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National Government Services Part A Medical Review Newsletter September 2021

The National Government Services MR Department would like to welcome you to our newest service; a regular newsletter. It is our hope that you will find this newsletter helpful in providing you with the resources you need to stay up-to-date on the on the MR activities performed here at NGS for Medicare Part A and home health and hospice services.

What’s New?

CMS Resumes Targeted Probe and Educate Program

CMS is restarting the Targeted Probe and Educate program to help educate providers and reduce future denials and appeals. If your Medicare Administrative Contractor audits you, take advantage of the TPE education, and get up to three rounds of educational claim review to help you bill accurately.

What is the purpose of TPE and how does TPE work?

The TPE program is designed to help providers reduce claim denials and appeals through one-on-one help. Providers with high denial rates or unusual billing practices may be chosen to participate in the TPE program. A majority of providers who participate in the TPE process increase the accuracy of their claims. See Improving the Medicare Claims Review Process for detailed information.

What are some common claim errors?

  • The signature of the certifying physician was not included.
  • Encounter notes did not support all elements of eligibility.
  • Documentation does not meet medical necessity.
  • Missing or incomplete initial certifications or recertification.

TPE Frequently asked Questions 

  1. How will a provider/supplier know if they have been selected for TPE review?

    Answer: Providers/suppliers who are included in the TPE process will receive a notification letter from their MAC. This letter will outline why the provider/supplier has been selected for review as well as what to expect throughout the review and education process.

  2. What should a provider/supplier expect during a one-on-one education session?

    Answer: 
    During a one -on-one education session (usually held via teleconference or webinar), the MAC will educate the provider regarding claims with errors representative of those identified during review. Providers/suppliers will have the opportunity to ask questions regarding their claims and the CMS policies that apply to the item/service that was reviewed.

  3. What error percentage is considered a “high denial rate” and what other factors are used to determine whether a provider moves on for additional review?

    Answer: 
    The error percentage that qualifies a provider/supplier as having a high denial rate varies, based on the service/item under review. The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. Other factors that determine the need for additional review may include but are not limited to decrease in error rate with each round, as well as participation in and improvement with education.

How to have a successful TPE experience

  • Ensure NGS has accurate contact information for a point of contact, including a working telephone number and email address.
  • Submit complete medical records as soon as possible, and request an extension if you are unable to meet the 40 day deadline. Nonresponse to medical record requests will count as an error.
  • Recommended: Have a clinical staff member review the medical records prior to submission and have this staff member attend TPE educational sessions.
  • Accept the educational sessions offered and review materials supplied by the educator. Educational sessions are not an appeals forum and do not extend the appeal period. Follow the appeal process outlined in the Review Results Letter and on our website when appealing a claim.

Have you Received a Comparative Billing Report from NGS?

  • The CMS defines a CBR as an educational resource and a tool for possible improvement.
  • CBRs are often used to alert providers if their billing statistics appear unusual compared to their peers.
  • The CBR is an educational tool to support the effort of safeguarding the Medicare Trust Fund.
  • CBR PEPPER is a helpful resource for providers regarding CBR’s.
  • Additional information on CBR is available on our YouTube video: Part A Comparative Billing Reports or by reaching out to us at JKAcasemanagement@anthem.com or J6Acasemanagement@anthem.com.

Educational Resources

Individual Psychotherapy Services

NGS JK and J6 Part A Medical Review is currently reviewing Individual Psychotherapy Services. Shared here are tips and resources to help your facility successfully reply to an ADR for these services.

Reference Documentation

Documentation Requirements

  • Physician orders and progress notes with a clear history of why the beneficiary is in treatment and how they have progressed with treatment.
  • History and physical/history of why the beneficiary is in treatment.
  • Record must include a signed, current plan of care/treatment plan stating the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals.
  • Type and total time spent in each psychotherapy session must be documented.
  • Services rendered must be directly related to the treatment plan (active treatment) with rationale for frequency/duration of services and progress towards goals.
  • Clinic note for date(s) billed which summarizes the diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis and progress to date with the signature and credentials of personnel licensed by the state to render the service.
  • Medication management by personnel licensed to prescribe: to include review of the medications such as dosage, side effects, response. Prescriptions and dosage adjustment/changes.
  • Documented pharmacologic management to include prescription and dosage adjustment/changes.
  • Any documentation to justify medical necessity of services billed.
  • If applicable - documentation of physician supervision if services provided off site or off facility grounds.
  • Any documentation to justify medical necessity of services billed.
  • If an ABN was issued, please include a copy of the signed and dated ABN of noncoverage given to the beneficiary.

ADR Helpful Tips

  • NGS recommends responding to ADR’S within 35‒40 days of letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
  • Read the ADR carefully and submit all of the documentation requested. Include all records necessary to support the services for the dates requested.
  • If you are mailing in your ADR, please send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
  • Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
  • Records must be complete and legible. Be sure to include both sides of double-sided documents.
  • All services must include necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”
  • Verify that your correspondence address for ADR receipt is accurate; CMS requires that changes in information, such as address, are reported within 90 days. Corrections to the mailing address must be completed through the Provider Enrollment process, either electronically using the PECOS or completing the CMS-855A form.  More information about reporting a change can be found on our website. Select the Enrollment heading and then select “Change Existing Provider Enrollment Information”.

NGSMedicare.com

We recently launched a combined landing page for NGSMedicare.com and NGSConnex based on provider feedback. The NGSMedicare.com website no longer supports the IE browser. To access either the secure, self-service provider portal, NGSConnex or the provider content website, you are required to use a supported browser (Microsoft Edge, Google Chrome, Mozilla Firefox, or Apple Safari). Look for upcoming emails with additional website updates! Under the Events heading you will find training opportunities including walkthrough/open question and answer sessions of the new provider content.

NGSConnex

Submitting Late or Additional Documentation via NGSConnex

If the claim selected is past the time limit to respond (45 days) or has already been responded to, the Respond to ADR button will be disabled. However, you can still use NGSConnex to submit the medical record documentation for an MR ADR. Simply select the Respond to ADR not in list button; if you use this option, you will need to manually enter all of the required data elements from the ADR. The only information that will auto-populate is the provider account information.  After entering all of the required information, it will allow you to attach and submit your medical record documentation. Detailed instructions can be found in the NGSConnex User Guide.

Service Specific Post Payment Review Announcements

Providers are encouraged to visit the Medical Review Focus Area on our website. This dedicated area will identify services areas under review, required documentation, and provide more details on these service specific post-payment reviews. Upon entering our website, select Medicare Compliance> Medical Review> Medical Review Focus Areas.

Jurisdiction K Part A Edits

  Type of Review

HCPCS Code

Definition

Wound Debridement

97597

Active wound care management for selective wound debridement (typically recurrent debridement), performed with minimal anesthesia.

Wound Debridement

97598

Active wound care management for selective wound debridement (typically recurrent debridement), performed with minimal anesthesia, total wound(s) surface area greater than 20 square centimeters.

Group Psychotherapy

90853

Outpatient group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

Individual Psychotherapy

90832

Individual psychotherapy services rendered for 30 minutes by a licensed mental health provider, with patient.

Individual Psychotherapy

90834

Individual psychotherapy services rendered for 45 minutes by a licensed mental health provider, with patient.

Trastuzumab/Herceptin

J3955

Injection, Trastuzumab (Herceptin), excludes biosimilar, 10 mg.

Fosaprepitant Injection

J1453

Injection, Fosaprepitant, 1 mg.

IVIG

J1459

Injection, immune globulin (Privigen), intravenous “IVIG”, non-lyophilized (e.g. liquid), 500mg.


Jurisdiction K Home Health Edits

Type of Review

Edit Reason Code

Definition

Home Health Medical Necessity

5AAG1

32X, 33X


Jurisdiction K Hospice Edits

Type of Review

Edit Reason  Code

Definition

Length of Stay over 730 Days

5ANKP

81X, 82X


Jurisdiction 6 Part A Edits

Type of Review

HCPCS Code

Definition

Physical Therapy Reevaluations

97164

Physical therapy reevaluations

Individual Psychotherapy

90832-90834

Individual psychotherapy services rendered for 45 minutes by a licensed mental health provider, with patient.

Group Psychotherapy

90853

Outpatient group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

Hyperbaric Oxygen (HBO) Services

G0853

HBO under pressure, full body chamber, per 30 minute interval.

Trastuzumab/Herceptin

J9355

Injection, Trastuzumab (Herceptin), excludes biosimilar, 10 mg.

Intravenous Immune Globulin Services

J1459

Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg.

Ambulance Services

A0427

Ambulance service, advanced life support, emergency transport, level 1.

Nail Debridement

11719-11721

Bill Type 13X


Jurisdiction 6 Home Health Edits

Type of Review

Edit Reason Code and Bill Type

Definition

Orthopedic Aftercare (Z47)

5CDX1/5WDX1, 32X

3/1/2020 and after


Jurisdiction 6 Hospice Edits

Type of Review

HCPCS Code

Definition

General Inpatient (GIP) Services

Pending and 81X, 82X

0656, 7 or more days


Contact Us

  If you have received an ADR or CBR from NGS, and have questions, you may contact the Case Management Team at the following email address

States Email Address
Connecticut, Maine, Massachusetts, New Hampshire, New York, Vermont, Rhode Island JKAcasemanagement@anthem.com
Illinois, Minnesota, Wisconsin J6Acasemanagement@anthem.com


Posted 9/7/2021