Improving Drug Utilization Review Controls in Part D Effective January 1, 2019, CMS announced new strategies to further help Medicare Part D sponsors prevent and combat opioid overuse including additional safety alerts at the time of dispensing as a proactive step to engage both patients and prescribers about overdose risk and prevention. As of Dec 15 2018, the web page is found here: https://www.cms.gov/Medicare/Prescription-Drug-coverage/PrescriptionDrugCovContra/RxUtilization.html Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate...
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Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes. https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html
Announcement of Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter and Request for Information April 3, 2017 for CY 2018 Page 64 https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2018.pdf Table VII-5. List of Disease Hierarchies for RxHCC Model
Reducing Opioid Misuse from CMS. They are focused on three main areas: Prevention, Treatment and Data. Click on link below to access page and then click on 'See our roadmap." https://www.cms.gov/about-cms/story-page/reducing-opioid-misuse.html As of August 28, 2018, from the MLN Matters Number: SE19004, Medicare would like to include opioid use in the 'Review of Medical and Family History' element of the AWV. Providers are encouraged to pay close attention to opioid use during this element of the AWV. If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have Opioid Use Disorder bus is possibly at risk. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the auth...
Social determinants include societal and environmental conditions such as food, housing, transportation, education, violence, social support, health behaviors and employment. Among these “Z” codes are the following series related to potential hazards due to family and social circumstances impacting health status: Z55-Z65 – Persons with potential health hazards related to socioeconomic and psychosocial circumstances Z55 – Problems related to education and literacy Z56 – Problems related to employment and unemployment Z57 – Occupational exposure to risk factors Z59 – Problems related to housing and economic circumstances Z60 – Problems related to social environment Z62 – Problems related to upbringing Z63 – Other problems related to primary support group, including family circumstances Z64 – Problems related to certain psychosocial circumstances Z65 – Problems related to other psychosocial circumstances Based on the ICD-10-CM Official Guidelines for Cod...
"ACOs participating in the Medicare Shared Savings Program (Shared Savings Program) are required to completely and accurately report quality data that are used to calculate and assess their quality performance. In order to be eligible to share in any savings generated, an ACO must meet the established quality performance standard that corresponds to its performance year. This document presents the 31 quality measures used to assess ACO quality performance and the quality performance standard for the 2018 performance year for the Shared Savings Program ." ACO are evaluated by 4 domains: 1. Patient/Caregiver Experience 2. Care Coordination/Patient Safety 3. Clinical care for At-Risk Population 4. Preventative Health https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-reporting-year-narrative-specifications.pdf Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM ...
This page from Noridian covers Documentation Guidelines for Amended Medical Records. Please use it for reference. Topics include: Elements of a Complete Medical Record Amended Medical Records - Late Entry - Addendums - Corrections Falsified Documentation This includes the creation of new records at the time records are requested - Back-dating entries - Post-dating entries - Pre-dating entries - Writing over, or - Adding to existing documentation (except as described in late entries, addendums and corrections) https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-amended-records [Jurisdiction E - Medicare Part B] JE Part B / Medical Review / Documentation Guidelines for Amended Records ...
Q: The question is whether or not specialty clinics diagnostic codes count for HCC coding for the patient. We have several patients being followed very closely by a specialist and our primary care providers are being asked to put the HCC coding for those diseases. Does the provider need to list all the codes even if a specialist has entered them and sending them to billing? A: The HCC diagnosis codes submitted and documented by specialists are accepted by CMS. When the encounter data is submitted to the health plans the specialists data is included in their submission to CMS. There are a few exceptions, such as radiology. When a patient is primarily seeing a specialist it is still a good idea for the PCP to note the condition and that it is being treated by the specialist. Per the ICD-10 official guidelines for coding and reporting: “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect pat...
Noridian has created on demand tutorials around Medicare Initial Preventive Physical Exam (IPPE) and the Annual Wellness Visit (AWV). The presentations contains coverage criteria, eligible providers, components of the visit and frequency guidelines. https://med.noridianmedicare.com/web/jeb/education/tutorials in the left hand column, look for 'Preventative Services'
Claim Submission https://med.noridianmedicare.com/web/jea/topics/claim-submission So in the world of risk adjustment we are interested in ICD-10 codes, well, we also need to understand the claims process. If we make sure the diagnosis are properly documents but our claims do not make it to CMS and get accepted...our efforts can be stifled. I am posting his web page from Noridian as a reference. Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
Medical Documentation Signature Requirements https://med.noridianmedicare.com/web/jea/cert-reviews/signature-requirements The link for the webpage takes you to medical documentation signature requirements. These are provided by CMS via CMS Change Request (CR)9225, CR9332, CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 [If the link isn’t working cut and paste the name of the manual into your browser.] Further down the page you will find information about Signature for Amendments Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or ...
Industry Collaboration Effort can be found at http://iceforhealth.org/home.asp You can join ICE by registering with them. With your log-in you can gain access to their website. To find the slides and audio, click on Podcasts. From there you fill find the 2017 ICE Conference Podcasts. There are sessions dealing specifically with Risk Adjustment & STAR Ratings. Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
Results from an Office of Inspector General (OIG) report on "CMS Paid Practitioners for Telehealth Services That Did Not Meet Medicare Requirements" Medicare paid a total of $17.6 million in telehealth payments in 2015, compared with $61,302 in 2001. Medicare telehealth payments include a professional fee, paid to the practitioner performing the service at a distant site, and an originating-site fee, paid to the facility where the beneficiary receives the service. A Medicare Payment Advisory Commission study of 2009 claims found that Medicare professional fee claims without associated claims for originating-site facility fees were more likely to be associated with unallowable telehealth payments. Full Summary is available at: https://oig.hhs.gov/oas/reports/region5/51600058.asp The 26 page report with recommendations is available at: https://oig.hhs.gov/oas/reports/region5/51600058.pdf string to locate report: Home > Reports & Pub...
CMS has published the latest MLN catalog. As of today, it can be found here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf if the link doesn't work in the future, do an internet search for: CMS MLN CATALOG APRIL 2018 Below is the Table of Contents
Provider Compliance Tips for Hospital Beds and Accessories MLN Fact Sheet ICN 909476 February 2018 PROVIDER TYPES AFFECTED Physicians and other practitioners who write requisitions or orders for hospital beds and accessories BACKGROUND The Medicare Fee-For-Service (FFS) improper payment rate for hospital beds and accessories for the 2017 reporting period was 78.5 percent, representing a projected improper payment amount of $66.2 million and accounting for 0.2 percent of the overall Medicare FFS improper payment rate. REASONS FOR DENIALS During the 2017 reporting period, the majority of improper payments for hospital beds and accessories were due to insufficient documentation. TO PREVENT DENIALS The following conditions must be met: 1. General Requirements for Coverage of Hospital Beds A physician’s prescription and such additional documentation as the Medicare Administrative Cont...
From the Noridian website: Examples of acceptable electronic signatures are, but not limited to: Chart ‘Accepted By' with provider's name ‘Electronically signed by' with provider's name ‘Verified by' with provider's name ‘Reviewed by' with provider's name ‘Released by' with provider's name ‘Signed by' with provider's name ‘Signed before import by' with provider's name ‘Signed: John Smith, M.D.' with provider's name Digitalized signature: Handwritten and scanned into the compute. ‘This is an electronically verified report by John Smith, M.D.' ‘Authenticated by John Smith, M.D.‘ ‘Authorized by: John Smith, M.D.‘ ‘Digital Signature: John Smith, M.D.‘ ‘Confirmed by' with provider's name ‘Closed by' with provider's name ‘Finalized by' with provider's name Note: ‘Signed but not read' is not acceptable Signature Requirement Questions...
This is a document from Noridian to outline all the documentation requirements for Jurisdiction E which covers California and a few other states. Preventive Services Documentation Requirements Initial Preventive Physical Examination (IPPE) Annual Wellness Visit (AWV) UPDATED OCT 20 2017 https://med.noridianmedicare. com/web/jeb/topics/preventive- services/documentation- requirements
https://datawarehouse.hrsa. gov/tools/analyzers/geo/ telehealth.aspx Use the above referenced web site to ch eck if an address is eligible for Medicare telehealth originating site* payment. *Authorized originating sites include: Offices of a Physician or Practitioner Hospitals Critical Access Hospitals Community Mental Health Centers Skilled Nursing Facilities Rural Health Clinics Federally Qualified Health Centers Hospital-Based or Critical Access Hospital (CAH)-Based Renal Dialysis Centers (including satellites) If address comes up as NO…that location cannot be originating site where the provider is located Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to t...
This is a link to further information on the Medicare Preventive Services. The layout of it reminds me of a bingo card! Medicare Learning Network is the educational arm of Centers for Medicare and Medicaid Service (CMS). Remember this is further information on different types of screenings available to Medicare beneficiaries. https://www.cms.gov/Medicare/ Prevention/PrevntionGenInfo/ medicare-preventive-services/ MPS-QuickReferenceChart-1. html#AWV Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.
The Centers for Medicare and Medicaid have posted a revised, ten-page MLN Booklet entitled MEDICARE AND MEDICAID BASICS from Medicare Learning Network Publications & Multimedia. As of July 2017. This booklet provides an overview of the Medicare and Medicaid Programs and some brief information on other types of health coverage. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProgramBasicsText-Only.pdf The Centers for Medicare & Medicaid Services (CMS) oversees Medicare and Medicaid along with other Federal health care programs and services. This booklet provides an overview of the Medicare and Medicaid Programs and some brief information on other types of health coverage.
Noridian has posted information from their review of subsequent Annual Wellness Visits (AWV) for prepayment claims. By the information on their website, it appears to have been a one-time task for claims from Southern California. The summary of their findings is very interesting. https://med.noridianmedicare. com/web/jeb/search-result/-/ view/10525/g0439-annual- wellness-visit-subsequent-–- final-results-of-service- specific-prepayment-review- southern-california Summary of Findings Findings of claims reviewed from March 10, 2017 - June 8, 2017 are as follows: • 740 Claims Reviewed • 129 Claims Paid • 611 Claims Corrected or Denied • 82.59% Error Rate Also available on this page for review are: Top Denial Reasons Educational Resources and References Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate a...
From Noridian's Medicare web page, Jurisdiction E - Medicare Part B covering California and a few other states... comes the details on... Initial Preventive Physical Exam Screening Electrocardiogram Annual Wellness Visit (AWV) 1. First AWV components 2. Subsequent AWV components It has the components for each type of exam. This is another resource, beside the CMS website for these details. http://med.noridianmedicare. com/web/jeb/search-result/-/ view/10542/annual-wellness- visit-awv-and-initial- preventive-physical-exam-ippe- Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The inf...