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February 6, 2013

CGS Ask the Contractor Teleconference: "What's New in 2013?" Questions and Answers

Question: Our organization has been going through the revalidation process. We received the letters in late October. We're really struggling with working with Provider Enrollment on this process. We initially did the application through Internet PECOS. When we contacted Provider Enrollment, they told us they were not able to see all the information in Internet PECOS, so we printed it out and sent it to them on paper. Now, we are being told that they never received the packages we sent via registered mail. We are also being asked for an EFT form, although we are already on EFT. Whom can we work with to get this resolved?

Response: We apologize; this is not the kind of service we want to provide. We appreciate you letting us know and for being on the call. Jennifer Brown will contact you after the call to get the specifics from you and will work with you and Provider Enrollment to get this resolved.

Question: We are having some difficulty getting our patients to understand they are responsible for deductibles and coinsurance. Can CGS do anything to assist us with this? We are turning some patients over to a collections agency.

Response: In some cases, the patients may have other insurance; some are dual eligible for both Medicare and Medicaid and some of them may have some supplemental plans as well. If this is the case, the other plans may be able to make some payment. Your understanding is correct that this is a patient responsibility. In general, we anticipate that you will handle situations like this for Medicare patients the same way you would handle collecting deductible and coinsurance amounts from patients with other insurance. If these are hardship situations, there are some provisions that may allow you to waive the deductible or coinsurance in hardship situations. The guidelines regarding hardship situations are pretty specific, though, and not something you'd want to do across the board. Beyond this, the issue of payment is really between the patients and you. as a provider. There are some patient-friendly materials on that you may also want to share with your patients.

We also work with the Ohio Medicare Partners; these are the different agencies and individuals who educate the patients. We are meeting with this group next week and will ask them to continue to educate the patients that this is their responsibility.

Question: We saw a lot of requests for medical records last year from CGS for nursing home visits (CPT code 99310). Is CGS still requesting records for this procedure? It's a lot of work for me to gather all of the documentation, especially the lab results and other test results, so I have stopped billing this code. Most of my records for these services are at the nursing homes.

Response: CGS has asked for records for that code periodically, to make sure that the code being billed was supported by the documentation. It's possible we will continue to ask for documentation for this service. If this is the right code, the one that represents the service you provided, we want you to keep submitting it and to send the documentation if we request it. We also have a documentation checklist on our web site that may help you identify what documentation to send. This is a comprehensive code with a high level of medical decision-making, and that's why we are asking for the supporting information, to show that the service meets the requirements in the CPT book for that level of care. We understand it can be difficult to get the records from the nursing home; the reason we request them from you is because you are submitting the claim, so it's important that you obtain the records and submit them to us if you receive a letter asking for this information.

Question: What effect or new changes are there in the new law for mental health and substance abuse treatment?

Response: We haven't received official notification yet about any specific changes for mental health or substance abuse related procedures from CMS, related to the new law (the American Taxpayer Relief Act of 2012). There are some new CPT codes, effective for dates of service on or after January 1, 2013. Until more guidance is available from CMS, we encourage you to refer to your CPT manual and your state specialty association.

Question: We understand that we have to submit Medicare Secondary Payer (MSP) claims electronically. We have one Part B claim, though, that just won't go through; it is being rejected as a "billing error" and our remittance advice also says something about "impact of the prior payer adjudication, including payments and/or adjustments." We are submitting all of the information from the primary payer. What should we do?

Response: It sounds like you are submitting the correct information. We would probably need to look at your specific claim with you in our system to make sure that you're putting the primary payer information in the right fields. It's also important to use the right MSP type, and we can look at your claim with you to verify this. Juan Lumpkin will take your contact information and call you after we are done on this call.

Question: You talked about making corrections to medical records earlier. We have electronic medical records and you were stating don't ever take anything out, keep in the old record or whatever problem records you have and put the new one in. What should we do if we accidentally made an entry for one patient in a different patient's chart?

Response: Our best suggestion for this situation is to put a note in the record that those records were erroneously entered and they are for a different patient. The whole goal of the instruction about how to make changes to medical records is so any changes are "tracked" and there is a kind of audit trail, so it never looks like records were "falsified." If there is a way to highlight or flag that section in your electronic records to note that the entry was made in error and applies to a different patient, we suggest using that method so it's clear why you made the change. Reference: CGS article "Entries Medical Records: Amendments, Corrections, and Addenda".

Question: Our question is about the new transitional care management (TCM) codes for 2013: CPT codes 99495 and 99496. I'm a little confused about the description and how to bill those. The CPT description specifies that the first face-to-face contact is included in that initial TCM code. Does that mean the first face-to-face contact from discharge or the very first initial face-to-face? We are getting conflicting guidance when we call Medicare about this; we were told that we could bill the face-to-face contact in addition to the TCM code, but that's not what the CPT manual says.

Response: Unfortunately, we haven't received any specific guidance on these codes from CMS, nor is there any information posted on our website yet. Our best suggestion at this point is to follow the CPT guidance in terms of whether the new TCM codes can be submitted in addition to another face-to-face visit. When we receive additional information regarding these codes, we will post it on our website and send it out through our listserv.

Question: I work in outpatient mental health and chemical dependency. We are a new agency, and we have questions about the new E/M codes and how this works from a billing perspective with the old psychotherapy codes. I really need help with the basics, like where to put the codes on the claim form and how to show the prices; can someone assist me?

Response: We would be glad to walk through this with you. Shuanya Lovitt will take your contact information and call you as soon as this call is done. One place you can look is in the 2013 CPT book, on page 485; this provides some explanation about which code is primary and which is the add-on code.

Question: Will you expand on the multiple procedure reduction for cardiology? We see a lot of elderly patients, and sometimes they will need a stress test plus a vascular procedure and maybe an echocardiogram. With these types of procedures, I think we are going to see the reduction on the lesser procedure – is that correct? Also, if we decide to bring the patient back on another day instead of doing multiple diagnostic procedures on the same day, what are your thoughts on that?

Response: Yes, your understanding about the reduction is correct. We are looking at MLN Matters article MM7848, and this is effective January 1, 2013. The reduction will be applied to the technical component of the lesser procedure(s), so these will be reimbursed at 75% of the fee schedule amount. The procedure with the highest fee schedule amount will not be reduced. If you want to see how the reduction will work, you can type a list of codes into the CMS Physician Fee Schedule Look-up tool and see the fee schedule amounts.

As far as bringing the patient back on another day, our main concern would be the medical necessity of having that patient return, versus performing all of the medically necessary diagnostic procedures on the same day. If you were going to have the patient return on another day, we recommend that you carefully document the medical necessity. In most cases, it is probably best to continue doing what you have been doing, that is, doing all of the ordered tests on the same day.

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