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Q: Why is Medicare changing to MAC’s, what is a MAC and when will it happen?

A: Medicare is in the process of converting from Carrier and Intermediary Contractors to Medicare Administrative Contractors (MACs) and one of the intents is for them to be a one stop shop for providers. Efficiency, accuracy and accountability are all goals of this conversion.

The MACs will serve as the providers’ primary point-of-contact for enrollment, training on Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for service claims within their respective jurisdictions and they will also perform all core claims processing operations for both Part A and Part B.

Please open the PDF file below to review the A/B Jurisdictions and conversion schedule

If you have not been advised of the conversion, if there was one, it might be because the incumbent or bidding contractor contested the award. There are other MACs (not noted below) that will be or have been awarded Specialty Services contracts. 12-9-08

Q. What are the deadlines for including the NPI # in the Primary Fields on claims?

A. Here are the deadlines for your reference:
• Part A---January 1, 2008
•  Part B--- March 1, 2008
• The NPI must be in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields)
• NPI/legacy pairs may be submitted in these fields or only the NPI # on the claim

12-19-07

Q: Is it accurate that in 2008 if a therapist participates in the Physician’s Quality Reporting Initiative (PQRI) he/she must report on a minimum of three (3) measures?

Yes, that is accurate. Please remember that each of the three (3) measures must meet the 80% threshold? Here is a list of the measures that therapists may choose from:

Measure # 4 Risk for Future Falls

Measure # 124 Adoption/Use of Health Information Technology

Measure # 126 Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation

Measure # 127: Diabetic Foot and Ankle Care, Ulcer Prevention: Evaluation of Footwear

Measure # 128 Universal Weight Screening & Follow Up

Measure # 130 Universal Documentation & Verification of Current Medications

Measure # 131 Pain Assessment Prior to Physical Therapy

Measure # 132 Patient Co-Development of Treatment Plan & Plan of Care

To obtain more information on the measures, the specifications, coding requirements, exclusions, and data collection forms you may go PQRI Resources on this website

1-01-08

 

Q: Do you have any suggestions about how our practice can stay up to date on matter related to Medicare in California?

A: While it is challenging to stay current on all regulations you do have excellent resources available to you. First, I’d recommend that you maintain an active role in your state association; California Physical Therapy Association has very competent leadership. Second, you and your office administrator should join your MAC/carrier/intermediary email notification service (listserv) so that you can be informed of important updates and changes that could impact your practice. While these email alerts are quite varied it is common for them to have provider specific notification for you to choose from. All you have to do is go to your payor’s website and subscribe…you might have to dig through a few menus, but most reference them on their home page. Of course you can subscribe to our “Seriously Important Practice Alerts (SIPA) which also provides state and federal updates. 1-12-08

Download PDF Titled Jurisdictions and Award Schedule

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Q. We have read that the Therapy Cap Exceptions was extended and that the Plan of Care Re-certification is now 90 days but TrailBlazer is not acknowledging either of these at this point?

A. The Therapy Cap Exception was extended by the Medicare, Medicaid and SCHIP Extension Act of 2007 and the Plan of Care Recertification was modified to 90 days as a part of the 2008 Physician Fee Schedule, but TrailBlazer is not able to formally recognize them until CMS generates a Change Request/Transmittal and the resultant CMS Manual revisions which should come before either situation presents a major problem. One problematic situation could be carry-over patients from 2007 who have a re-certification due per previous regulations. I would suggest that you contact TrailBlazer on a case by case basis until the Manuals are revised or TrailBlazer notifies you of the proper course of action. 1-13-08

 

Q. How do I change information I submitted on my NPI number?

A. You can go to the NPPES website at the link below and make your changes or you can go to the same site for a mailing address for hardcopy changes. Please remember that all health care providers who are covered entities under HIPAA are required to notify the National Plan Provider Enumeration System (NPPES) of changes in their required NPPES data elements within 30 days of the changes.

https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

1-13-08

Q. Is it true that Rehab Agencies must have a MSW review “ALL” patients for social and/or vocational needs?

A. Yes, that is absolutely a requirement. It has been in place for a number of years, but due to interpretation variances it has not be rigorously enforced until recent years. You may find this and other critical requirement in CMS’ State Operations Manual at this Link
2-16-06

Update: A direct and written quote from an authorized CMS representative (CMS/CMSO/SCG/DCCP) “There is nothing to preclude a physician from documenting in a patient’s medical record that social services are not indicated, at this time.  (This then allows the agency to recommend social services anytime a need arises).” 
5-16-07

Q. Will you be generating any information about the Medicare’s new Quality Reporting Program (PQRI). If so when and when does this reporting go into effect.

A. I will be providing my clients detailed ‘how to’s’ the second week of June. This will allow them to develop their screening tool as well as test the required modifier with their software vendor and Medicare contractor. The Quality Reporting Program goes into effect July 1, 2007 and covers the six month period from July 1, 2007 through December 31, 2007.

As a quick summary: therapists will be allowed to participate in the PQRI for screening for ‘falls’. At least 80% of their Medicare population treated would have to be screened in order for the clinic to be eligible for the 1.5% bonus payment covering the last half of 2007. The screening will be tracked by individual, not group/facility, NPI’s.
6-6-07

Q. Does the NPI number (National Provider Identification Number) contingency plan eliminate the need for all suppliers (Part B clinicians) to have a NPI by 5-23-07?

A. No, the requirement to have a NPI number still has a May 23, 2007 deadline. The contingency, among other things, just allows providers to continue to bill with both the NPI and the legacy (provider number/UPIN) until testing reveals that a sufficient number of claims can be transmitted successfully with the NPI number. Please note that, in addition to all Part B clinicians, all Part A institutions/facilities and Part B Groups must also have the NPI place by May 23, 2007.
5-20-07

Q. How can I tell if I am using the correct CMS 1500 form, I understand that there is some error on the form?

A. You are correct, many of the CMS 1500 forms (Version 8-2005) had an alignment error that could present scanning issues for some payers and thus cause claims to be rejected. You are allowed, until notified by your payers, to continue to use the CMS 1500 form (Version 12-90) if you do not have the correct 8-2005 Version available. One of the limitations of the 12-1990 Version is that it can not accommodate the 10 digit NPI number which means you can not test the transmission capability of the NPI number while using the legacy number simultaneously. The 1990 Version also doesn’t incorporate several other changes made to the Physician/Supplier section of the form which, when the contingency period is halted, will result in rejected claims.

You are advised to review your 8-2005 Version of the CMS 1500 to check the alignment. To do so you should verify that the arrow in the right upper corner is ¼ inches from the top of the page; if the arrow is less than that it might compromise accurate scanning.

Please note, that during the contingency period you should make every attempt to convert to the correct 8-2005 form and test your claims transmission with your payers. The National Uniform Claims Committee has a nice reference manual regarding the completion of the 1500 Claim form. It has been revised since March, so please refer to the updated information provided below, as well. These documents are located at:
Version 2.1 3/7
Version 2.1 4/7
6-06-07

Q. What is the difference between the Notice of Exclusion from Medicare Benefits (NEMB) and the Advanced Beneficiary Notice (ABN) or when should one be use verses the other?

A. The NEMB is a CMS or custom form used to inform the beneficiary of the therapy financial limitation and cap exception process; it also is the only form to use once the cap has been exceeded. The ABN is a CMS form used to inform the beneficiary that services/items provided are not expected to be covered because they do not satisfy Medicare’s medical necessity requirements; it is used when services delivered are within the cap limit.
5-20-07

Q. What are the required components of a Plan of Care and can it be included in the Evaluation?

A. The Plan of Care may be included in the initial evaluation as a component of it or may be a stand alone document. Regardless of which method is used all elements, as noted below, must be documented.

Q. What standardized measurement instruments do Medicare recommend? Are there alternative tests that are acceptable to Medicare? Do you have a list of common test?

A. The list below represents the instruments recommended, but not required, by Medicare

Q. How will I know if Medicare has transferred the remainder of a patient’s claim to his/her supplemental insurance company?

A. Once Medicare has completed the claim processing (and if the claim was completed properly with the secondary payer information) you will see on the Medicare Remittance Advice (RA) if the claim was forwarded to the other insurance for processing (this is called Coordination of Benefits). You should check the Remark/Reason Code for clarification of the transfer. The Codes are listed at the bottom of the RA and for a full listing and a comprehensive tutorial you can go to this Link:
3-03-06

Q. How do I know where to affix the 59 modifier for codes that are bundled under the Correct Coding Initiative (CCI)?

A. The 59 modifier should be appended to column 2 code for both the Column and Mutually Exlusive Categories. You can access the National Correct Coding Initiative table at this Link:
3-03-06

Q. Do physical therapy services provided by a Home Health Agency apply to the financial limits (cap) for Part B Physical Therapy?

A: Home Health Services are typically provided under Medicare Part A and therefore do not impact the ‘cap’ for Part B services. A prudent provider should make certain that the patient is discharged from the home health agency prior to initiating care so that services provided do not fall under the Consolidated Billing provision for Home Health Agencies. Please note that, while rare, there are situations that Home Health reimbursement is under Part B. Please see FAQ on this subject. 
2-16-06  

Q. How can I determine if a patient has had Home Health services or if he/she is still under the Home Health Agency?

A: Of course, the first line of establishing home health status is by questioning the patient or responsible party, but unfortunately these individuals don’t often understand the full scope of home health and often state that they haven’t ever or are not now participating in any home health. For starters you might ask if his/her physician asked any one to come to his/her home to help or treat you in any way. For example:

If the patient states “yes” then further probing should follow to inquire when, who, how long, last visit, etc? The second line of verification to contact the Part A intermediary (sometimes this information is cross-walked to the Part B Carrier also) to see if the patient is currently enrolled in home health. Phone lines and EDI services have been mandated by the HIPAA regulation to assure benefit and eligibility verification. Your carrier or fiscal intermediary can provide you with the appropriate access line information. 
2-16-06

 Q. What is the National Provider Identifier? Do I need this and, if so, by when?

A. The National Provider Identifier (NPI) will take the place of the UPIN (Unique Provider Identification Number and the PIN (Provider Identification Number). It will be required to be used by all providers by May 23, 2007. The application and process is simple and takes only minutes. The application and associated resources are available on this Link:
2-16-06

Q. What is an LCD? Why do I need to have it? How do I locate the applicable one for me in my state?

A: LCD stands for, as it relates to Medicare, Local Coverage Determinations. These are developed in the absence of a National Coverage Determination for the purpose of providing guidance concerning Medicare’s coverage and payment policies for various diagnostic conditions and/or therapeutic interventions. These same LCD’s serve as internal guidelines and edits for medical reviewers and claims management personnel at the payer (Medicare contractor) level. Examples of content are:

It is critical that each provider of Medicare services be familiar with his/her state specific LCD’s. They can be obtained by going to the Fiscal Intermediary’s or Carrier’s website and querying for LCD’s (it is usually classified under physical therapy or physical medicine and rehabilitation). It is important that you abide by the ‘current’ not draft LCD’s and that you take advantage of the right to comment on any draft policies when the comment period is in force. Many therapists have been successful in thwarting faulty LCD’s by providing practical examples and also by sound and evidence based justifications for consideration. 
2-16-06

 Q. Should I use the NEMB (Notice of Exclusions of Medicare Benefits) or an ABN (Advanced Beneficiary Notice) to advise the patient of financial limits “cap” on physical therapy?

A. Under normal circumstances I would recommend that the NEMB be used. I would suggest that if you are using the CMS template that you add a signature line, as none exists on its form. For situations that require a Medicare denial so that a secondary/supplemental insurer can be billed you should bill Medicare and append a GY modifier to each line item to indicate that you know that the statutory limit has been met but that you are billing to obtain a denial. 
2-16-06

 Q: Is it true that if I billed Medicare at its allowable fee (MPFS) I have to request a refund for the 4.4% underpayment on claims since January 1, 2006.

A. Yes, that is correct, Providers who billed the Medicare fee schedule amount, and need to increase their billed amounts, will need to request a redetermination in writing with the appropriate redetermination form (CMS 20027). Please click on the following link for this form
This is not necessary for providers who billed at his/her usual and customary rates.
2-18-06

 Q. It is my understanding that a provider may not, routinely, waive or discount a Medicare Beneficiary’s co-insurance. Will I be violating the Federal AntiKickBack law if I don’t attempt to collect the 4.4% retroactive fee that applied to my patient’s co-insurance and deductible for services delivered January 1, 2006 through February 8, 2006 (the date President Bush signed the legislation)?

A. Ordinarily you are required, unless due to established financial hardship, to collect any cost sharing responsibility the patient has however it appears that CMS is granting some latitude to providers related to inducement/Anti-KickBack violations in this situation. The following support statement has been provided for your reference: (DHHS/CMM Letter January 6, 2006 to Honorable Bill Thomas from Herb Kuhn, Director CMS) made by CMS stating that “we believe that where a beneficiary has already been charged for the appropriate cost sharing amount under an existing physician fee schedule, and an additional cost sharing amount is subsequently due because of a retroactive application of a statutory fee schedule adjustment, a waiver of the additional cost-sharing amount would be unlikely to serve as an inducement to the beneficiary.”
2-18-06