North Carolina MGMA Spring Conference

Presented by Palmetto GBA Provider

Outreach amp Education

May 13th 2015

552015 1

Disclaimer

The information provided in this presentation was current as of 05042015

Any changes or new information superseding the information in this presentation is provided in articles with

publication dates after 05042015 posted on our website at

wwwPalmettoGBAcomJ11B

552015 2

CPT only copyright 2014 American Medical Association All rights reserved

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT) Copyright copy 2014 American Dental Association

(ADA) All rights reserved

Disclaimer

The information provided in this presentation was current as of 05042015

Any changes or new information superseding the information in this presentation is provided in articles with

publication dates after 05042015 posted on our website at

wwwPalmettoGBAcomJ11B

552015 2

CPT only copyright 2014 American Medical Association All rights reserved

The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT) Copyright copy 2014 American Dental Association

(ADA) All rights reserved

Agenda

Medicare Updates and Changes

CERT

Medical Review Spotlight

Hot Topics and Reminders

News to Use and Resources

552015 3

Updates and Changes

4

Provider Enrollment Form

CMS 855R (Reassignment of Benefits) form revised

Mandated use - May 31 2015

Current or revised form accepted from the date the revised form is published through May 31 2015

Revised form available on CMS website - December 29 2014

552015 5 MMSE1432

Laboratory Services for ESRD Claims

Effective April 1 2015

Elimination of the 5050 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims

ESRD PPS requires all renal dialysis laboratory services be paid in the ESRD facility bundled payment and therefore may only be billed by the ESRD facility

552015 6 MM8957

Health Professional Shortage Area (HPSA)

CMS 2015 HPSA Zip Code Files Applicable on claims with dates of service on

or after January 1 2015 through December 31 2015 Separate Primary Care and Mental Health Zip

Code Files

httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHPSAPSAPhysicianBonusesindexhtmlredirect=HPSAPSAPhysicianBonuses01_overviewasp

552015 7 MM8942

Updates and Changes

4

Provider Enrollment Form

CMS 855R (Reassignment of Benefits) form revised

Mandated use - May 31 2015

Current or revised form accepted from the date the revised form is published through May 31 2015

Revised form available on CMS website - December 29 2014

552015 5 MMSE1432

Laboratory Services for ESRD Claims

Effective April 1 2015

Elimination of the 5050 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims

ESRD PPS requires all renal dialysis laboratory services be paid in the ESRD facility bundled payment and therefore may only be billed by the ESRD facility

552015 6 MM8957

Health Professional Shortage Area (HPSA)

CMS 2015 HPSA Zip Code Files Applicable on claims with dates of service on

or after January 1 2015 through December 31 2015 Separate Primary Care and Mental Health Zip

Code Files

httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHPSAPSAPhysicianBonusesindexhtmlredirect=HPSAPSAPhysicianBonuses01_overviewasp

552015 7 MM8942

Provider Enrollment Form

CMS 855R (Reassignment of Benefits) form revised

Mandated use - May 31 2015

Current or revised form accepted from the date the revised form is published through May 31 2015

Revised form available on CMS website - December 29 2014

552015 5 MMSE1432

Laboratory Services for ESRD Claims

Effective April 1 2015

Elimination of the 5050 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims

ESRD PPS requires all renal dialysis laboratory services be paid in the ESRD facility bundled payment and therefore may only be billed by the ESRD facility

552015 6 MM8957

Health Professional Shortage Area (HPSA)

CMS 2015 HPSA Zip Code Files Applicable on claims with dates of service on

or after January 1 2015 through December 31 2015 Separate Primary Care and Mental Health Zip

Code Files

httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHPSAPSAPhysicianBonusesindexhtmlredirect=HPSAPSAPhysicianBonuses01_overviewasp

552015 7 MM8942

Laboratory Services for ESRD Claims

Effective April 1 2015

Elimination of the 5050 Payment Rule for Laboratory Services on End Stage Renal Disease (ESRD) Claims

ESRD PPS requires all renal dialysis laboratory services be paid in the ESRD facility bundled payment and therefore may only be billed by the ESRD facility

552015 6 MM8957

Health Professional Shortage Area (HPSA)

CMS 2015 HPSA Zip Code Files Applicable on claims with dates of service on

or after January 1 2015 through December 31 2015 Separate Primary Care and Mental Health Zip

Code Files

httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHPSAPSAPhysicianBonusesindexhtmlredirect=HPSAPSAPhysicianBonuses01_overviewasp

552015 7 MM8942

Health Professional Shortage Area (HPSA)

CMS 2015 HPSA Zip Code Files Applicable on claims with dates of service on

or after January 1 2015 through December 31 2015 Separate Primary Care and Mental Health Zip

Code Files

httpwwwcmsgovMedicareMedicare-Fee-for-Service-PaymentHPSAPSAPhysicianBonusesindexhtmlredirect=HPSAPSAPhysicianBonuses01_overviewasp

552015 7 MM8942

Health Professional Shortage Areas (HPSA) Incentive

Submitting HPSA modifiers on claims that do not qualify for the HPSA incentive payment may result in Erroneous incentive payments

A referral to the Zone Program Integrity Contractor (ZPIC) for fraud and abuse investigation

bull Palmetto GBA will suppress HPSA payments for providers with four or more quarters of erroneous billing of the AQ HCPCS modifier

httpwwwpalmettogbacompalmettoprovidersnsfdocsCatProviders~Jurisdiction201120Part20B~Browse20by20Topic~Incentive20Programsopenampexpand=1ampnavmenu=Browse^by^Topic||

552015 8

Anti-Markup and Reference Laboratory Claims

Effective dates

January 1 2015 - Analysis Design and Programming

April 1 2015 - Testing and Implementation

April 6 2015 ndash Edits turned on

Anti-markup and reference laboratory claims must report

Name address and ZIP code in block 32 or electronic equivalent and

NPI of the provider who actually performed the service in block 32a or electronic equivalent

552015 9 MM8806

Documentation Requests

Effective April 1 2015

Documentation for pre-payment reviews must be submitted within 45 calendar days of request

Claims denied on day 46

552015 10

MM8583

Administrative Law Judge (ALJ) and Federal District Court Appeals

Calendar Year 2015 Amount in Controversy

ALJ requests

Filed prior to January 1 2015 - $140

Filed January 1 2015 and after - $150

Federal District Court requests

Filed prior to January 1 2015 - $1430

Filed January 1 2015 and after - $1460

552015 11

2015 Drug Testing Codes

The Centers for Medicare amp Medicaid (CMS) has announced that the 2015 drug testing CPT codes 80300 ndash 80377 will not be recognized at this time by Medicare Until further notice new HCPCs G6030 ndash G6058 should be used when reporting drug testing performed on or after January 1 2015 Claims submitted with CPT code 80300 ndash 80377 on or after January 1 2015 will be rejected as unprocessable

CMS provides details of this change in the Clinical Laboratory Fee Schedule (CLFS) Final Determinations

Document (PDF 119 KB)

Documentation Requests

Effective April 1 2015

Documentation for pre-payment reviews must be submitted within 45 calendar days of request

Claims denied on day 46

552015 10

MM8583

Administrative Law Judge (ALJ) and Federal District Court Appeals

Calendar Year 2015 Amount in Controversy

ALJ requests

Filed prior to January 1 2015 - $140

Filed January 1 2015 and after - $150

Federal District Court requests

Filed prior to January 1 2015 - $1430

Filed January 1 2015 and after - $1460

552015 11

2015 Drug Testing Codes

The Centers for Medicare amp Medicaid (CMS) has announced that the 2015 drug testing CPT codes 80300 ndash 80377 will not be recognized at this time by Medicare Until further notice new HCPCs G6030 ndash G6058 should be used when reporting drug testing performed on or after January 1 2015 Claims submitted with CPT code 80300 ndash 80377 on or after January 1 2015 will be rejected as unprocessable

CMS provides details of this change in the Clinical Laboratory Fee Schedule (CLFS) Final Determinations

Document (PDF 119 KB)

Administrative Law Judge (ALJ) and Federal District Court Appeals

Calendar Year 2015 Amount in Controversy

ALJ requests

Filed prior to January 1 2015 - $140

Filed January 1 2015 and after - $150

Federal District Court requests

Filed prior to January 1 2015 - $1430

Filed January 1 2015 and after - $1460

552015 11

2015 Drug Testing Codes

The Centers for Medicare amp Medicaid (CMS) has announced that the 2015 drug testing CPT codes 80300 ndash 80377 will not be recognized at this time by Medicare Until further notice new HCPCs G6030 ndash G6058 should be used when reporting drug testing performed on or after January 1 2015 Claims submitted with CPT code 80300 ndash 80377 on or after January 1 2015 will be rejected as unprocessable

CMS provides details of this change in the Clinical Laboratory Fee Schedule (CLFS) Final Determinations

Document (PDF 119 KB)

2015 Drug Testing Codes

The Centers for Medicare amp Medicaid (CMS) has announced that the 2015 drug testing CPT codes 80300 ndash 80377 will not be recognized at this time by Medicare Until further notice new HCPCs G6030 ndash G6058 should be used when reporting drug testing performed on or after January 1 2015 Claims submitted with CPT code 80300 ndash 80377 on or after January 1 2015 will be rejected as unprocessable

CMS provides details of this change in the Clinical Laboratory Fee Schedule (CLFS) Final Determinations

Document (PDF 119 KB)

Comprehensive Error Rate Testing

(CERT)

13

Partnering for Error Rate Reduction

552015 14

Evaluation and

Management Services

Laboratory Services

Minor Procedures

Advanced Imaging Services

Ambulance Services

Chiropractic Services

Lab Claim Error Impact

bull Laboratory or performing provider is responsible for working with the ordering physician to complete and document the order or intent to order all tests

bull Ordering providerrsquos revenue is not tied to completing the laboratory order when tests performed by outside lab

bull Laboratory providers struggle to obtain the needed documentation from the ordering physician

15

Corrective Action

bull Implement processes to check for signed and dated order or records to support order or intent to order for each test before rendering lab test

bull Develop relationships with ordering providers ndash Let them know what supporting documentation is

needed when ordering

ndash Request necessary documentation when it is missing

bull Check for all necessary documentation prior to submitting

bull Self audit

bull Fix known deficiencies

16

Evaluation and Management Services

Categorized into different settings depending on where the service is furnished Examples of settings include

Office or other outpatient setting

Hospital inpatient

Emergency department (ED)

Nursing facility (NF)

17

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Partnering for Error Rate Reduction

552015 14

Evaluation and

Management Services

Laboratory Services

Minor Procedures

Advanced Imaging Services

Ambulance Services

Chiropractic Services

Lab Claim Error Impact

bull Laboratory or performing provider is responsible for working with the ordering physician to complete and document the order or intent to order all tests

bull Ordering providerrsquos revenue is not tied to completing the laboratory order when tests performed by outside lab

bull Laboratory providers struggle to obtain the needed documentation from the ordering physician

15

Corrective Action

bull Implement processes to check for signed and dated order or records to support order or intent to order for each test before rendering lab test

bull Develop relationships with ordering providers ndash Let them know what supporting documentation is

needed when ordering

ndash Request necessary documentation when it is missing

bull Check for all necessary documentation prior to submitting

bull Self audit

bull Fix known deficiencies

16

Evaluation and Management Services

Categorized into different settings depending on where the service is furnished Examples of settings include

Office or other outpatient setting

Hospital inpatient

Emergency department (ED)

Nursing facility (NF)

17

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Lab Claim Error Impact

bull Laboratory or performing provider is responsible for working with the ordering physician to complete and document the order or intent to order all tests

bull Ordering providerrsquos revenue is not tied to completing the laboratory order when tests performed by outside lab

bull Laboratory providers struggle to obtain the needed documentation from the ordering physician

15

Corrective Action

bull Implement processes to check for signed and dated order or records to support order or intent to order for each test before rendering lab test

bull Develop relationships with ordering providers ndash Let them know what supporting documentation is

needed when ordering

ndash Request necessary documentation when it is missing

bull Check for all necessary documentation prior to submitting

bull Self audit

bull Fix known deficiencies

16

Evaluation and Management Services

Categorized into different settings depending on where the service is furnished Examples of settings include

Office or other outpatient setting

Hospital inpatient

Emergency department (ED)

Nursing facility (NF)

17

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Corrective Action

bull Implement processes to check for signed and dated order or records to support order or intent to order for each test before rendering lab test

bull Develop relationships with ordering providers ndash Let them know what supporting documentation is

needed when ordering

ndash Request necessary documentation when it is missing

bull Check for all necessary documentation prior to submitting

bull Self audit

bull Fix known deficiencies

16

Evaluation and Management Services

Categorized into different settings depending on where the service is furnished Examples of settings include

Office or other outpatient setting

Hospital inpatient

Emergency department (ED)

Nursing facility (NF)

17

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Evaluation and Management Services

Categorized into different settings depending on where the service is furnished Examples of settings include

Office or other outpatient setting

Hospital inpatient

Emergency department (ED)

Nursing facility (NF)

17

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Why are Errors Occurring

bull Insufficient documentation

bull No response to documentation request

bull Illegible

bull Documentation for wrong patient or date of service submitted

bull Documentation does not support level of EM billed

bull Documentation does not adequately describe the service defined by the CPTHPCS code or HCPCS modifier billed

Signature issues - no signature (or no legible signature) and no signature log or attestation submitted

bull Does not meet key elements - medical decision making history or physical exam for billed EM service level

18

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Evaluation amp Management

19

Great teaching tool

Printing Options

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

EM Help Center

20

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

EM Weekly Tips

21

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

CERT Tips

Review denials

Submit missing documentation directly to CERT if denial is not a medical necessity denial

Appeal medical necessity denials

‒ CERT Redetermination Request Form

Designate a CERT ldquoPoint of Contactrdquo (POC)

httpswwwcertprovidercom

552015 22

Medical Review Spotlight

23

CERT vs Palmetto GBA Medical Reviews

bull CERT

ndash Traditionally conducts post-payment reviews ndash after the claim has finalized

ndash CERT contractor selects claim sample requests records and completes the review

ndash Failure to respond to a CERT record request may result in a contact from Palmetto GBA to assist the CERT in obtaining the records

bull Palmetto GBA

ndash Medical reviews can be pre-payment or post-payment reviews

ndash Palmetto GBA selects the claim sample sends the request for medical records and completes the reviews

ndash Based on a service specific review MR may conduct a provider-specific review

24

Active Medical Reviews

552015 25

httpwwwpalmettogbacompalmettoprovidersnsfDocsCatProviders~Jurisdiction201120Part20B~Medical20Review~General~9NNJBX6701openampnavmenu=Medical^Review||||

CERT vs Palmetto GBA Medical Reviews

bull CERT

ndash Traditionally conducts post-payment reviews ndash after the claim has finalized

ndash CERT contractor selects claim sample requests records and completes the review

ndash Failure to respond to a CERT record request may result in a contact from Palmetto GBA to assist the CERT in obtaining the records

bull Palmetto GBA

ndash Medical reviews can be pre-payment or post-payment reviews

ndash Palmetto GBA selects the claim sample sends the request for medical records and completes the reviews

ndash Based on a service specific review MR may conduct a provider-specific review

24

Active Medical Reviews

552015 25

httpwwwpalmettogbacompalmettoprovidersnsfDocsCatProviders~Jurisdiction201120Part20B~Medical20Review~General~9NNJBX6701openampnavmenu=Medical^Review||||

Active Medical Reviews

552015 25

httpwwwpalmettogbacompalmettoprovidersnsfDocsCatProviders~Jurisdiction201120Part20B~Medical20Review~General~9NNJBX6701openampnavmenu=Medical^Review||||

Comparative Billing Report (CBR)

Developed by eGlobalTech (eGT) and Palmetto GBA

National CBR on use of modifier 25 by providers under family practice specialty code

CBR contains data-driven tables and graphs with an explanation of findings that compare providers billing patterns to those of their peers in the state and across the nation for claims filed with Modifier 25

httpwwwcbrinfonetcbr201409html

552015 26

Medical Review Strategy

ldquoThe Listrdquo ndash Part B

Drugs and Biologicals

Evaluation amp Management

Laboratory

Emergency Department Visits

New Providers

Hot-Spot Focus Category

27

Medical Review Strategy

Laboratory

82542 ndash Column ChromatographyMass Spectrometry

Drug testing for opioid heroin etc (costs)

Can not have standing orders for this(med necc must be specific)

Emergency Department Visits (non-signature)

99283 ndash Emergency Department Visit for the EampM of a Patient - Expanded

99284 ndash Emergency Department Visit for the EampM of a Patient - Detailed

99285 ndash Emergency Department Visit for the EampM of a Patient - Comprehensive

28 CPT only copyright 2012 American Medical Association

All rights reserved

Medical Review Strategy

New Providers

New Part B Medicare Providers

Hot-Spot Focus Category

17000 17004 17110 17311 amp 17312 Destruction of Lesions and Mohs Examination of Specimens

MR Tip MOHS has very specific guidelines Must follow guidance in codebook Pathologist amp Surgeon bill at the same time so be clear on who is billing what The most common mistake is usually no pathology report

29 CPT only copyright 2012 American Medical Association

All rights reserved

Hot Topics and Reminders

30

Enrollment Application Status

Interactive Voice Response (IVR) Unit

Use DCN number or PTAN associated with that provider enrollment application

Status information updated approximately 24 hours after each transaction

552015 31

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

Medical Review Strategy

Laboratory

82542 ndash Column ChromatographyMass Spectrometry

Drug testing for opioid heroin etc (costs)

Can not have standing orders for this(med necc must be specific)

Emergency Department Visits (non-signature)

99283 ndash Emergency Department Visit for the EampM of a Patient - Expanded

99284 ndash Emergency Department Visit for the EampM of a Patient - Detailed

99285 ndash Emergency Department Visit for the EampM of a Patient - Comprehensive

28 CPT only copyright 2012 American Medical Association

All rights reserved

Medical Review Strategy

New Providers

New Part B Medicare Providers

Hot-Spot Focus Category

17000 17004 17110 17311 amp 17312 Destruction of Lesions and Mohs Examination of Specimens

MR Tip MOHS has very specific guidelines Must follow guidance in codebook Pathologist amp Surgeon bill at the same time so be clear on who is billing what The most common mistake is usually no pathology report

29 CPT only copyright 2012 American Medical Association

All rights reserved

Hot Topics and Reminders

30

Enrollment Application Status

Interactive Voice Response (IVR) Unit

Use DCN number or PTAN associated with that provider enrollment application

Status information updated approximately 24 hours after each transaction

552015 31

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

Medical Review Strategy

New Providers

New Part B Medicare Providers

Hot-Spot Focus Category

17000 17004 17110 17311 amp 17312 Destruction of Lesions and Mohs Examination of Specimens

MR Tip MOHS has very specific guidelines Must follow guidance in codebook Pathologist amp Surgeon bill at the same time so be clear on who is billing what The most common mistake is usually no pathology report

29 CPT only copyright 2012 American Medical Association

All rights reserved

Hot Topics and Reminders

30

Enrollment Application Status

Interactive Voice Response (IVR) Unit

Use DCN number or PTAN associated with that provider enrollment application

Status information updated approximately 24 hours after each transaction

552015 31

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

Hot Topics and Reminders

30

Enrollment Application Status

Interactive Voice Response (IVR) Unit

Use DCN number or PTAN associated with that provider enrollment application

Status information updated approximately 24 hours after each transaction

552015 31

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

Enrollment Application Status

Interactive Voice Response (IVR) Unit

Use DCN number or PTAN associated with that provider enrollment application

Status information updated approximately 24 hours after each transaction

552015 31

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

ROADTO10ORG

552015 32

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

ICD-10 ndash Resources

October 1 2015

552015 34

bull httpwwwcmsgovMedicareCodingICD10indexhtmlredirect=icd10

ICD-10 - CMS

bull httpwwwpalmettogbacompalmettoicdnsfDocsCatHomeICD-10

ICD-10

Palmetto GBA

News to Use and Resources

35

GBD Blog and Twitter

Palmetto GBA is using the Going Beyond Diagnosis (GBD) blog and Twitter account to help facilitate communication on error rate reduction

httppalmgbacomgbd

BeyondDx

552015 36

GBD Blog and Twitter

Palmetto GBA is using the Going Beyond Diagnosis (GBD) blog and Twitter account to help facilitate communication on error rate reduction

httppalmgbacomgbd

BeyondDx

552015 36

Provider Enrollment Open House Available the First Tuesday of the Month

Palmetto GBArsquos Provider Enrollment Department holds an open house at our Palmetto GBA office located at 17 Technology Circle Columbia South Carolina 29203 the first Tuesday of each month This open house is for any of Palmetto GBArsquos J11 Part B providers who would like to stop by and receive answers to their questions concerning their Medicare provider enrollment applications

Self Service Tools

552015 39

wwwPalmettoGBAcomJ11B

OPS ndash New Features

Submission of documentation to satisfy an Additional Documentation Response (ADR)

Unlimited PDF attachments (each up to 40 MB for a maximum total of 150MB)

Select lsquoMedical Reviewrsquo then lsquoMR ADR Responsersquo form

552015 40

New OPS Feature

Get Your First-Level Appeal Letters Delivered Electronically

Palmetto GBA now offers an eDelivery option for receiving your redetermination decision letters electronically Imagine getting your Medicare

redetermination notices (MRNs) the same day that they are issued delivered directly to your computer You even can choose to get an email to let you know that the letter

is waiting for you

New OPS Feature

bull To start receiving your Medicare redetermination letters electronically you must be signed up for our Online Provider Services (OPS) tool

bull Once you have signed into OPS and selected Admin a drop-down box will provide you with your eDelivery options Just choose eDelivery to start receiving your letters through OPS You can also select User Email Notification to start receiving emails when your MRN letters are available for you Every choice is so easy and user-friendly

bull Once you have chosen the eDelivery option all of your MRNs will come to you electronically even if you sent in your appeal request via fax or mail

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Self Service Tools

552015 39

wwwPalmettoGBAcomJ11B

OPS ndash New Features

Submission of documentation to satisfy an Additional Documentation Response (ADR)

Unlimited PDF attachments (each up to 40 MB for a maximum total of 150MB)

Select lsquoMedical Reviewrsquo then lsquoMR ADR Responsersquo form

552015 40

New OPS Feature

Get Your First-Level Appeal Letters Delivered Electronically

Palmetto GBA now offers an eDelivery option for receiving your redetermination decision letters electronically Imagine getting your Medicare

redetermination notices (MRNs) the same day that they are issued delivered directly to your computer You even can choose to get an email to let you know that the letter

is waiting for you

New OPS Feature

bull To start receiving your Medicare redetermination letters electronically you must be signed up for our Online Provider Services (OPS) tool

bull Once you have signed into OPS and selected Admin a drop-down box will provide you with your eDelivery options Just choose eDelivery to start receiving your letters through OPS You can also select User Email Notification to start receiving emails when your MRN letters are available for you Every choice is so easy and user-friendly

bull Once you have chosen the eDelivery option all of your MRNs will come to you electronically even if you sent in your appeal request via fax or mail

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

OPS ndash New Features

Submission of documentation to satisfy an Additional Documentation Response (ADR)

Unlimited PDF attachments (each up to 40 MB for a maximum total of 150MB)

Select lsquoMedical Reviewrsquo then lsquoMR ADR Responsersquo form

552015 40

New OPS Feature

Get Your First-Level Appeal Letters Delivered Electronically

Palmetto GBA now offers an eDelivery option for receiving your redetermination decision letters electronically Imagine getting your Medicare

redetermination notices (MRNs) the same day that they are issued delivered directly to your computer You even can choose to get an email to let you know that the letter

is waiting for you

New OPS Feature

bull To start receiving your Medicare redetermination letters electronically you must be signed up for our Online Provider Services (OPS) tool

bull Once you have signed into OPS and selected Admin a drop-down box will provide you with your eDelivery options Just choose eDelivery to start receiving your letters through OPS You can also select User Email Notification to start receiving emails when your MRN letters are available for you Every choice is so easy and user-friendly

bull Once you have chosen the eDelivery option all of your MRNs will come to you electronically even if you sent in your appeal request via fax or mail

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

New OPS Feature

Get Your First-Level Appeal Letters Delivered Electronically

Palmetto GBA now offers an eDelivery option for receiving your redetermination decision letters electronically Imagine getting your Medicare

redetermination notices (MRNs) the same day that they are issued delivered directly to your computer You even can choose to get an email to let you know that the letter

is waiting for you

New OPS Feature

bull To start receiving your Medicare redetermination letters electronically you must be signed up for our Online Provider Services (OPS) tool

bull Once you have signed into OPS and selected Admin a drop-down box will provide you with your eDelivery options Just choose eDelivery to start receiving your letters through OPS You can also select User Email Notification to start receiving emails when your MRN letters are available for you Every choice is so easy and user-friendly

bull Once you have chosen the eDelivery option all of your MRNs will come to you electronically even if you sent in your appeal request via fax or mail

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

New OPS Feature

bull To start receiving your Medicare redetermination letters electronically you must be signed up for our Online Provider Services (OPS) tool

bull Once you have signed into OPS and selected Admin a drop-down box will provide you with your eDelivery options Just choose eDelivery to start receiving your letters through OPS You can also select User Email Notification to start receiving emails when your MRN letters are available for you Every choice is so easy and user-friendly

bull Once you have chosen the eDelivery option all of your MRNs will come to you electronically even if you sent in your appeal request via fax or mail

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Additional OPS Features

The OPS application provides information access over the Web for the following online

services bull Eligibility bull Claims Status bull eClaim Submissions bull Remittances Online bull Financial Information - payment floor last three checks

paid eOffset requests and eCheck payments bull Appeals bull Medical Review ADR Response Form bull eDelivery - Receive Paperless Additional Documentation

Requests via your OPS Message Inbox

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Additional OPS Features

All forms currently have a file size limitation of 5 MB per attachment Users may attach up to five files depending on the form Form MR ADR Response forms OPS users may submit attachments up to 40 MB in size While there is no longer a limit to the number of files that can be attached to the form the combined size of all attachments cannot exceed 150 MB in size

Note All attachments must be in PDF format

OPS is our free Internet-based provider self-service portal

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Palmetto GBA Advanced Clinical Editing (P-ACE)

Available at no cost to all direct submitters and those transmitting claims through a clearinghousebilling service

lsquoSmart editsrsquo will appear on claim rejection reports (277CA)

Claims failing the pre-adjudication editing afford providers an opportunity to review the claim for correctness and resubmission or if appropriate modifications can be made to the claim and then resubmitted

There is no software to download

552015 45

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Physician Fee Schedule

Tool

46

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

CMS National and Open Door Calls and E-News National Provider Calls and Events

httpwwwcmsgovOutreach-and-EducationOutreachNPCNational-Provider-Calls-and-Eventshtml

Open Door Forums httpwwwcmsgovOutreach-and-

EducationOutreachOpenDoorForumsindexhtml

bull CMS E-News ‒ httpwwwcmsgovOutreach-and-

EducationOutreachFFSProvPartProgProvider-Partnership-Email-Archivehtml

47

Claim Processing Issue Log (CPIL)

552015 48

49

Progressive Corrective Action is simply a way of targeting and directing medical review efforts on claims for services where there exists the greatest risk of inappropriate program payments

50

Progressive Corrective Action(PCA)

To maximize program protection against inappropriate payments

To decrease the receipt of claims for non-covered or unnecessary services

To educate providers on appropriate practices

Goals of the PCA process

To help improve quality of care for beneficiaries

To avoid inconvenience to providers who adhere to program requirements

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

49

Progressive Corrective Action is simply a way of targeting and directing medical review efforts on claims for services where there exists the greatest risk of inappropriate program payments

50

Progressive Corrective Action(PCA)

To maximize program protection against inappropriate payments

To decrease the receipt of claims for non-covered or unnecessary services

To educate providers on appropriate practices

Goals of the PCA process

To help improve quality of care for beneficiaries

To avoid inconvenience to providers who adhere to program requirements

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Progressive Corrective Action is simply a way of targeting and directing medical review efforts on claims for services where there exists the greatest risk of inappropriate program payments

50

Progressive Corrective Action(PCA)

To maximize program protection against inappropriate payments

To decrease the receipt of claims for non-covered or unnecessary services

To educate providers on appropriate practices

Goals of the PCA process

To help improve quality of care for beneficiaries

To avoid inconvenience to providers who adhere to program requirements

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

To maximize program protection against inappropriate payments

To decrease the receipt of claims for non-covered or unnecessary services

To educate providers on appropriate practices

Goals of the PCA process

To help improve quality of care for beneficiaries

To avoid inconvenience to providers who adhere to program requirements

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

To help improve quality of care for beneficiaries

To avoid inconvenience to providers who adhere to program requirements

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Analyze your Remittance Advice to improve future reimbursement

Palmetto GBA encourages all providers to review the top denials when filing claims to prevent denials

Utilize the information to develop a checklist

The checklist can then be used to review documentation and codes prior to filing

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Medical Review Top Denials Rank Denial

Code Denial Description

1 F12

Documentation received contains incorrectincompleteinvalid patient identification or date of service

2 F10 Documentation requested for this date of service was not received or was incomplete

3 630 Payer deems the information submitted does not support Medical Necessity of services billed

4 F26 Claim billed in error per provider

5 F41 Information submitted contains an invalidillegible provider signature

6 F06 Documentation lacks the necessary provider signature

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Medical Review Top Denials Rank Denial

Code Denial Description

7 015 Documentation requested for this date of service was not received or was incomplete

8 093 Information submitted deemed illegible

9 529 Payer deems the information submitted does not support medical necessity of services billed

10 023 Original medical record has been altered

11 022 Documentation requested for this date of service was not received or was incomplete

12 F46 Information submitted contains an invalidillegible provider signature

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

99213 - Office or Other Outpatient Visit for the EampM of an Established Patient Expanded Requires at least 2 out of 3 key components

An expanded problem focused history

An expanded problem focused examination

Medical decision making of low complexity

E amp M Office Visits ndash Established

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Currently under Post ndashpay review

99214 - Office or Other Outpatient Visit for the EampM of an Established Patient Detailed

o Requires at least 2 out of 3 key components

A detailed history

A detailed examination

Medical decision making of moderate complexity

E amp M Office Visits ndash Established

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Office visits continuedhellip

99215 - Office or Other Outpatient Visit for the EampM of an Established Patient

Comprehensive

Requires at least 2 out of 3 key components

o A comprehensive history

o A comprehensive examination

o Medical decision making of high complexity

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Palmetto GBA performed service-specific prepayment targeted medical review on claims for EM code 99233 Subsequent Hospital Inpatient Care (Typically 35 Minutes Per Day)

At the end of the probe North Carolina as a region continued on the probe

Subsequent Hospital Inpatient Care (99233)

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

CPT code 99233 (Subsequent Hospital Care) is used (per day) for the Evaluation and Management (EM) of an established patient Two of these three key components are necessary in order to bill this code

A detailed interval history

A detailed examination

Medical decision making of high complexity

The Components of Subsequent Hospital Care

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

296-NODOC-During education calls it was noted that addresses had not been updated per the 855B form

F12-WRONG-The wrong documentation was submitted

620-Downcode-Level of services billed were not documented therefore services were down-coded

Common Errors included

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Letrsquos look at possible Root Causes of Denialshellip

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

The submitted documentation supports a code that does not support 99233 ie 99231 or 99232

Education calls revealed that most of the check list used during the Emergency Room Visits donrsquot capture the documentation components necessary to bill for 99233

Another discovery was that third party billing companies did not have a process in place to receive medical documentation timely resulting in 296 denials(NODOC)

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Simple Equals Significant Remember that a few simple interventions can

drastically effect the charge denial rate

Make sure you are signed up for the Palmetto GBA listserv to be updated on upcoming probes to be conducted

Assess the chain of communication between billing and documentation submission

Is there someone who reviews the documentation prior to submitting

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

This family of CPT codes are used to report evaluation and management services provided in the emergency department

Palmetto GBA began the probe edits for emergency department for 9928399284 and 99285 in November 2014

Edit effectiveness has been completed for approximately one-half and some expected provider specific complex reviews based on their individual results

Emergency Department Services

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Due the high cost of biologicals and the increasing utilization trends several drugs were identified for review during the upcoming option year All of the drugs selected are categorized as Major Risk per the Part B Prioritization Report

They are the top drugs based on dollars at risk and CERT error rates Some of the top drugs have been excluded due to MAU edits already in place

Drugs ampBiologicals

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

J2778 ndash Ranizumab (Lucentis) Injection 1 mg

J0178 ndash Aflibercept (Eylea) Injection 1 mg

J0897 ndash Denosumab (Prolia) Injection 1 mg

J9041 ndash Bortezomib (Velcade) Injection 1 mg

Edits will be set for the following Medications

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Is the documentation submitted for the correct beneficiary

Is the documentation present for the dates of service billed

Is there documentation of Physician order or intent to administer drug

If the order is present does the order include the dosage of the drug to be administered

The ldquoRight Documentation Prescriptionrdquo for Drugs and Biologicals

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Does the order include the frequency of the drug to be administered

Does the order include the route of the drug to be administered

Is there a physician certified diagnosis submitted in the medical record to substantiate the medical need for the drug

Is the recommended dosing schedule for the covered diagnosis documented in the record

Is documentation present for the administration of drug

Continuedhellip

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Do the units billed correspond with the vials used in documentation submitted for review

Is there a corrected UB indicating all or part of the claim was billed in error

Drugs amp Biological Billing

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Diagnostic Test

A diagnostic test includes all diagnostic x-ray tests all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary

Letrsquos take a ldquostabrdquo at Labs

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

A treating physician is a physician as defined in sect1861(r) of the Social Security Act (the Act) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Physician

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

A treating practitioner is a nurse practitioner clinical nurse specialist or physician assistant as defined in sect1861(s)(2)(K) of the Act who furnishes pursuant to State law a consultation or treats a beneficiary for a specific medical problem and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem

Treating Practitioner

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

A testing facility is a Medicare provider or supplier that furnishes diagnostic tests A testing facility may include a physician or a group of physicians (eg radiologist pathologist) a laboratory or an independent diagnostic testing facility (IDTF)

Testing Facility

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

An order is a communication from the treating physicianpractitioner requesting that a diagnostic test be performed for a beneficiary The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physicianpractitioner (eg if test X is negative then perform test Y)

Orders-the missing link

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

An order may be delivered via the following forms of communication

A written document signed by the treating physicianpractitioner which is hand-delivered mailed or faxed to the testing facility

Orders continuedhellip

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

A telephone call by the treating physicianpractitioner or hisher office to the testing facility

An electronic mail by the treating physicianpractitioner or hisher office to the testing facility

If the order is communicated via telephone both the treating physicianpractitioner or hisher office and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

The order or the intent to order is vital and must be included in the medical record

CERT denials related to the billing of the Professional Component due to missing orders or intent to order remains at the top of the list for denials

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

CERT Errors-

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Missing the physician order or clinical documentation of intent of ordering lab

Missing signed and dated clinical documentation to support medical necessity for the lab

Common Errors-

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Medicare contractors do two things when conducting medical reviews or audits of claims submitted by independent labs

Obtain corroborating test results which show the billed services were rendered

Verify that the tests were medically necessary based upon documentation sent to the laboratory by the orderingreferring provider

Medicare Part B Claim Reviews

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Verifying the ordering-treating providerrsquos intent and involvement with requesting the patientrsquos tests is a crucial aspect of establishing medical necessity

The presence of a signed (electronic or otherwise) order by the authorizing provider is often the simplest means by which to validate the tests performed and billed by an independent clinical laboratory however it is not the only means

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

In accordance with the CMS Program Integrity Manual (CMS Pub 100-08) Chapter 3 3412 and 42 CFR sect41032 review contractors must first ask the billing laboratory for relevant records to establish medical necessity

If the laboratory provides a signed order for the test(s) then it is considered confirmation of the physicianrsquosNPPrsquos intent and medical necessity can be determined at this point

Independent Labs

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

If the ordering physicianNPP fails to respond with the necessary documentation the lab services will be denied and the independent clinical laboratory assumes financial responsibility for the overpayment

Therefore it is imperative that lab clients such as ordering physicians NPPs and staff understand their responsibility in documenting and establishing coverage for tests submitted to Medicare contractors

The Lab ldquoglitchrdquohellip

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Develop an action plan to decrease lab denials by-

o Using a tracking system to determine your ldquolabrdquo flowhelliphow is the order transmitted to the lab

o Who reviews the documentation prior to submission for the ldquo 5 Lab rightsrdquo

Lab Partners

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

The right patient

The right date of service

The right documentation

The right order(or intent to order)

The right lab test

The 5 Lab Rights

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

ICD-10

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

ICD-10 Page

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Testing Information

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Related Sites

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

ICD-10 Acknowledgement Testing

National Testing week scheduled

June 1 - 5 2015

Last chance before implementation on 10012015

Unlimited testing

Will receive normal reports 999 277CA

Claims will NOT be processed

Remittances will NOT be created

MLN Matter Article MM8858 provides details

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

End-to-End Testing

National Testing Week Scheduled

July 20 - 24

Limited provider and claims testing

Will receive 999 and 277CA reports

Claims will be processed

Remittances will be created where applicable

Unprocessable Claims(RTP) will be returned

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

ICD-10 Update Successful weeks of provider testing Next End to End testing in late July 20 - 24 PRO32 software is HIPAA compliant and ICD-10

tested Communicate with your clearinghousebilling

service to ensure they are testing and going to be ready to submit your ICD-10 claims in October

Use available resources on CMS website to get the complete list of ICD-10 codes under the downloads section httpwwwcmsgovMedicarecodingICD102015-ICD-10-CM-and-GEMShtml

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

ICD-10 Testing Test a good sampling of all the types of claims that

you currently submit for production including Medicare Secondary Payer(MSP) and Coordination of Benefits(COB)

Consider sending claims that you know should reject ndash negative testing

Submit claims with multiple lines of service

Test specific LCDs and complicated scenarios

Review the 999 and 277CA Response Report Results to ensure your claims accepted or rejected as they should

Report any software issues to your vendor

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Testing Requirements Test claims must be sent to the same contractor as production claims

Test files must use the Submitter ID (Trading Partner ID) used during volunteer registration

Maximum of five NPIs and ten HICNS for each testing week

Claim files must be marked as ldquoTestrdquo in the ISA15 field with a ldquoTrdquo

Test claims with ICD-10 diagnosis codes must be submitted with dates of service on or after October 1 2015 Claims with ICD-9 diagnosis codes should be submitted with dates of service before October 1 2015

Test claim volume is limited to a total of 50 claims for the entire testing week submitted in no more than 3 test files If more than 50 claims are submitted over the course of the testing week they may not be processed

You should receive Electronic Remittance Advice (ERA) files for claims that are processed

ERA files will be marked as ldquotestrdquo files in the ISA15 field with a ldquoTrdquo

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Common Errors to Avoid Only use Submitter Ids NPIs PTANs and HICNs that

you provided for set up

The name and spelling on the claim should match the HICN

Avoid submitting claims for the HICN for the same date of service and procedure

Ensure that your claims have complete information so not to reject for anything not related to ICD-10

Claims with DOS onafter 100115 must have indicator of 0 and claims with DOS onprior to 93015 must have indicator of 9

All claims must have physician and NPIs as required

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Contact Information

EDI Helpdesk hours 800 ndash 500 ET

Telephone number 1-855-696-0705 please listen carefully to the options and have your PTAN NPI and Submitter ID available

Email address for basic questions MedicareediPalmettogbacom

EDI Fax Numbers begin with 803

Contacts

552015 98

855-696-0705

Provider Contact Center

Resources

Palmetto GBA J11 Part B Home Page

wwwpalmettogbacomj11b

Palmetto GBA E-Mail Updates

wwwpalmettogbacomj11b Select E-MAIL UPDATES

Provider Enrollment Resources

wwwpalmettogbacomj11b Click on lsquoBrowse By Topicrsquo then

lsquoProvider Enrollmentrsquo

Contact Us By Email

J11PartBPalmettoGBAcom

Self Service Tools

wwwpalmettogbacomJ11B (center of home page)

Social Networking

552015 99