Tag: CMS
As every healthcare executive knows, a healthy revenue cycle relies on precise paperwork. That’s why all Medicare providers should be paying close attention to the revised medical necessity form, which will be mandatory starting January 1, 2021. Failure to use the new Advance Beneficiary Notice of Non-coverage (ABN) form could lead to denied claims, financial penalties and a subpar patient experience. We interviewed Theresa Marshall, senior director of data compliance at Experian Health, about what’s changed and what providers can do to prepare. What is a medical necessity form? Medicare only pays for services and procedures considered “medically necessary.” In situations where a procedure isn’t considered medically necessary, providers must issue the patient with an ABN which ultimately transfers financial responsibility to the patient. Services that could be considered medically unnecessary might include treatment in hospital that could have been provided in a lower-cost setting, screening or therapies that are unrelated to the patient’s symptoms, or hospital stays that exceed a specified length of time. Perhaps a patient is receiving support with personal care from a home health agency – this may not be strictly medically necessary, so the provider might anticipate that it won’t be covered by Medicare. An ABN isn’t required for services that are never covered by Medicare, such as dental care or cosmetic surgery. What’s changed on the new medical necessity form? The new form, CMS-R-131, replaces the version released by CMS in June 2017. The main change is the addition of new instructions for Dual Eligible beneficiaries. These are patients who are eligible for both Medicare and Medicaid, and most likely enrolled in the Qualified Medicare Beneficiary Program (QMB), which means Medicaid pays for any Medicare-covered services. Providers must not levy any charges against QMB patients, or they’ll face sanctions. The new instructions specify that in addition to edits that strike through specific language, “dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.” How should providers prepare? Should they chose, providers can start using the new form now. The important thing to remember is that they must have the new form in place by the new year. Any outdated forms after the first of the year will be invalid. Many providers are still using manual processes which require checking medical necessity rules for both Medicare and commercial payers via the CMS website, then calculating and preparing the required paperwork themselves. This can be time-consuming and vulnerable to errors, which also results in denied claims and extra days in accounts receivable (A/R) – not to mention the extra stress it causes for patients. A time-saving alternative is an automated tool such as Experian Health’s Medical Necessity. With automation, you can validate clinical orders against payer rules quickly and accurately, for cleaner claims the first time around. Medical Necessity integrates seamlessly with multiple electronic medical records (EMR), scheduling and registration systems, to run automatic checks for medical necessity, frequency and duplication. With up to half of denied claims occurring early in the revenue cycle, any actions to minimize errors and delays during registration could bring big financial benefits. Medical Necessity from Experian Health will include an automatic check of a Medicare beneficiary’s QMB status ahead of the January 2021 deadline, so the electronic ABN can be updated immediately, ready for the patient’s signature. Could this improve the patient experience? Yes, definitely. In addition to reducing manual processes, preventing denied claims and protecting against lost revenue and financial sanctions, automating medical necessity checks also creates a much less stressful experience for patients. For individuals who are financially vulnerable, any lack of clarity about their medical bills can be a huge source of worry. But when providers can quickly identify patients who shouldn’t be charged, the billing experience is a much smoother ride. Medical Necessity is just one of the many ways that Experian is working to reduce the burden on hospital resources, improve patient experiences, and ensure that hospitals are fully compensated for the care they provide. Find out how we can help your organization get your paperwork in order in time for the new ABN requirements in January 2021, so you can offer a better patient experience and reduce claim denials at the same time.
An estimated 82 percent of hospitals receiving Medicare and Medicaid payments in fiscal year 2019 are expected to have their payments reduced because their readmission rates are too high. The Centers for Medicare and Medicaid Services implemented the Hospital Readmissions Reduction Program to reduce the number of patients being readmitted to hospitals less than 30 days after leaving. This program’s goal is to improve patient care. While a number of factors influence hospital readmission rates, they often occur when patients are not communicating issues with their doctors or when more communication is needed between patient care teams. For example, when the attending physician in the Emergency Room (ER) doesn’t have the necessary background on a patient’s condition, a patient is more likely to be readmitted. This can lead to longer waits to get proper treatment. To best serve patients by reducing hospital readmissions, healthcare organizations need to improve patient care coordination. Technology enhances communication among inpatient, outpatient, and long-term care teams, and it gives patients more of a stake in their own care. Coordinating patient care USMD WellMed Health System set a goal to significantly decrease its readmission rates, so it needed a way to alert physicians if their patients showed up in the emergency room, particularly within 30 days of leaving the hospital. The organization implemented Experian Health’s Care Coordination Manager and MemberMatch® solutions. Care Coordination Manager provides a messaging platform for patients’ post-discharge care plans, which is a secure place for patients and providers to communicate. It helps hospitals and health systems provide solutions for 30-day and 90-day management of health episodes. In one case, a doctor was able to intervene when a patient with chronic obstructive pulmonary disease showed up in the ER. The doctor was notified, spoke to the ER physician, and developed a course of action that allowed the patient to go home without being admitted to the hospital. In addition to avoiding hospital readmission penalties, USMD WellMed provided better care with the service and made the patient happier as well. While healthcare professionals agree there is a growing need to help patients become more engaged in their care, many are uncertain about the tools and opportunities to make it happen. Care Coordination Manager introduces an easy way for patients themselves to communicate with their providers and get clarifications on follow-up care. USMD WellMed also implemented MemberMatch, which lets Accountable Care Organizations (ACO), ESRD Seamless Care Organizations (ESCO), and health plans better manage members’ clinical episodes by alerting care managers when a patient is admitted, discharged or shows up in the ER. Doctors appreciate notifications Despite the numerous benefits of reducing hospital readmissions, there was one major reservation when the phone alerts were implemented. While USMD’s physicians wanted to be more attuned to their patients’ needs, they were worried that they would be inundated with text notifications. The program was initially limited to high-risk patients. But once physicians started getting the alerts, they immediately realized the benefits . Some doctors even asked to expand the platform to all of their patients. Ultimately, this tool improved both USMD WellMed’s provider and patient satisfaction. USMD WellMed was able to reach its goal of significantly reducing readmission rates in a short period of time, according to Dr. Bryan Demarie Sr., Market Medical Director of USMD WellMed. The Care Coordination Manager helps physicians and patients take a more proactive approach to treatment by handling problems before they escalate to another stay in the hospital. Opening the lines of communication allowed the healthcare organization to meet its readmission goals, improve patient care and save USMD WellMed from costly penalties. Support the sharing of post-acute patient care information to help providers succeed in the new era of value-based reimbursement. Learn more.
As of January 1, 2019, thousands of hospitals in the U.S. are being required to post an online list of the cost of their services due to a new requirement by the Centers for Medicare & Medicaid Services (CMS). However, amid growing confusion about which fields are required or what format the list of standard services needs to be in, many health systems feel this new law will only create confusion among patients. One health system described the new requirements as, “It would be like walking into a car dealership looking at a new car, asking the salesman how much the car was going to cost and having them hand you the parts catalog. Obviously, when you have the parts catalog, you don\'t know what parts are in your car or which ones you\'re going to use or how much labor is going to go into making the car.\" While posting the list of prices is required by CMS, some health systems have invested in the needed technology to make it easy for patients to shop online for care. For example, in an interview with Modern Healthcare, El Camino Hospital explains they “launched a consumer self-service tool in May 2017, after about a year of development work with Experian Health. Since then, more than 3,000 people have visited the hospital\'s website, selected one or more of about 90 medical or surgical services they were interested in, entered their insurance information, and received an instant out-of-pocket cost estimate the hospital claims is 95% to 99% accurate.” Health systems like El Camino Hospital know that patients want to avoid costly surprises, and they should be able to understand their financial obligations upfront, including deductibles and copays. In fact, McKinsey research found nearly three-quarters of participants were worried about healthcare expenditures. Legislative help The new CMS requirement is only one of a few initiatives in the works from a legislative standpoint. In an effort to help patients, some members of Congress are trying to bring attention to the topic. A bipartisan group of U.S. senators in 2018 wrote a letter to healthcare stakeholders and experts requesting information in an effort to learn more about price transparency as they considered possible legislation on the matter. Also in the letter, the senators cited the lack of state laws and regulations requiring healthcare providers to make that information available to patients. More than 40 states were cited by the Catalyst for Payment Reform and the Health Care Incentives Improvement Initiative in 2016 because they were deficient in healthcare transparency legislation. And that same report found that some patients were paying thousands of dollars more than others for the same procedures, depending which healthcare provider they used. Alleviating patient stress Transparency in billing creates more satisfied patients because they know how much they will be paying for services, which makes it easier for them to budget. Going to the hospital is usually a stressful time for patients and their families. An easy way for healthcare providers to alleviate that stress is to help patients understand their costs upfront Most healthcare organizations already have the basic data they need to use automated technology to construct estimates for basic services, including claims data, real-time eligibility and benefits information, payer contracts and charge description master (CDM) information. Experian Health has the technology to help healthcare organizations convert this information into patient costs through Patient Estimates. This kind of transparency provides several benefits to both providers and patients. Online estimates published on healthcare provider websites give patients access to the information any time, including late at night and on weekends. And these estimates can be obtained confidentially, so patients who may be uncomfortable asking about certain procedures can find that information on their own. And that helps them be more relaxed about making appointments and scheduling treatments because they have confidence they won\'t face billing surprises. This feel-better result of having prices at their fingertips has a clear benefit for the healthcare providers as well. Patients are able to plan and pay for services, decreasing unpaid balances for hospitals and other healthcare providers. Ability to budget for healthcare costs Patients who know what to expect can budget wisely and actively take charge of their healthcare bills. They go in with their eyes open, which leads to improved revenue cycle management. In the end, both the patient and the hospital get what they want. With Congress and state legislatures looking at transparency in healthcare, providers can expect to see more of these rules. Healthcare organizations can get ahead of them with software like Experian Health\'s Patient Estimates. Healthcare consumers don\'t like surprises in their billing. Price transparency gives them the information and peace of mind they need to secure healthcare services and be assured that they know what they will be paying for them. Learn more about how Experian Health can help you achieve price transparency for your patients.
The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently released an updated Mid-Year Work Plan for fiscal year 2016. The updated Work Plan summarizes new and ongoing reviews and activities that OIG plans to pursue in the current year and beyond. This edition of the Work Plan describes OIG audits and evaluations that are underway or planned, and certain ongoing legal and investigative initiatives. Summaries of 9 new review activities to be awar of follow: CMS’ Implementation of New Medicare Payment System for Clinical Diagnostic Laboratory Tests – Mandatory Review We will assess CMS’s ongoing activities and progress toward implementing CMS’s new Medicare payment system for clinical diagnostic laboratory tests. CMS is required to replace its current system of determining payment rates for Medicare Part B clinical diagnostic laboratory tests with a new market-based approach that will use rates paid to laboratories by private payers (Protecting Access to Medicare Act of 2014, § 216). OIG is also required to conduct analyses of the implementation and effect of the new payment system Intensity-Modulated Radiation Therapy We will review Medicare outpatient payments for intensity-modulated radiation therapy (IMRT) to determine whether the payments were made in accordance with Federal requirements. IMRT is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. Prior OIG reviews have identified hospitals that have incorrectly billed for IMRT services. In addition, IMRT is provided in two treatment phases: planning and delivery. Certain services should not be billed when they are performed as part of developing an IMRT plan. Medicare Home Health Fraud Indicators We will describe the extent that potential indicators associated with home health fraud are present in home health billing for 2014 and 2015. We will analyze Medicare claims data to identify the prevalence of potential indicators of home health fraud. The Medicare home health benefit has long been recognized as a program area vulnerable to fraud, waste, and abuse. OIG has a wide portfolio of work involving home health fraud, waste, and abuse. National Background Check Program for Long-Term-Care Employees We will review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks. We will determine the outcomes of the States’ programs and determine whether the checks led to any unintended consequences. This mandated work will be issued at the program’s conclusion as required, which is expected to be 2018 or later. Outpatient Outlier Payments for Short-Stay Claims We will determine the extent of potential Medicare savings if hospital outpatient stays were ineligible for an outlier payment. CMS makes an additional payment (an outlier payment) for hospital outpatient services when a hospital’s charges, adjusted to cost, exceed a fixed multiple of the normal Medicare payment (Social Security Act (SSA) § 1833(t)(5)). The purpose of the outlier payment is to ensure beneficiary access to services by having the Medicare program share in the financial loss incurred by a provider associated with individual, extraordinarily expensive cases. Prior OIG reports have concluded that a hospital’s high charges, unrelated to cost, lead to excessive inpatient outlier payments. Skilled Nursing Facility Prospective Payment System Requirements We will review compliance with the skilled nursing facility (SNF) prospective payment system requirement related to a 3-day qualifying inpatient hospital stay. Medicare requires a beneficiary to be an inpatient of a hospital for at least 3 consecutive days before being discharged from the hospital, in order to be eligible for SNF services (SSA § 1861(i)). If the beneficiary is subsequently admitted to a SNF, the beneficiary is required to be admitted either within 30 days after discharge from the hospital or within such time as it would be medically appropriate to begin an active course of treatment. Prior OIG reviews found that Medicare payments for SNF services were not compliant with the requirement of a 3-day inpatient hospital stay within 30 days of an SNF admission. Potentially Avoidable Hospitalizations of Medicare and Medicaid Eligible Nursing Home Residents for Urinary Tract Infections We will review nursing home records for residents hospitalized for urinary tract infections (UTI) to determine if the nursing homes provided services to prevent or detect UTIs in accordance with their care plans before they were hospitalized. A CMS-sponsored study identified UTIs as being associated with potentially avoidable hospitalizations and found that UTIs are generally preventable and manageable in the nursing home setting. UTIs acquired during the course of health and medical care could indicate poor quality of care. In a hospital setting, there are payment implications for hospital-acquired catheter-associated urinary tract infections. Nursing homes must develop and follow comprehensive care plans addressing each resident’s care needs, which includes urinary incontinence (42 CFR § 483.25(d)). Physician-Administered Drugs for Dual Eligible Enrollees We will determine whether Medicare requirements for processing physician-administered drug claims impact State Medicaid agencies’ ability to correctly invoice Medicaid drug rebates for dual eligible enrollees. Dual eligible describes individuals who are enrolled in both Medicare and Medicaid. States are required to collect rebates on physician-administered drugs. To collect these rebates, State agencies must submit to the manufacturers the National Drug Codes for all single-source drugs and for the top 20 multiple-source physician-administered drugs. For dual eligible enrollees, covered Medicare Part B prescription drugs received in a hospital outpatient setting (which include physician-administered drugs) require a copayment, which Medicaid is generally responsible for paying. If a State agency paid any portion of a drug claim to the provider, the State agency must then invoice the eligible drugs for rebate and the manufacturer would thus be liable for payment of the rebate. State Medicaid Fraud Control Unit FY 2015 Annual Report We will analyze the statistical information that was self-reported by the MFCUs for FY 2015, describing in the aggregate the outcomes of MFCU criminal and civil cases. We will identify common themes from onsite reviews of the 50 MFCUs that were published from FY 2011 through FY 2015. We will identify the potential costs and benefits of creating MFCUs in jurisdictions that currently do not have a Unit. OIG’s mission is to protect the integrity of HHS programs, as well as the health and welfare of program beneficiaries. In fulfillment of this mission, we promote provider compliance, recommend program safeguards, and follow up on those recommendations ...” — Inspector General Daniel R. Levinson The OIG Mid-Year Workplan can be reviewed here: https://oig.hhs.gov/reports-and-publications/archives/workplan/2016/WorkPlan_April%202016_Final.pdf
Effective January 1, 2017, when processing claims for Part B drugs and biologicals, except those provided under Competitive Acquisition Program (CAP), the use of the JW modifier to identify unused drugs or biologicals that are appropriately discarded is required. The current policy allows contractors the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented. In order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals. Also, effective January 1, 2017, providers are required to document the discarded drug or biological in the patient\'s medical record. CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner. Read the entire MedLearn Matter Article 9963 here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf
On May 26, Centers for Medicare & Medicaid Services (CMS) outlined additional unspecified diagnosis codes the agency is excluding from both ICD-9 and ICD-10 reporting beginning January 2, 2017. The technical alert states the codes, “will not be accepted in the in the Alleged Cause of Injury, Incident or Illness (Field 15) or in any ICD Diagnosis Code field starting with Field 18. Updates to previously submitted records using these excluded codes, will also be rejected.” These additions and upcoming changes to the ICD-10 codeset underline the need for clinical documentation improvement and ICD-10 training, experts say, as code and rule freezes are lifted by the healthcare payment agency. ICD-10-CM will include 1900 new codes and several more changes and deletions. Attention to documentation quality will be paramount. Impacts Workers’ Comp and Auto CMS writes that this change supersedes the applicable language in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No Fault Insurance, and Workers’ Compensation User Guide (Version 4.9). The following ICD-9-CM will be added to the list of excluded diagnosis codes: 999.9 (Other and unspecified complications of medical care, not elsewhere classified) The following ICD-10-CM will be added to the list of excluded diagnosis codes: T88.7XXA (Unspecified adverse effect of drug or medicament, initial encounter) T88.7XXD (Unspecified adverse effect of drug or medicament, subsequent encounter) T88.7XXS (Unspecified adverse effect of drug or medicament, sequela) T88.8XXA (Other specified complications of surgical and medical care, not elsewhere classified, initial encounter) T88.8XXD (Other specified complications of surgical and medical care, not elsewhere classified, subsequent encounter) T88.8XXS (Other specified complications of surgical and medical care, not elsewhere classified, sequela) T88.9XXA (Complication of surgical and medical care, unspecified, initial encounter) · T88.9XXD (Complication of surgical and medical care, unspecified, subsequent encounter) T88.9XXS (Complication of surgical and medical care, unspecified, sequela) Read the Technical Alert here: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Technical-Alert-New-Excluded-Diagnosis-Codes.pdf
An add-on code is a HCPCS/CPT code that describes a service that, with one exception (see next paragraph), is always performed in conjunction with another primary service. An add-on code with one exception is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code with one exception is never eligible for payment if it is the only procedure reported by a practitioner. The Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 12, Section 0.6.12(I) requires a provider to report CPT code 99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)) without its primary code CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) if two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service. For the same date of service only one physician of the same specialty in the group practice may report CPT code 99291 with or without CPT code 99292, and the other physician(s) must report their critical care services with CPT code 99292. Add-on codes may be identified in three ways per CMS Transmittal 2636 The code is listed in this CR or subsequent ones as a Type I, Type II, or Type III, add-on code. On the Medicare Physician Fee Schedule Database an add-on code generally has a global surgery period of \"ZZZ\". In the CPT Manual an add-on code is designated by the symbol \"+\". The code descriptor of an add-on code generally includes phrases such as \"each additional\" or \"(List separately in addition to primary procedure).\" CMS has divided the add-on codes into three Groups to distinguish the payment policy for each group. Type I – This type of add-on code has a limited number of identifiable primary procedure codes. The CR lists the Type I add-on codes with their acceptable primary procedure codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service Type II –. A Type II add-on code does not have a specific list of primary procedure codes. The CR lists the Type II add-on codes without any primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on codes. Like the Type I add-on codes, a Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service. Type III – The third type of add-on code has some, but not all, specific primary procedure codes identified in the CPT® manual. CMS advises claims processing contractors that the primary procedure codes in the CPT® manual are not exclusive, and encourages contractors to develop their own lists of additional primary procedure codes. To reference the Type I, Type II or Type III lists of CMS add-on CPT® codes, see the bottom pages of the transmittal here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2636CP.pdf
Back in 1996, the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding and prevent inappropriate payment of Medicare Part B claims. As this is an automated prepayment review by CMS, the NCCI edits reduce payment error by identifying coding errors made by providers. In 2009, 7.8 % of Medicare dollars did not comply with one of more Medicare coverage, coding, billing or payment rules, translating into $24.1 billion dollars in Medicare overpayments and underpayments annually. The NCCI edits define when two HCPCS/CPT® procedure codes may not be reported together except under special circumstances. The Centers for Medicare & Medicaid Services (CMS) based the NCCI coding policies on current coding conventions, coding guidelines, national and local Medicare policies (NCDs and LCDs), and standard medical and surgical practice. Coding polices and guidelines require that procedures are reported with the most comprehensive CPT® code that describes the services performed. For example, a coder should not report a Basic Metabolic Panel (BMP, CPT® 80047) with a Comprehensive Metabolic Panel CMP,CPT® code 80053) as all the analytes in CPT® 80047 BMP are a subset of the Comprehensive Metabolic Panel and would have been already performed as part of that procedure. As a claim is processed by the Medicare contractor, the system tests every pair of procedure codes to determine if they comply with the NCCI edit policy. This means every code pair reported for the same date of service for the same beneficiary by the same provider is reviewed against the NCCI-edit tables. If a pair of codes on the claim matches (“hits”) a pair in the NCCI edit table, the “Column Two” code of the edit pair is denied for payment. Using the CMP/BMP example above, in the NCCI edit tables, CPT® 80047 is the “Column Two” code and would have payment denied. NCCI-associated modifiers are used to indicate the special circumstances such as when the procedures are performed at different anatomic sites, a separate procedure or repeat clinical diagnostic laboratory test. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together. NCCI-associated modifiers may not be used to bypass an edit unless the criteria for use of the modifier are met. Each active NCCI edit has a modifier indicator of 0 or 1. A modifier indicator of “0” indicates that an edit can never be bypassed even if a modifier is used. In other words, the Column 2 code of the edit will be denied. A modifier indicator of “1” indicates that an edit may be bypassed with an appropriate modifier appended to the Column 1 and/or Column 2 code. The NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91. In January 1, 2013, additional modifiers were added to the list of NCCI-associated modifiers that will allow an edit to be bypassed when the modifier is used correctly (i.e., edits with modifier indicator of “1”). These were LM (left main coronary artery), RI (ramus intermedius), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery). Effective Jan 15, 2015, new more specific modifiers become effective (see also Compliance Matters, Sept 2014) supplementing Modifier -59 (Distinct Procedural Service). XE Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner: A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Services denied based on NCCI edits may not be billed to Medicare beneficiaries, nor can a provider use an “Advanced Beneficiary Notice” (ABN) to seek payment from the patient since these denials are based on incorrect coding rather than medical necessity or a benefit exclusion. Hospitals, like physicians and other providers, must follow national correct coding policies. Though the NCCI edits were initially developed for processing professional claims, the NCCI edits are incorporated into the Outpatient Code Editor (OCE) used for processing outpatient hospital service claims, outpatient physical therapy and speech-language pathology services, skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and home health agencies (HHAs). These are commonly referred to as the NCCI “Hospital” Version of CCI edits. Review the NCCI manual on CMS here: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/
Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers. In 2003 the Centers for Medicare & Medicaid Services (CMS) was directed via Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 to replace the Part A FIs and Part B carriers with A/B Medicare Administrative Contractors (MACs) in accordance with the Federal Acquisition Regulation (FAR). A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including: Process Medicare FFS claims Make and account for Medicare FFS payments Enroll providers in the Medicare FFS program Handle provider reimbursement services and audit institutional provider cost reports Handle redetermination requests (1st stage appeals process) Respond to provider inquiries Educate providers about Medicare FFS billing requirements Establish local coverage determinations (LCD’s) Review medical records for selected claims Coordinate with CMS and other FFS contractors Currently there are 12 A/B MACs and 4 DME MACs in the program that process Medicare FFS claims for nearly 70% of the total Medicare beneficiary population, or 37.5 million Medicare FFS beneficiaries. The MACs serve more than 1.5 million health care providers enrolled in the Medicare FFS program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually, 210 million Part A claims and more than 1 billion Part B claims, and paid $367 billion in Medicare benefits. MAC A/B Jurisdiction Map (Dec 2015): Source: www.cms.gov
