "waiting" days (from the claim date of receipt) for the paperwork documentation to be faxed or ten calendar waiting days to be mailed. The seven and ten day waiting periods apply to claims for both Part A and Part B.

If the PWK data is not received within the waiting timeframe and additional documentation is needed, a development request will be sent. If documentation is received after the timeframe has elapsed, the documentation will not be used for adjudication of the claim. Thus, the paperwork will need to then accompany our request for additional documentation to prevent possible claim denials.

Claims submitted with a PWK segment, that would not otherwise suspend for review and/or require additional development, will process routinely and will not be held for the seven or ten day waiting period.

Faxination numbers

First Coast has provided designated faxination lines to expedite receipt of the PWK coversheets/attachments, depending on the provider’s line of business and location (Part A or Part B; Florida, Puerto Rico, or the U.S. Virgin Islands.

Each fax/mail coversheet includes the appropriate First Coast return mailing address and faxination number, based on the provider's selection.

2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus - Update from Medicare

Provider Action Needed:

Change Request (CR) 8942 alerts you that the annual HPSA bonus payment file for 2015 will be made available by the Centers for Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA bonus payments on applicable claims with dates of service on or after January 1, 2015, through December 31, 2015. You should review Physican Bonuses below , whether you need to add modifer AQ to your claim in order to receive the bonus payment, or to see if the ZIP code in which you rendered services will automatically receive the HPSA bonus payment. Make sure that our billing staffs are aware of thes changes.

HPSA Designations

The Health Resources and Services Administration (HRSA) published an updated Federal Register Notice on June 27, 2013, that contains important information about new and withdrawn HPSA designations. For purposes of the Medicare Physician Bonus and the Medicare Surgical Bonus programs, changes in designation status are effective for dates of services on and after January 1 of the year following the designation date. Therefore, areas whose designation is shown as “Withdrawn” on the June 27, 2013 Federal Register list, remain eligible for the HPSA bonuses through December 31, 2013.

MMA Section 413(b) required CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. If a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

MMA Changes

Effective January 1, 2005, a modifier no longer has to be included on claims to receive the HPSA bonus payment, which will be paid automatically, if services are provided in ZIP code areas that either:

• Fall entirely in a county designated as a full-county HPSA; or
• Fall entirely within the county, through a USPS determination of dominance; or
• Fall entirely within a partial county HPSA.

However, if services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

The following are the specific instances in which a modifier must be entered:

• When services are provided in ZIP code areas that do not fall entirely within a designated full county HPSA bonus area;
• When services are provided in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
• When services are provided in a ZIP code area that falls partially within a non-full county HPSA;
• When services are provided in a ZIP code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.

To determine if a service will automatically qualify to receive the bonus payment, review the information provided on the CMS Web site.  The HRSA website should be reviewed for the most recent designations.  Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims.

Some points to remember include the following:

• Medicare contractors will base the bonus on the amount actually paid (not the Medicare approved payment amount for each service) and the ten-percent bonus will be paid on a quarterly basis.
• The HPSA bonus pertains only to physician's professional services. Should a service be billed that has both a professional and technical component, only the professional component will receive the bonus payment.
• The key to eligibility is not that the beneficiary lives in a HPSA nor that the physician's office or primary location is in a HPSA, but rather that the services are actually rendered in a HPSA.
• To be considered for the bonus payment, the name, address, and ZIP code of the location where the service was rendered must be included on all electronic and paper claim submissions.
• Physicians should verify the eligibility of their area for a bonus before submitting services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment.
• Services submitted with the AQ modifier will be subject to validation by Medicare.

Affordable Care Act of 2010 Changes (New for January 2011 for the HSIP Bonus)

The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs.  Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period.  This additional payment, referred to as the HPSA Surgical Incentive Payment (HSIP) will be combined with the original HPSA payment and will be paid on a quarterly basis.  Modifier AQ should be appended for these major surgical procedures similar to claims for the Medicare original HPSA bonus when services are provided in ZIP code areas that do not fall entirely within a full or partial county HPSA.

Some points to remember:

•  The current HPSA physician bonus program requirements will remain intact.
• Medicare contractors will identify and pay the additional bonus on eligible services rendered in eligible ZIP code areas based on the HPSA ZIP code file as of December 31^st of the prior year.
• Medicare contractors will calculate the bonus amount based on the amount actually paid for the service, not the Medicare approved amount

Services submitted with modifier AQ will be subject to validation by Medicare.

CMS - 1500 Claim Form Instructions: Revised for Form Version 02/12

Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with claims received on and after April 1, 2014:

·         Medicare will being accepting claims on the revised form, 02/12, on January 6, 2014;

·         Medicare will continue to accept claims on the old form, 08/05, through March 31, 2014;

·         On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500 claim form, 02/12; and

·         On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 claim form, 08/05.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers and expands the number of possible diagnosis codes on a claim to 12.

The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

·         DN - Referring Provider

·         DK - Ordering Provider

·         DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that Medicare therefore for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore ssuppoers the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception.

News Flash : Generally, Medicare Part B covers one fly vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries. Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers and patients.

Note: The flu vaccine is not a Part-D covered drug.

CO 253 - Medicare EOB sequestration payment reduction code

New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Payment Due to Sequestration 

This article is based on CR 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.

As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to explain the adjustment in payment.

Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims.

The new CARC is as follows:

•  253 - Sequestration - Reduction in Federal Spending

Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.


The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

For example:

The Net Medicare Payment for the claim line is $104.46 and the Medicare Payment Reduction was $2.13.

* Add $104.46 to $2.13, which is $106.59

* $104.46 represents Medicare’s Payment for the service or item and $2.13 represents the Medicare Payment Reduction related to the service or item

* Enter the Sum, which is $106.59, as ‘Medicare Paid (incl. Medicare Reduction(s)) Amount’


How will Medicare physician payments be affected?

• All Medicare physician claims with a date of service on or after April 1 will be subject to a 2 percent payment cut.

• Costs for physician-administered drugs included on the physician claim will also be subject to the 2 percent cut.

• The cut will be applied to the payment itself, not the underlying “allowed charge” in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, the 2 percent cut is imposed only on the 80 percent of the allowed charge that a participating physician would receive directly from
Medicare. The 20 percent copayment amount (and any deductible) that the physician collects from the patient will be based on the full allowed charge amount.

• With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount).

How long will the sequestration last?

• The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. So, unless Congress takes action to change the law, federal spending will be subject to sequestration until 2022.

• Because the American Taxpayer Relief Act that was signed into law in January delayed the 2013 sequester for two months (with a budget offset), the Defense and discretionary program cuts are less severe now than they will be in coming years.

• As an entitlement program, the Medicare payment cut is treated a little differently than the cuts being imposed on programs subject to the appropriations process. The Medicare cut will never be higher than 2 percent.

• Importantly, the Medicare cuts each year are not cumulative. So, the 2 percent cut this year will not be followed by another 2 percent cut next year, and so forth, producing a cumulative double-digit cut at the end of the sequestration period. In other words, this year’s 2 percent cut will simply remain in place every year through 2022 (unless Congress takes action to stop it).

What are the prospects of Congressional action to stop the sequester?

• With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, we are mid-way through the fiscal year and, barring a major backlash, it is expected that the sequester cuts will remain in effect through at least Sept 30, 2013.

• The future of sequestration beyond 2013 is likely to depend on whether or not Congress and the White House are able to reach a new budget agreement to address deficit and spending concerns.

Medicare schedule update - Important steps and dates involved in every year

 Key Implementation Dates  

A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed schedule is provided under separate cover by CMS.
Carriers must:

October: 
• Download fee schedules
 • Download HCPCS

November:  
• Release participation materials and disclosure reports;
 • Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;

December:  
• Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;
 • Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;
 • Process participation elections and withdrawals; and,
• Send a complete fee schedule to the State medical societies and State beneficiary associations.

January:  
• Implement annual fee schedule amounts;
• Implement annual HCPCS update;
• Send an updated provider file to the Railroad Retirement Board; and
• Load MEDPARD equivalent information on the carrier Web site.


February:
• Submit participation counts to CMS Central Office via CROWD.

Do we need to update the addition office address to insurance?

 
ADDRESS CHANGE or OTHER PRACTICE INFORMATION:

Yes. In order for CarePlus to maintain accurate participating provider  irectories and also for reimbursement  purposes, all changes to address or practice information should be submitted in writing to CarePlus as  soon  as  possible.  Notices  of  any  changes  must  adhere  to  time  frames  outlined  in  the  participation  agreement.

Changes that require notice to CarePlus may include, but are not limited to, the following:

* Provider Information
* Tax Identification Number
* National Provider Indicator (NPI)
* Address
* Phone Number
* Practice Name
* Adding a physician – physician joining practice/group. Please note that the new  physician must be credentialed first before rendering treatment to any CarePlus member.
* Provider deletions – provider no longer participating with the practice/group
* Medicare numbers


SITE VISITS – FACILITIES AND ENVIRONMENT:

CarePlus  conducts  site  visits  to  assess  the  office  environment  as  it  relates  to  physical  accessibility,  physical appearance, adequacy of patient care areas and medical equipment, medical record policies and  practice management. A site visit may be conducted upon initial credentialing and on other occasions as  determined by the Plan (e.g., quality review).



The standards reviewed during site visits include, but may not be limited to, the following:

 Accessibility/Physical Appearance

1.  Site is operated in a safe and secure manner.

2.  Provide reception areas, toilets, and telephones in accordance with patient/visitor volume.

3.  Adequately marked patient/visitor parking, when appropriate.

4.  Examination rooms, dressing rooms, and reception areas are constructed and maintained  in a manner that ensures patient privacy.

5.  Provisions are made to reasonably accommodate disabled individuals.

6.  Adequate lighting and ventilation are provided in all areas.

7.  Office/Facility is clean and properly maintained.

8.  Space allocated for a particular function or service is adequate for the activities performed  therein.

9.  Smoking is prohibited in the office/facility.

10. Office/Facility must be in compliance with applicable state and local building codes and  regulations; state and local fire prevention regulations; applicable federal regulation and  receive periodic inspection by local or state fire control agency, if this service is available  in the community.

Medicare update on Importance of Preparing/Maintaining Legible Medical Records

Many claim denials occur because the providers or suppliers do not submit sufficient documentation to support the service or supply billed. Frequently, this documentation is insufficient to demonstrate medical necessity. In accordance with Section 1862(a)(1)(A) of the Social Security Act, CMS must deny an item or service if it is not reasonable and necessary.(See item 1 in the "References" section below.) When determining the medical necessity of the item or service billed, Medicare's review contractors must rely on the medical documentation submitted by the provider in support of a given claim. Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials.

 Key Points

General Principles of Medical Record Documentation

The general principles of medical record documentation to support a service or supply billed for Medicare payment includes the following (as applicable to the specific setting/encounter):

1. Medical records should be complete and legible; and
2. Medical records should include the legible identity of the provider and the date of service.


Medicare Signature Requirements

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature.

• If the signature is illegible or missing from the medical documentation (other than an order), the review contractor shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.

• If the signature is missing from an order, the review contractor shall disregard the order during the review of the claim (i.e., the reviewer will proceed as if the order was not received). Signature attestations are not allowable for orders

Medicaid EHR adopting, implementing or upgrading final rule

The Medicaid provisions of the final rule for Adopting, implementing, or  upgrading certified EHR technology and Demonstrating meaningful use of EHR technology


Adopting, Implementing, or Upgrading Certified EHR Technology

The final rule:

•  Discusses that providers in their first year of participation in the Medicaid incentive payment program may demonstrate that they have adopted (e.g. acquired, purchased or secured access to), implemented (e.g. installed or commenced utilization of ) or upgraded to   certified EHR technology in order to qualify for an incentive payment;

• Describes the methodology for demonstrating adoption, implementation and upgrading, and for states to monitor these activities;

 Demonstrating Meaningful Use of Certified EHR Technology
 The final rule:

•  Finalizes a shared minimum definition of meaningful use with Medicare. However, CMS will allow states to request CMS approval to require that four public health related measures be core instead of menu measures for Medicaid providers and to specify some of the destination and transmission details;

• Discusses how clinical quality measures reporting will be submitted to the states by Medicaid providers, such as via attestation or electronically via EHRs.

Review of practice performance from Medicare - how to get the report

Requesting a comparative billing report -- Part B providers


Comparative billing report (CBR) information is available to providers by request. The purpose of the CBR is to show comparative data Medicare considers when determining how a provider’s billing patterns contrast with other providers in the same specialty. A CBR may be a helpful tool when conducting self-audits or preparing for a seminar or medical society meeting.

Types of comparative billing reports

Part B Provider-Specific

This type of CBR, best suited for individual physicians and non-physician practitioners, contains comparative information for all procedure codes billed. It is also available to specialties such as independent diagnostic testing facilities or clinical laboratories; however, due to the various types of services offered, the results will not be an “apples-to-apples” comparison. This type of CBR does not have value for physician groups.

Since Medicare bases a CBR on dates of service and not processed dates, Medicare must allow two to three months to permit claims to be finalized before a report can be generated. For example, January data is not available until April or May.

Evaluation and Management Distribution -- Provider-Specific

This type of CBR compares an evaluation and management (E/M) code family (example: CPT codes 99211-99215) to the provider’s peer group (specialty) within Florida and the nation. The report is a bar graph distribution and depicts a provider’s percentage of allowed services per procedure code as compared to Florida and the nation. This CBR is useful to identify potential variances in coding within a code family.

Medicare updates the reports two times per year for the following dates of service:

• January through June

• July through December

Since Medicare bases a CBR on dates of service and not processed dates, Medicare must allow three to four months to permit claims to be finalized before a report can be generated. For example, the January through June timeframe is not available until September or October.

Evaluation and Management Distribution -- Service-Specific

This CBR compares Florida’s utilization of E/M codes to the nation by specialty. This report is useful for medical society meetings to show variance within a code family between Florida’s provider specialties and the nation.

The CMS Data Center updates the national data two times per year for the following dates of service:

• January through June

• July through December

Medicare must allow three to four months before a report can be generated. For example, the January through June timeframe is not available until September or October.

How to request a comparative billing report

To request a CBR, providers must follow these steps:

• A provider must request a CBR on office or corporate letterhead and the provider/officer signature must be affixed. A request from a corporate entity must be submitted by a corporate officer, or in the case of a hospital, the hospital administrator. If the requesting provider wants the information sent to another party, it must be noted in the letter.

• The request must include the following information: the type of CBR(s) desired, the individual provider number(s), and the dates of service preferred. Please beware that a CBR cannot be produced using the group Medicare number.

• The mailing address must be stated clearly and legibly in the letter, since these reports will only be sent via the U.S. mail and not electronically.

• The request must be faxed to Statistical and Medical Data Analysis at 904-361-0543 or mailed to:

First Coast Service Options
Statistical and Medical Data Analysis
P.O. Box 44288
Jacksonville, FL 32231-4288

There is no fee for providing these reports.

Once Medicare receives a CBR request, the report and a CBR explanation document will be mailed to the requesting provider (or authorized party) within 10 business days.

Medicare part b payment and deductible update as of Feb 2012

New law includes physician update fix through February 2012




On Friday, December 23, 2011, President Obama signed into law the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA). This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect immediately. While the negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012, the administration remains strongly opposed to letting this cut take effect. As he has repeatedly made clear, President Obama is committed to a permanent solution to eliminating the sustainable growth rate’s cut. We will continue to work with Congress to achieve this goal.

The Centers for Medicare & Medicaid Services (CMS) has also recently implemented several important changes for Medicare providers and beneficiaries, and we would like to remind physicians and practitioners of some of these key changes for 2012. For many of your patients, Medicare costs will go down. Medicare cost-sharing for Part B services will decline in some cases and, for the first time, the Part B deductible will decrease, by $22, to $140.

Additionally, health care professionals will be paid more to provide certain important services for people with Medicare. CMS has increased the payment amount for the initial and annual wellness visit -- which has no cost sharing for patients -- to account for the introduction of health risk assessment (HRA). CMS believes it is important to balance the comprehensiveness of the HRA with the potential burden on patients and health professional time constraints. As such, in 2012, CMS will allow for variation in the content of the HRA.

The Medicare Part D prescription drug program has also been enhanced for 2012, with the coverage gap being further reduced as it is phased-out over the next several years. These improvements to the drug benefit from the Affordable Care Act have already saved millions of seniors nearly $2 billion.

CMS wishes to remind physicians and practitioners about the Primary Care Incentive Program. Again in 2012, primary care physicians, nurse practitioners, clinical nurse specialists, and physician assistants may be eligible to receive an incentive payment equal to 10 percent of their allowed charges for primary care services under Medicare Part B. This incentive is paid in addition to any physician incentive payments for services furnished in Health Professional Shortage Areas. Please remember that if a practitioner has reassigned his or her benefits to another entity, such as a group practice, Medicare will pay that entity and not the individual practitioner.