Provider enrollment requirements for writing prescriptions for Medicare Part D

The Centers for Medicare & Medicaid Services (CMS) finalized new rules which require physicians and, when applicable, other eligible professionals who write prescriptions for Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to covered under Medicare Part D.

According to CMS, prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Medicare administrative contractors (MAC) by June 1, 2015, to ensure that MACs have sufficient time to process the applications or affidavits. 

Medicare patients’ prescription drug claims will be denied by their Part D plans, beginning December 1, 2015, if the prescriber does not have a valid enrollment or opt-out status with Medicare.

Provider Action Needed

The Centers for Medicare & Medicaid Services (CMS) finalized CMS-4159-F “Medicare 

Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and 

the Medicare Prescription Drug Benefit Programs” on May 23, 2014. This rule requires 

physicians and, when applicable, other eligible professionals who write prescriptions for 

Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file 

for their prescriptions to be covered under Part D. The final regulation stated that the effective date for this requirement would be June 1, 2015. However, CMS is announcing that it will delay enforcement of the requirements in 42 CFR 423.120(c)(6)until December 1, 2015. Nevertheless, prescribers of Part D drugs must submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by June 1, 2015, or earlier, to ensure that MACs have sufficient time to process the applications or opt out affidavits and avoid their patients’ prescription drug claims from being denied by their Part D plans, beginning December 1, 2015. Note that enrollment functions for physicians and other prescribers are handled by Part B MACs.

If you write prescriptions for covered Part D drugs and you are not enrolled in Medicare in 

an approved status or have a valid record of opting out, you need to submit an enrollment 

application or an opt out affidavit to your Medicare Administrative Contractor (MAC) by 

June 1, 2015, or earlier. You may submit your enrollment application electronically using the Internet -based Provider Enrollment, Chain, and Ownership System (PECOS) located at https://pecos.cms.hhs.gov/pecos/login.do or by completing the paper CMS-855I or CMS-855O application, which is available at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html  on the CMS website. Note that an application fee is not required as part of your application submission. If you wish to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, you must complete the CMS-855I application. The CMS-855O, which is a shorter, abbreviated form, should only be completed if you are seeking to enroll solely to order and refer and/or prescribe Part D drugs. (While the CMS-855O form states it is for physicians and non- physician practitioners who want to order and refer, it is appropriate for use by prescribers, who also want to enroll to prescribe Part D drugs.) If you do not see your specialty listed on either of the applications, select the Undefined Physician/Non-Physician Type option and identify your specialty in the space provided.

Reporting the NPI on anti-markup and reference laboratory claims

Summary

The Provider Enrollment, Chain, and Ownership System (PECOS) allow the contractor to verify all national provider identifiers (NPIs), regardless of the jurisdiction in which they are enrolled.

Beginning April 1, 2015, physicians and suppliers billing anti-markup and reference laboratory claims must report the national provider identifier (NPI) of the physician or supplier who actually performed the service. This new requirement applies to all claims, including claims for services where the performing provider is out of the processing contractor's jurisdiction.

This article is based on Change Request (CR) 8806, which provides guidance for physicians and suppliers billing anti-markup and reference laboratory claims. Effective for anti-markup and reference laboratory claims submitted with a receipt date on and after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and the National Provider Identifier (NPI) of the performing physician or supplier when the performing physician or supplier is enrolled in a different contractor's jurisdiction. Make sure your billing staffs are aware of this update.

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires that all covered health care entities follow the same standard for submitting and processing electronic claims transactions. According to the instructions for use of the American National Standards Institute (ANSI) X12 837 professional electronic claim transaction, suppliers must submit the NPI that matches the name and address of the servicing provider/supplier identified on the claim.

On anti-markup and reference laboratory claims, physicians and other suppliers are required to identify the supplier's name, address, and ZIP code in Item 32 of the CMS-1500 claim, or the corresponding loop and segment of the ANSI X12 837 professional electronic claim format. The NPI of the physician or supplier who actually performed the service is required in Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12 837 professional electronic claim transaction.

However, prior to the implementation of the Provider Enrollment, Chain, and Ownership System (PECOS), MACs used systems that were specific to each MAC and did not allow MACs from one State to view provider enrollment information from another State. This systems limitation prevented MACs from being able to share information about existing providers/suppliers, and increased the potential for fraud. As a result, physicians and suppliers that were enrolled in another MAC's jurisdiction could not validate the NPI in Item 32a of the CMS-1500 claim form or on the ANSI X12 837 professional electronic claim format, because the function was not available in PECOS.

ICD 10 countdown - Some important website to brush up

List of Valid ICD-10-CM Codes

CMS has posted a complete list of the 2016 ICD-10-CM valid codes and code titles on the 2016 ICD-10-CM and GEMs web page

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Code-Descriptions-in-Tabular-Order.zip

. The file is named icd10cm_codes_2016.txt. This file will be useful for physician offices and other providers who want to check to make sure that they are reporting all characters in a valid ICD-10-CM code. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.

A similar list of the 2016 ICD-10-PCS valid codes and code titles is available on the 2016 ICD-10 PCS and GEMs web page. The file is named icd10pcs_codes_2016.txt.

Use of Unspecified Codes in ICD-10-CM

CMS has a number of resources that explain unspecified codes and how they should be used in ICD-10-CM:

• MLN Matters® Article SE1518, “Information and Resources for Submitting Correct ICD-10 Codes to Medicare”

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1518.pdf

 • ICD-10 Basics MLN Connects National Provider Call - Call Materials from August 22, 2013

http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2013-08-22-ICD-10-Call.html?DLPage=1&DLEntries=10&DLFilter=ICD-10&DLSort=0&DLSortDir=descending

Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule - Update from CAQH CORE

Provider Types Affected

This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice 

(HH&H) MACs and Durable Medical Equipment MACs (DME MACs) for services to Medicare Beneficiaries.

Provider Action Needed

Change Request (CR) 8983 deals with regular update in Council for Affordable Quality Healthcare (CA QH) Committee on Operating Rules for Information Exchange (CORE) defined code combinations per Operating Rule 360 - Uniform Use of CARCs and RARCs (835) Rule. CAQH CORE will publish the next version of the Code Combination List on or about February 1, 2015, and CR8983 instructs the MACs to use that list as of April 1, 2015. This update is based on November 1, 2014, CARC and RARC updates as posted at the Washington Publishing Company (WPC) website.

The Department of Health and Human Services (HHS) adopted the Phase III CAQH CORE Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rule Set that must be implemented by January 1, 2014, under the Affordable Care Act. The 

Health Insurance Portability and Accountability Act (HIPPA) amended the Social Security Act by adding Part C-Administrative Simplification - to Title XI of the Act, requiring the Secretary of the Department of HHS (the Secretary) to adopt standards for certain transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information.

Global Surgery General Information part 2

What services are included in the global surgery payment?

When the physician who furnishes the surgery also furnishes the following services, Medicare includes them in the global surgery payment:

•Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-

operative visits the day before the day of surgery. For minor procedures, this includes pre-operative

visits the day of surgery;

•Intra-operative services that are normally a usual and necessary part of a surgical procedure;

• All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room;

• Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery;

• Post-surgical pain management by the surgeon;

• Supplies, except for those identified as exclusions: and

• Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

What services are not included in the global surgery payment?

The following services are not included in the global surgical payment. These services may be billed and paid for separately:

• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separately only for major surgical procedures:

Note: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.

• Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;

• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;

• Diagnostic tests and procedures, including diagnostic radiological procedures;

• Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications;

Global Surgery General Information part 1

Definition of a Global Surgical Package

This fact sheet is designed to provide education on the components of a global surgery package. It includes information about billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians. Medicare established a national definition of a global surgical package to ensure that Medicare contractors make payments for the same services consistently across all Medicare contractor (Medicare Administrative Contractor (MAC)) jurisdictions. 

This policy helps prevent Medicare payments for services that are more or less comprehensive than 

intended. In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries. The information that follows describes the components of a global surgical package and billing and payment rules for surgeries, endoscopies, and global surgical packages that are split between two or more physicians. 

The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 

Frequently Asked Questions:

Is the global surgery payment restricted to hospital inpatient settings?

Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, Ambulatory 

Surgical Center (ASC), and physician’s office. When a surgeon visits a patient in an intensive care or critical care unit, Medicare includes these visits in the global surgical package.

List of Preventive Services and Screenings Covered by Medicare

•    Abdominal Aortic Aneurysm Screening

•    Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care

•    Annual Wellness Visit (Including Personalized Prevention Plan Services)

•    Bone Mass Measurements

•    Cancer Screenings 

•    Breast Cancer (mammograms and clinical breast exam)

•    Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])

•    Colorectal Cancer 

                 o    Fecal Occult Blood Test

                 o    Flexible Sigmoidoscopy

                 o    Colonoscopy

                 o    Barium Enema

•    Prostate (PSA blood test and Digital Rectal Exam)

•    Cardiovascular Disease Screening

•    Depression Screening in Adults

•    Diabetes Screening

•    Diabetes Self-Management Training

•    Glaucoma Screening

•    Hepatitis C Screening

•    Human Immunodeficiency Virus (HIV) Screening

•    Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

•    Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)

•    Intensive Behavioral Therapy for Cardiovascular Disease

•    Intensive Behavioral Therapy for Obesity

•    Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)

•    Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs

•    Tobacco-Use Cessation Counseling

As a result of the Affordable Care Act, Medicare now covers many of these services without cost to patients, including the Annual Wellness Visit that was created under the Affordable Care Act.

How to avoid denial CO/PR B7 CO 97 Remark Code - M15, M144

Denial reason code CO/PR B7

We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

You received this denial, because the date of service on the claim is prior to the provider’s Medicare effective date, or after his/her termination date, or because you are billing for a procedure code beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.

• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.

• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. 

Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of up to 60 days after receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.

Submit claims for laboratory services within the scope of the provider’s CLIA certification.

• Verify service/procedure code is listed as approved under the scope of the provider’s certification. 

• Refer to the complete list of downloads of Categorization of Tests on the Centers for Medicare & Medicaid Services (CMS) website. 

• Refer to the List of Waived Tests from the CMS website to determine which codes require the modifier QW (CLIA waived tests).

• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.

Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.

Or, if applicable, request a telephone reopening. Note: The First Coast Service Options Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.

Denial reason code CO 97 

We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below, as applicable, to avoid this denial.

Face-to-Face Encounters and Certification for Home Health Care and Physician Documentation Requirements

Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).

Background: Qualifying Criteria for the Medicare Home Health Benefit

To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements: 

•    Be confined to the home;

•    Under the care of a physician; 

•    Receiving services under a plan of care established and periodically reviewed by a physician;

•    Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or

•    Have a continuing need for occupational therapy.

The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).

Major Documentation Errors

Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF.  The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:

•    The encounter was related to the primary reason for home care

•    How the patient’s condition supports the patient’s homebound status; or 

•    How the patient’s condition supports the need for skilled services