Revenue Cycle Management

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Revenue Cycle Management
Medicare Changes
April 08, 2011
WSOPP
Presented by:
Chris Duprey
Carrie Romandine
Agenda
2010-2011 Highlight Changes
• Medicare Policy
• Billing Rules
• Compliance Changes and
Notifications
• Appeal Process
Medicare Policy Changes
Prosthetics and Orthotics Ordered in a Hospital
or Home Prior to a Skilled Nursing Facility
Admission
CMS Ordering/Referring Provider Report
Updated (PECOS)
Healthcare Provider Taxonomy Codes April 2010
Update
Auto Denial of Claims with GZ Modifier
Prosthetics and Orthotics Ordered in a Hospital
or Home Prior to a Skilled Nursing Facility
Admission – October 2010


P&P regarding circumstances a supplier may deliver
DME, prosthetics, and orthotics, but not supplies to a
beneficiary who is in an inpatient facility that does not
qualify as the beneficiary’s home.
SNF consolidated billing (CB) provision of the Balanced
Budget requirement under which the SNF itself is
responsible for billing Medicare for all services that its
residents receive.
Responsibility Grid
Transfer from IPH
to SNF Part A
Requires an
Orthotic or
Prosthetic Device
Facility where
medical need
occurred is
responsible for
billing
If device is medical
necessary occurs at
time beneficiary in
IPH
Device is not
delivered until the
beneficiary has
arrived at the SNF
Facility remains
responsible for
billing the item, not
the SNF
If device medical
necessity occurs
after the beneficiary
is transferred from
IPH and enters SNF
Part A
SNF is responsible
for billing of the
prosthesis or
orthothis
Most prosthetics
and all orthotic
devices are subject
to the SNF CB
Item would be included within the global per diem payment unless
specifically excluded from SNF consolidated billing.
Who Bills?
If
Need for these
devices were
established while
in SNF,
And
Then
Then
Supplier is to bill
the DME MAC
When prosthesis
or orthosis is
required while
patient is in the
home
Is entered into a
SNF for covered
Part A stay
DME MAC should
be billed by the
party which
supplied the device,
not the SNF
If beneficiary
enters SNF for a
non-covered stay
Develops a medical
need for a
customized device
which the SNF
orders
SNF would bill the
DME MAC for the
item since SNF CB
rules do not apply
CMS Ordering/Referring Provider
Report Updated (PECOS)
Effective January 3, 2011 DMEPOS suppliers will
not receive payment from Medicare for items
that are ordered if you do not have a current
enrollment in the PECOS.
 Providers who can order DMEPOS items
include:

Applicable to O&P
Others
Medicine or Osteopathy
Dental Medicine or Dental
Surgery
Nurse Practitioner
Certified Clinical Nurse Specialist
Physician Assistant
Optometry
Nurse Practitioner
Healthcare Provider Taxonomy
Codes April 2010 Update
Taxonomy codes are required for X12 837 Professional and
Institutional Implementation Guides
NUCC updates the code set twice per year effective April 1
and October 1.
Taxonomy for Prosthetics and Orthotics is 335E00000X –
this should be included on your file when electronic billing
or box 31(rendering provider), 32 (rendering facility) and 33
(billing location)
Auto Denial of Claims Submitted
with a GZ Modifier
The Health and Human Services Office of
General Counsel (OGC) has provided guidance
that Medicare contractors that process both
institutional and professional claims have
discretion to automatically deny claims billed with
the GZ modifier.
 Effective for dates of service on or after July 1,
2011.
 In addition, line items denied due to the presence
of the GZ modifier will reflect a claim adjustment
reason code of 50 and Group code of CO –
meaning provider/supplier liability.

Billing Changes 2010-2011
Policy
Billing
Reimbursement
2010-2011 Billing Changes
New Uses of the KX, GA, GZ, and GY Modifiers
Patient Responsibility – PR Group
Use of Upgrade Modifiers
Therapeutic Shoe Policy Revision /Documentation
Timely Filing Requirement
Top Error Codes
New Uses of the KX, GA, GZ, and
GY Modifiers Effective 5-01-2011

Definitions:
◦ KX – Requirements specified in the medical
policy have been met
◦ GA – Waiver of liability (expected to be denied
as not reasonable and necessary, ABN on file)
◦ GZ – Item or service not reasonable and
necessary (expected to be denied as not
reasonable and necessary, no ABN on file)
◦ GY – Item or service statutorily excluded or
does not meet the definition of any Medicare
benefit
Tips to Understand About Modifiers
Claim lines will be rejected if the proper use
of the modifiers are not used according to
the LCDs
 If the claim line is rejected for an incorrect
or missing modifier – you may resubmit that
single claim line with the corrected modifier
vs. reopening of the claim Effective 5/1/2011
 GA, GZ and/or GY may not be used on the
same claim lines
 GY and KX are inappropriate to report on
the same line

Modifier KX

Serves as an attestation by the supplier that the
requirements for its use that are defined in the
particular LCDs are true for that specific beneficiary –
requirements vary from policy to policy
◦ Therapeutic Shoes For Diabetics Only
◦ Ankle-Foot/Knee-Ankle-Foot Orthoses
◦ Orthopedic Footwear


Suppliers may only append the KX modifier when all
requirements for its use have been met
Adding the KX modifier without ascertaining that all
requirements specified have been met could be viewed
as filing a false claim and potential abuse of the Medicare
Program (fines can be 3x value of the false claim, plus from
$5,500 to $11,000 in fines, per claim)
Modifier GA
When an item or service that is provided to a Medicare beneficiary does NOT meet
the coverage condition outlined in the medical policy, it is the responsibility of the
supplier to notify the beneficiary in writing through use of the ABN before the item or
service is delivered or purchased
Example: L3020
Use of the GA modifier indicates the supplier has a waiver of
liability statement on file.
Modifier GA must not be appended to the claim line if the
supplier did not properly execute an ABN
Modifier GZ
Item or service that is provided does not meet the coverage criteria outlined in the
medical policy, an ABN must be executed.
When the ABN is not properly executed the GZ modifier would be used to append the
claim.
Denial will be received as not medically necessary
Review criteria within LCDs for use
Ankle-Foot/Knee-Ankle-Foot
Modifier GY
An item or service is statutorily excluded or does not meet the
definition of any Medicare benefit.
Some LCDs require use of modifier GY to indicate when an item
or service may be excluded from coverage in a specific situation.
Example:
• Orthopedic Footwear Policy
• Therapeutic Shoes for Diabetics Only
Impacts of Incorrect Modifier Usage
PR – Patient
responsibility:
• Amount may be billed to the beneficiary or to
another payer on beneficiary’s behalf.
• Examples:
• Patient’s deductible or coinsurance
• The patient assumed financial
responsibility for the service not
considered reasonable and necessary
(ABN)
• Charge denied as a result of the patient’s
failure to supply primary payer other
information
• Patient is responsible for payment of
excess non-assigned charges
Patient Responsibility – PR Group
Charges that have not
been paid by
Medicare and/or are
NOT included in a PR
group – beneficiaries
not responsible
Providers may be
subject to penalties if
they bill a patient for
charges not identified
with the PR group
code, regardless if it is
assigned or
unassigned.
• Examples:
• Late filing penalty (reason code B4)
• Excess charges on an assigned claim
(reason code 42)
• Excess charges attributable to rebundled services (reason code B15)
• Charges denied as a result of the
failure to submit necessary
information
• Services not reasonable and necessary
for care (reason code 50 or 57) for
which there are no indemnification
agreements
Patient Responsibility

Providers may be subject to penalties if
they bill a patient for charges not
identified with the PR group code,
regardless if it is assigned or unassigned.
Use of Upgrade Modifiers – April
2011

Definition of an Upgrade:
◦ Item goes beyond what is medically necessary
under Medicare’s coverage requirements

Fact:
◦ Considered an upgrade even if the physician
has signed an order for it
◦ Item does not meet coverage criteria stated
in LCD – supplier can still obtain partial
payment at time of initial determine with
upgrade modifiers
Upgrade Modifiers

GK: Reasonable and necessary
item/service associated with a GA or GZ
modifier
◦ Practitioner ordered: L3020 vs. A5513

GL: Medically unnecessary upgrade
provided instead of non-upgraded item,
no charge, no ABN
Claim Example
DOS
POS
HCPCS
MOD
CHG
2-4-2011
11
L3020
GA
120.00
2-4-2011
11
A5513
GK
80.00
EOR Example
DOS
HCPCS
MOD
CHG
PD
2-4-2011
L3020
GA
120.00
PR-96
2-4-2011
A5513
GK
80.00
CO-45
16.00
PR-2
40.00
64.00
Beneficiary liability will be the sum of (a) difference between the
submitted charge for the GA claim line and the submitted charge for
the GK claim line and (b) the deductible and co-insurance that relate
to the allowed charge for the GK claim line. Supplier may charge
U&C fee for the upgraded item that is provided.
Upgraded Item – Supplier’s Decision
An upgraded item may be provided by a
supplier at their discretion with no ABN
on file—however, this upgrade must be
free of charge
 To bill the following modifiers would be
used:
 GL modifier to the item that is covered
based on the LCD. In this situation, the
supplier does not bill the HCPCS code
that describes the item that was provided.

Beneficiaries Decision to Upgrade
Supplier decides to provide it at no
additional charge, no ABN is obtained.
 On one claim line supplier bills with a GZ
on the item that was provided.
 Second claim line, supplier bill with a GK
modifier and the HCPCS code that
describes the item that is covered based
on the LCD.
 Claims for upgraded modifiers must be
billed in this order.

Therapeutic Shoe Policy Revision
/Documentation Sept 2010

Addresses two main areas:
◦ 1). In person fitting and delivery addressed by
Article by May 2010
◦ II). Certification Statement required by the
physician managing the patients diabetes
Summary of Requirements
Activity
Responsible Timeframe
Person
1
Visit to document
diabetes
management2
Certifying
MD/DO
Within 6 months prior to delivery
2
Visit to document
qualifying foot
condition2
Certifying
MD/DO, other
MD/DO, DPM,
PA, NP, CNS
Within 6 months prior to delivery
3
Completing
Certification
Statement
Certifying
MD/DO
•
•
•
•
4
Providing dispensing
order to supplier4
Prescribing
Physician
After visit(s) to document diabetes
management and qualifying foot condition
After Certifying Physician reviews and
signs report of visit documenting qualifying
foot condition by other MD/DO, DPM, PA,
NP, CNS – if applicable
Prior to initial provision of shoes and
inserts
For subsequent provision of shoes and
inserts, required if delivery is > 1 year after
most recent certification statement
After visit with Prescribing Physician
Before delivery
Summary Requirements, Con’t
Activity
Responsible Timeframe
Person
5
Signing detailed
written order
Prescribing
Physician
6
Selection Visit
Supplier
7
Delivery Visit
Supplier
•
•
After selection visit
After receiving dispensing order or
detailed written order
8
Submitting claim
Supplier
•
•
•
After delivery
After receiving detailed written order
After receiving Certification Statement
After visit with Prescribing Physician
1 If the table states that one event needs to occur “before”
or “after” another event, both could occur on the same date
if that sequence was followed
2 Effective for dates of service on/after 1/1/2011
3 Applicable if qualifying foot condition is not documented on
visit with certifying physician
4 Separate dispensing order not needed if detailed written
order received by supplier prior to delivery
Timely Filing Requirement

Reminder timely filing for Medicare has
been reduced to 1 year; all extensions
have been exhausted.
Top Error Codes 2010
CO-13 – The date of death precedes the
date of service
 CO-16 – Claim/service lacks information
which is needed for adjudication
 CO-18 – Duplicate claims
 CO-22 – Payment adjusted because this care
may be covered by another payer per
coordination of benefits
 OA – 109 – Claim not covered by this
payer/contractor.You must send the claim to
the correct payer/contractor

Compliance Changes and
Notifications

CEDI Recertification Process – Effective
January 2011 recertification will be
required annually (13,000 trading partners
are affected)
◦ Schedule is as follows:




January 2011 – Trading Partner ID A08
February 2011 – Trading Partner ID D08
March 2011 – Trading Partner ID C08
April 2011 – Trading Partner ID B08
◦ Process is expected to be completed by
August 2011
Medicare – April 08, 2011
QUESTION/ANSWER

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