9/13/2023 Part B POE Advisory Group Meeting
Meeting Minutes
Meeting Time: 10:00 a.m.‒12:00 p.m. ET
Member Attendees: Jennifer Asencio, Doris Barnes, Madelon Berger, Brenda Bedard, Sheila Bembenek, Madelon Berger, Dawn Burchett, Mary Casaburri, Ilka Collier, Eileen Conlan, Tracy Essling, Stephanie Fiedler, Liz Fitzgerald, Deb Gregoire, Darren Goodwin, Martha Harris, Christie Hewson, Stephanie Hirst, Allison Israelson, Kevin Kile, Cindy Kisselburgh, Jenny Kovich, Dr. Lloyd Kupferman, Maud Lawrence, Vera Loftin, Sara Luther, Liz Maas, Jessica Marden, Sheila Mulka, Joyce Neurenberg, Louise Reist, Maria Rivera, Debra Rossi, Allison Ruffolo, Nancy Schuessler, Wendy Shreve, Ekaterina Spirin, Stephanie Thebarge, Susan Tucker, Theresa Weiland, (3 additional members joined by telephone only)
National Government Services Associates: James Bavoso, Laura Brown, Dr. Stephen Boren, Michelle Coleman, Madeleine Collins, Cathy Delli Carpini, Michael Dorris, Arlene Dunphy, Linda Klug, Lori Langevin, Jen Lee, Ashley Liddick, Phyllis McAdams, Julia Meehan, Christine Obergfell, Carleen Parker, Michele Poulos, Nadine Riccobene, Jean Roberts, Nena Rodrigues, Susan Stafford, Gail Toussaint
Agenda
- Welcome/Introductions
- Opening Remarks
- Tobacco Project (Tobacco Cessation)
- End of Public Health Emergency/Telehealth
- New CMS 855-I Enrollment Form
- Virtual Conference Feedback
- 2024 Proposed Rule comment period ended 9/11/2023
- Open Discussion
- LinkedIn, Outsourcing, Dental and IVR changes
- POE Advisory Meeting Remaining Date 12/14/2023
I. Welcome/Introductions
Lori Langevin, POE Consultant, NGS
Lori welcomed the members. Members received an invite with a link to the meeting and also an email with the agenda and handouts. She reminded members they can call in or use the computer audio, remembering to mute their phone lines if not speaking to avoid any unnecessary background noise. If joining by phone only, please send an email to let us know you attended.
Lori advised of the meeting agenda and turned it over to Jim for opening remarks.
II. Opening Remarks
Jim Bavoso, POE Manager, NGS
Jim thanked the members for their time and advised the lines were open to unmute and speak up or use the chat box to type in feedback or questions. Members were reminded how important it is to give feedback as we need their assistance and expert opinions on education and advice to determine if what we’re putting out is working.
III. Tobacco Project (Tobacco Cessation)
Jim Bavoso, POE Manager, NGS, Mandy Collins, POE Consultant, NGS, Ashley Liddick POE Consultant, NGS
According to the CDC, tobacco use is the leading cause of preventable disease, disability and death in the U.S. Tobacco cessation counseling is proven effective in reducing nicotine dependence. NGS identified rural areas in our Jurisdiction 6 Wisconsin and Jurisdiction K Maine workload where nicotine-dependent Medicare fee-for-service beneficiaries are underserved, utilizing the Medicare Part B benefits for tobacco cessation counseling well below the national average.
NGS received approval from CMS for a Health Equity Innovation to increase the utilization of this benefit in these two areas.
Our consultants work with rural stakeholders to increase the utilization of tobacco cessation counseling, targeting a two percent increase in rural Wisconsin and a three percent increase in rural Maine. We began this project 12 months ago. We barely made these targets. Our goal today is to adjust the education and get your feedback about how we can do this. We need to be sure we are getting to the right people in your organization that can help make an impact. Our goal is to work with CMS and see how we can move the needle in getting Medicare beneficiaries to take advantage of this program.
We would like to know what’s going on in your groups, what are your approaches, did you know these services existed and how to bill them and, are you currently providing them?
Member Feedback: A lot of providers are providing these services. The issue is they are not being specific enough in the documentation as to what counseling they're providing or the time component. They're not documenting the number of minutes that they're spending, so that's a constant area of education for us, to make sure that not only do you know that you're providing this counseling, but what is it? What does that counseling entail and how many minutes are you spending doing it? We have a number of different clients like primary care, pulmonology and cardiology who are having these conversations with the patient, but the documentation is not going to support actually billing for it. We use the documentation guidelines, but it’s just trying to get the doctors to follow it! We've even recommended that if they're going to do this service, they use a template that includes what they would normally discuss with the patient and then add specific details and the time component. A lot of times they just feel like it's too much extra work to add all of those details.
A number of members agreed.
NGS: When we sent out the agenda and some other items we included a one pager, like a cheat sheet, with documentation guidelines for your review. Take a look and see if this is something you may find helpful, we can also tweak it if needed to make it easier for you, but you hit the nail on the head.
We've heard from a lot of providers who have put this in their EMR's with templates how much easier the process flows. It's not only a reminder for the provider, but it’s easier to use some checkboxes and circle a time rather than adding great detail. Some EMR companies will come right in and work with providers on how they want to set that up within each group too.
Member Question: At this point in time is CMS/NGS only focusing on rural area beneficiaries or also integration in for example presurgical wellness programs and services?
NGS: This is a special project where we're targeting beneficiaries and the providers who treat them in these two rural areas because they have very large volumes of people who smoke but don’t take advantage of these services. However, these services are open to everyone. We do promote preventive medicine services to all physicians. We work with some of the beneficiary advisory advocacy groups to get it out there to help patients take advantage of it.
Medicare has close to 50 different covered preventive medicine services. We do find that many patients don't take advantage of them and many providers, many physicians are not aware of the services available to them. We do our best to get this information in their hands, but you can’t lead a horse to water, as they say.
Member Question: We also have a problem where when the patient gets their bill, they'll call and ask, why did I get charged for this? The customer service person will say, well, they talked to you for like five minutes about this. Then the patient states well, yes, but they also talked to me about not eating too much, and I shouldn't drink so much, and I should wear my seat belt and I need to start exercising. Why did they charge me just for the smoking? So, if they are coming in for an office visit 99213, and they bill the smoking cessation counseling is there an additional coinsurance they pay?
NGS: There is no coinsurance for tobacco counseling, it’s waived. You can bill for tobacco counseling outside of the E/M service. So having them call to say hey, I got billed for it, they're not actually getting a bill for it, they should not be getting a bill for tobacco counseling. If you're providing the service, the patient understands you're providing it, so they shouldn’t be calling and saying, nobody really even talked to me about tobacco counseling. There's something in the documentation or nothing in the documentation to support it.
We completely understand the provider tolerance, you know, additional documentation. If you look at the form that we sent it gives some hints. There is no, and I and I say this cautiously, there's nothing right now in regulation from Medicare that says this has to be what's in the documentation.
Member Question: You document the time. Make sure it's clear and distinct to any reviewer that you did the work for the benefit of the patient. What I am hearing is that we need to document the time. If the 99407 code says that it's three to ten minutes, do we still have to document in the record that the provider saw the patient for nine minutes, eight minutes, whatever time, or does the code 99407 take care of that?
NGS: Procedure code 99406 is the greater than three minutes up to ten minutes and 99407 is anything greater than ten minutes. If they billed the code because there's two different codes, we would say it is necessary to make sure that they're putting in the time. Because these are time-based codes, if the provider is just putting in a code and there's nothing in the documentation that notes the time, or maybe there's nothing in the documentation at all or one sentence that I provided counseling, upon review of the claim to verify if the code used is justified, there will be no indication of the time spent and that would be questionable.
Member Feedback: But what we hear from the providers is I want to use that code because I provided seven minutes. It’s in the code. Do you not trust me? And I have to say an extra little sentence in here. I swear that is our fight all day long. Well, sorry, we trust you. But somebody outside isn't going to unless you say it. So, anything we can do to make it simpler, I think would be great.
NGS: And it's like, I did a cataract extraction 99684, but I'm not doing an operative report. But did you really do it? I don't know any physician who loves doing documentation. I don’t know any physician that likes when anyone criticizes their documentation, including me. (Dr. Boren CMD) I really hated that when I was criticized. But a couple of points you brought up.
A number of years ago, we had a problem when I was with the prior contractor concerning a chiropractor didn’t want to do any medical records. He said I put down this CPT code., I put down this ICD-10 code, that’s enough. And he complained to CMS about me, who proceeded to tell him that he was wrong, and he better improve his documentation.
The other thing, that's so important in other cases a number of years ago, besides being a full-time Medical Director, I also did emergency medicine. I was called into a patient in the ICU who was accidentally extubated by himself, and the hospitalist couldn't intubate him again. I was called up to see him. I came up and it was a very tough intubation, and I did it. After I did it, I checked to make sure there were good breast sounds and all that, blood pressure, pulse, everything was fine. So, then I went to the medical record, and I put it in. I started out at the time, and I said who I was, why I was there, and I documented everything from, you know, the fact that it was good. I worked for a group and would never see a dime from that emergency to patient, and the group would see, maybe I think $135, which I would not see a dime of that either. But the thing was I wanted to protect myself. Not to make billing, but to keep myself out of trouble. And I think that's very important for anyone to do.
So that's my opinion on documentation. believe me, I remember one time in the emergency department, I did this fantastic job on this patient. It was very complicated and the next week one of my colleagues complained about my documentation to me and I was very upset. He showed it to me, and it really wasn't as good as I had thought it was. The documentation of the instructions to the patient was horrible, and the documentation of all the medical stuff was great, and the documentation of patient instructions is important too, so I'll get off my soapbox. Thanks.
Those of you who don't know Dr. Stephen Boren is one of our medical directors here at NGS and is somebody who we pick on all the time. Appreciate that you know my career here at Medicare and that you know the mantra that we've always used, if it's not in the medical record, it wasn't done.
Member Feedback: You know what’s necessary for the medical record, but I also wanted to just plug in here for coders and billers that when we reach out to query a provider. It's not that we are questioning your documentation to criticize your documentation. We just want to ensure, just as the provider wants, that the patient is taken care of. On the other hand, we as billers and coders, want to make sure that we get paid. I think we have to come to that common understanding that patient care is from the time the patient registers for that visit until the patients balance is zero. That's total patient care. We just have to learn to work together. But thank you so much doctor for that.
NGS Question: The next question: if you're providing the service, are you billing and coding the tobacco cessation codes separately from E/M services or including them in the E/M? We have seen some medical records where the doctor is only billing for an office visit, 99213 for instance, and then the medical record shows a complete document on the tobacco cessation. They are not billing separately for it. Can anyone comment on that? We have heard from some of you already that they are just billing the E/M.
NGS Question: Those of you who may offer tobacco cessation services, is there any barrier that you are seeing that patients are reluctant to take advantage of or are there issues within the community that the patients cannot take advantage of things like that, that you may be hearing?
Members Feedback: Programs that would be available to assist the patient in quitting smoking. Rural areas where beneficiaries did not have access to a smoking cessation program, so the physician may be trying to counsel them about smoking, but it's not his or her thing they do. So, they recommend them go to a smoking clinic, a smoking cessation clinic but there is nothing around.
NGS: We found that over the Health Equity programs like we worked on diabetes a couple of years ago and a true urban setting in Brooklyn, NY where patients didn't have access to the providers, and they would have to take a bus and a subway, and it was just not there for them. So, we're looking to see if there are any other barriers that might be out there that we can bring back to CMS and say, OK, to make this work, you have to do this.
Members Feedback: The largest barrier for us is the inability for these to be performed by certified tobacco specialist or other ancillary staff incident to a billable provider.
NGS: We have brought this to CMS attention and hope that they can make adjustments to the policy to allow for these. I don't want to call it ancillary, but allows for certified tobacco specialists nurse practitioners, pharmacists, you know, things like that. to do these services and others. Thank you for that, because I'm going to use your quote when I go back to CMS. It's a huge thing that we've heard.
In the meantime, we assume there are times patients need that counseling and are seeing one of the primary providers, whether it's the NP, PA or the physician. The primary is identifying nicotine dependence, they can and should let the patient know that’s something they need to talk about. Are you ready to quit? Let's talk a little bit about the health impact, because again, as the provider, you're hoping that they're talking about that and how it's detrimental to their health. But then saying, OK, are you ready to do this? Let's move you on to the certified tobacco treatment specialist for the bulk of that. If the provider is spending any time greater than three minutes in that education/counseling conversation, please take advantage of that and code and bill for it. From that perspective, as far as the barrier to get paid for the certified tobacco treatment specialist we are completely on that page. We're advocating for that, but we're also making sure the providers are still approaching that from their perspective as well and billing and coding for it.
NGS Question: We’ve been doing a lot of education on tobacco cessation counseling services. Overall, how it works. We've been inviting our targeted providers to come. We do these sessions a few times a month. We do “Let’s Chat” sessions and, we’ve done tobacco counseling as a telehealth service webinar. What are your top questions about Medicare tobacco cessation coverage and what education do you think we need to provide to make it more comfortable for the providers to use this?
Member Question: I've not heard tobacco cessation services has to be performed by a certified tobacco specialist (CTS). Is that a separate clinician? Can a MD provide the service? Currently the service is not covered when performed by a certified tobacco specialist.
NGS: It’s only covered by a physician at this point. and a couple of others. We are trying to bring this back to CMS to get them to expand on this and allow others to bill for it. So yes, physicians can bill for this at this point.
Member Feedback: I think the tip sheet you shared is definitely something if publicized a little more, is an excellent tool for education. Can you add utilization, how often to this?
NGS: That’s on our tobacco cessation tab on our website. We provide that information and resources but that's a good point. I think what we can probably do is send this out separately and then email a notification to the provider community. Utilization is included in a different document, but it's something we can work on.
Member Question: Maybe add we want you to be providing this service would be very helpful. Is there a particular certification? Do those people need to be identified separately as providers of these kinds of services? Because it sounds like what you see on the internet, I can have a high school diploma and take a course to be a certified tobacco specialist. Where do we find the information on that? Who do you recognize?
NGS: There’s a great amount of detail and hours that go into that, and a number of different programs. The actual certified folks go through lengths of education in order to do this. Is that what you're asking as far as what that would fall under? I would say until Medicare does recognize that, which they don't right now as far as billing for this service, that would be something that they would have to look into. As of right now, as it stands, they're not billing for this service, so it's not really looked at from the Medicare perspective to say, OK, you’re able to provide this service and we'll pay for this service because you're a certified tobacco treatment specialist if that makes sense.
Member Question: I'm reading here that Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or four intensive sessions with a total annual benefit covering up to eight sessions in the 12-month period. if a provider only provides one cessation attempt, does Medicare see it as an individual service? Do we have to do the two attempts with the eight visits a year to be considered a cessation attempt, so to speak? So, if I bill the 99407 or the 99406, will Medicare be looking for the other cessations to make it a full bundle? Or do they stand on their own?
NGS: They stand on their own. It's eight individual sessions.
NGS Question: Most of you who have billed for this, are you getting any feedback from your patients about it? Is there anything that we should know that we could take back? Including positives. If anybody's having anything where it's working really well for you, that would be really helpful.
There was no member feedback at this time.
NGS Question: Do you refer patients to a tobacco counseling program? We have already heard from you on this, that some of you definitely do.
There was no member feedback at this time.
NGS Question: What processes do you use to coordinate care with other practitioners or facilities when the patient is being seen by multiple physicians with different specialties? Are you coordinating with those other specialties, those are the physicians to see whether or not they are doing counseling as well.
There was no member feedback at this time.
NGS Question: We have tried to create a live resource listing that we can share with providers to include places that can recommend the patient to go to 800 hundred quit lines, different advocacy groups and so on. These are all out on the website. Is this something that’s beneficial to you or do physicians have their own groups and information that they rely on? We'll be putting more information together. We’ll send you a link to all of tobacco information that we have on our website that might make this a little clearer for some of you. Your feedback so far has been very helpful.
There was no member feedback at this time.
Member Feedback Received via Email Regarding the Tobacco Cessation Webpage
- This looks great. The only thing I find a little ambiguous is where the elements are listed, and it says may include but not limited to. I know some of our providers are going to interpret that as anything they document is going to work.
- We agree on that point. Maybe “industry accepted standard “or something along those lines.
- I wanted to verify that these are only billable when provided in an individual session and not in a group behavioral health setting.
- (YES)
- I bill 99406 separate from E/M if I do it. Where can I refer nicotine dependent patients elsewhere for tobacco counseling?
- NYS Quit line
- Exchange notes to PCPs.
- The only thing I can suggest is a vignette for a three-to-ten-minute discussion (99406) and maybe an inappropriate scenario/something that shouldn’t be billed. Otherwise, I like it.
- This looks good. Nothing jumped out at me. I do agree that the terminology is a bit ambiguous, but I think anything less or more would probably box them in, to try to make the documents meet the criteria.
NGS: Based on current guidelines: National Coverage Analysis (NCA) Decision Memo Counseling to Prevent Tobacco Use CAG-00420N
“CMS thus believes that individual cessation counseling (rather than group therapy) remains more effective and appropriate for Medicare beneficiaries.”
Currently, there is no specific Medicare regulation on the specifics of tobacco counseling documentation criteria; hence, our suggestions are best practices and hopefully will assist in the “lack of” documentation that many have reported. As discussed, we would always encourage discussions within each individual practice to develop what works best.
The only Medicare guidance and reminder that we can point out is from the CMS IOM Publication 100-4, Medicare Claims Processing Manual, Chapter 32, Section 12.6 Post-Payment Review for Smoking and Tobacco-Use Cessation Counseling Services.
As with any claim, Medicare may decide to conduct post-payment reviews to determine that the services provided are consistent with coverage instructions. Providers must keep patient record information on file for each Medicare patient for whom a counseling claim is made. These medical records can be used in any post-payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.
Thanks to all for this invaluable feedback!
IV. End of Public Health Emergency/Telehealth
Lori Langevin, POE Consultant, NGS
Lori shared a presentation with highlights on the end of the PHE, flexibilities that will remain through 2024 and the ones that will end as of 12/31/2023. Members were reminded that, if providers continue to render services from their home, reporting of their home address on the provider’s enrollment record will be required after 12/31/2023. Lori advised the members that we have scheduled webinars on these important updates regarding the end of the PHE and billing telehealth services through the end of the year. We feel it's important to get updated information from CMS out to our provider community in a timely manner.
The latest list of telehealth services is on the CMS website and continues to be updated (CMS Telehealth Services). The telehealth list will change for 2024 with adds and deletes as it usually does each year.
NGS Question: We want to hear from you, particularly the reporting of the home address that keeps coming up. Is this an issue for your organization or your practice or is it just that we're hearing from the same providers over and over again and they just have certain doctors that prefer to work from their home versus, back to the office location.
Member Feedback: I know there are some organizations throughout the country that are co-signing a letter to CMS and they're taking the stance on this from provider safety. I also think there's some administrative burden, but they're really honing in on the safety and the things that are going on and not wanting their home addresses out there. So, I know that there is some movement on this and providers are approaching CMS on, but that's all I'm aware of.
NGS: There's a lot of discussion on this and I will tell you that not a day goes by that we don't get 15 or 20 emails about this. I have some groups that send me an email weekly. Anything new, anything new? We’ve been feeding this to CMS, so they are fully aware of it.
Members Feedback: I was just going to say on that, on reporting the home address, I don't think there's a clear reason as to why that would be needed. Our providers asked why? Why do they need my home address? There isn't really a clear answer. Does it have to be the full address?
NGS: What it comes down to is we need to know where the physician is located, where they're doing the service. So that's their rationale behind it, that the physician is going to be working from home. that the address should be known to us. At this point in time, it has to be the physical address. We understand, we hear you loud and clear because if you look at a patient's Medicare summary notification, it shows the patient, the physician or the providers name and the address. I'm not sure if it's going to show the billing address or the address reported on the claim. I wish I had better answers for you, but there's more to come and I’m taking all of your comments back to CMS.
Member Question: On the slide where you said the reason for providing the services via audio only is. Are you looking for the reason for the visit being performed, or why the service is being done via audio only?
NGS: CMS states the medical record should support the reason for using audio only communication. Now, if the code itself states it's audio only, like the telephone ones, obviously that wouldn't be needed. But we're talking about the other codes that would normally require both the video and the audio. Something like, patient did not consent to a virtual call.
Member Question: Those of us who provide services in POS 11 that, if we provide telehealth services in 2024, do we need to provide to use POS 10 if the patient is in their home, and use POS 11 in general?
NGS: Right now, you use POS 11 for telehealth services. Starting 1/1/2024, it's either going to be POS 10 If the beneficiary is in their home and then O2 if it's other than the home. I hope that helps to clarify.
Member Comment: It does for me, but I know it will cause issues for IT staff to get to the side which claim goes where, but we'll figure it out.
NGS: And again, if you're not doing telehealth and it's your regular office visit, you're going to still use POS 11. We're just talking about telehealth moving into 2024.
Member Question: Are new patients via telehealth still valid in 2024?
NGS: We have not seen that. Some of the codes state that it has to be for an established patient. You really have to look at the code, the code description.
Member Question: What would be a service address for POS 10 patient address or provider location address?
NGS: POS 10 is just stating the originating site for the Medicare beneficiary that you're treating. Other than that, you're going to submit the claim as you would as far as the provider location, right.
V. New CMS 855-I Enrollment Form
Susan Stafford, POE Consultant, NGS
Susan advised the members Medicare has merged the CMS-855R into the CMS-855I paper enrollment application. If you’re submitting a provider that's going to be a reassignment to your group and they're totally new to this state, you’ll need to submit the CMS-855I now. The new CMS-855I is going to make your life a little easier, everything for the CMS-855R is on the new CMS-855I.
If you currently use PECOS, you will not see this change as it applies only to the paper application.
Physicians and nonphysician practitioners can reassign their right to bill the Medicare Program. They can receive Medicare payments for some, or all services rendered to Medicare beneficiaries, terminate a current reassignment of Medicare benefits or make a change in their reassignment of Medicare benefit information using the CMS-855I.
All data previously collected on CMS-855R and used to report reassignment information is now captured on the CMS-855I. The CMS-855R will no longer be used to report reassignment information. We’ve shared an attachment with information about the CMS-855I that was just published out on CMS's website.
They removed the section about employment arrangements, and you’ll identify a physician assistant in section 4F to be associated with your group. Then at the end the signing. Section for certification for Section 15-B, as well as 15-C. Now 15-B is for the individual provider to sign off because it's about their individual enrollment and 15-C is about the authorized or delegated official of the entity that they're reassigning an employment arrangement to. If you're adding, you don’t need to have employment arrangement signed by an authorized or delegated official at this time, because they're mimicking how the CMS-855I is submitted for the PA in PECOS. However, that obviously might change when new PECOS 2.0 comes about. Everybody else that's adding a reassignment, must have section 15-C signed by the authorized or delegated official of the entity.
Effective 10/31/2023 the old CMS-855I and the CMS-855R will no longer be accepted. So please get used to starting off with the new CMS-855I. It’s a little shorter and everything there is identified in one application. We are hosting webinars once a week in September and October to review how to complete the new form, registration is available on our website. We are also issuing weekly email notifications and adding to our enrollment FAQs. The biggest question we've gotten so far is who needs to sign section 15, so we have an FAQ out on the website at this time that will answer that question.
We also have a handout that goes over everything, it was with the invite. Please use that for understanding the consolidated new CMS-855I. It is sort of new, but it's not difficult. They carved out the section 2I, which was all about the PA and you just add the employment arrangement as a reassignment in that Section 4.
Member Feedback: A member noted they sent this information out to their credentialing staff.
NGS: We appreciate that and ask all of you if you have separate areas that handle your credentialing, your provider enrollments, send this off to them.
VI. Virtual Conference Feedback
Jim Bavoso POE Manager, NGS
As you know, each year we try to do two different virtual conferences. We used to do live events where we would rent hotel space and people would come in and so on. We may go back to doing that again, but in the meantime, we started hosting virtual conferences with the onset of the PHE. We would host multiple day virtual conferences on a particular item or topic. We're moving towards this again. In November. We have a three-day period that will be doing a virtual conference dealing with compliance issues for the most part. We have approximately 15 sessions over the course of three days.
On Monday, November 6th, topics will be: Medicare Compliance with the Incident To Provision, Critical Care and Medicare Billing Compliance, Fraud Prevention and Detection, Maintaining Your Provider Files and Medicare Part B Top Denials.
On Tuesday, November 7th, we will discuss Medical Necessity and the Advance Beneficiary Notice, Medicare Part B Targeted Probe and Educate, Medicare Compliance with Skilled Nursing Facility Consolidated Billing, Medicare Review Contractors and Submitting Medical Documentation Electronically.
On the last day, Wednesday, November the 8th, we'll discuss: The National Correct Coding Initiative and Medically Unlikely Edits for Part B Providers, Being Compliant by Avoiding Claim Denials, Reopenings and Redeterminations, Medicare Global Surgery, and we will end with a Let’s Chat About Medicare Compliance for all the topics presented over the three-day conference. The Let’s Chat will be similar to our Ask-the-Contractor calls.
We’ll be working with our medical review staff who are on the call today Heather Fitzmaurice and Nadine Riccobene. They'll be discussing how the TPE program works and provide some tips on how to work with that. There are other entities out there that do reviews, like the RAC, Program Safeguard Contractor ZPIC and so forth. We'll walk you through how they work and how we all interact. We'll be sending out advertising save the dates in the next week or so about this. But I wanted you to be aware that these are some of the things that will be discussed.
There was no member feedback at this time.
VII. 2024 Proposed Rule Comment Period Ended 9/11/2023
Jim Bavoso, POE Manager, NGS
On 7/13/2023, the CMS issued a proposed rule that announced and solicited public comments on proposed policy changes for Medicare payments under the PFS, and other Medicare Part B issues, on or after 1/1/2024. The CY 2024 PFS proposed rule is one of several proposed rules that reflect a broader Administration wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation. Comments were accepted by 9/11/2023. The comment period has ended.
Some of the topics in the proposed rule include CY 2024 PFS Rate-Setting/Conversion Factor, Evaluation and Management Services, Behavioral Health Services, Caregiver Training Services, Community Health Integration (CHI) and Principal Illness Navigation (PIN) Services, Social Determinations of Health (SDOH) Risk Assessment, Telehealth Services, and Dental and Oral Health Services.
I'm hoping if you had some comments you were able to get them into CMS. Some conversations took place this morning, there were comments about the home address and the fee schedule. As you know, the POE team provides Medicare updates each year, and they go through each of the changes that take place. We anticipate the final rule in early to mid-November, at which time POE will present it out to you and the provider community.
Jim shared a slide with some of the information from the proposed rule. The conversion factor which is a key component to the Medicare fee schedule. As you know, the way the rate setting is set up in the Medicare Program, the conversion factor was scheduled to receive a four percent reduction over the past two years. That has changed, but it's looking like there will be a reduction going forward, this is for 2024. Something that has been commented on by organized medicine and so on. It will take an act of Congress to make any adjustments to the fee schedule.
There are changes to evaluation and management. There are indications to behavioral health services, additions to caregiver services, community health integration, principal illness services, more about social detriments of health, HealthEquity care deficit programs. Telehealth is a big service now, so there are more changes that we anticipate also dental and oral health services.
In 2023 we added additional services that a dentist can perform. Prior to this year we only paid dental services for accident or accident/trauma to the jaw/mouth with very limited scope. That scope is expanding and from what we know, the administration is going to be expanding dental services completely over the next six to seven, or eight years. With that, I believe eventually all dental services will be included, even routine cleanings and things like that. But more to come down the road on that.
We’ll see what happens when the final rule is published, which we expect will be early to mid-November. We may not see anything about the rates/rate setting changes until December or maybe even later. You know, I have visions of 2010 when we had five different fee schedules. But let's hope that doesn't happen again.
Any comments at this time?
Member Question: What about the AUC that is officially sunsetting?
NGS: There is information out there already. View CMS’ Appropriate Use Criteria Program web page.
Members Question: E/M services and education?
NGS: As you know, we do a lot of training and education on E/M services. The add on code, split shared, incident to and so on. Any changes that come out of the final rule will be included in our Medicare updates, and our topic driven E/M services education as we move forward.
It'll be interesting to see, one of the things that we've always done with the provider advisory group is dedicate our December meeting to the changes that will take place in the next year.
I anticipate that we’ll do the same thing, and we'll ask you for your feedback on how we can make sure that the provider community is understanding us. More to come on that. Any comments or questions before we move on?
There was no member feedback at this time.
VIII. Open Discussion
Jim Bavoso, POE Manager, NGS
Jim mentioned the following items before open discussion.
Dental Coverage: We’ve been receiving information from CMS about dental services and what will happen in 2024. I really can't talk much about it because it's not official, but I may need some assistance from you with getting to the dental providers. One of the things we found, and in speaking to my own dentist and some of my staff speaking to their own dentists, they have never dealt with Medicare before, this is all new to them.
I may be asking you for assistance going forward with some of the dental services that come out. Chris Obergfell, Jennifer Lee and Jennifer DeStefano from our staff are working on information to get out to our community. I may need your feedback as we move forward.
We've already seen some claims coming in for astronomical services that are not covered. In the Specialties section of our website, under Dental, you'll see what services are covered and what conditions are covered for. It's more than it was in the past, but it's still a limited scope. Down the road, they'll be expanding it.
Dr. Boren added: One thing about the dental and I agree with you completely, Jim, this is a new thing for most dentists. They're not used to using CPT codes and most of them do not take Medicare for a number of reasons. But it's important for beneficiaries to understand that yes, CMS has interpreted the Social Security Act to allowing more dental services than before. However, there seems to be a widespread belief, particularly on beneficiaries and some dentists, that Medicare covers all dental services now, which is not true at all. It's a very limited amount. CMS is going to change and increase it next year, but next year is 2024, not 2023, so that doesn't matter at present.
LinkedIn: We’ve been using Twitter for a number of years now, and we have not gauged much feedback from it. We felt we put a lot of effort into it, but we weren't getting enough bang for our buck. My personal opinion is I didn't think we were getting any real feedback on it or even addressing it to the community of physicians, providers, billers compliance offices and so on. What we are doing is we are sunsetting our use of Twitter or X and we’re moving to LinkedIn.
We feel that LinkedIn is a better avenue for us, that we’ll be able to do longer formal, professional education. We kicked it off today and sent out a LinkedIn article in relation to smoking cessation. Our goal is to start using this more often, getting feedback and using this as one of our platforms. Social media is here with us, so we need to use it as best as possible. How many of you use LinkedIn? Do you foresee any issues with using LinkedIn? The link was shared with the members. LinkedIn.
Member Feedback: Quite a few members responded they use LinkedIn.
IVR Changes: We have some changes coming to our IVR system. I know many of you don’t use it, but we are making some adjustments as we will be changing platforms. We’re sending email updates about certain functionality that will no longer be available on the IVR.
The information available on the IVR can be found in our NGSConnex portal. I've been in Medicare forever and before we had a portal, many providers, many physicians, many billers said to us, why don't you put this on online so we don't have to use the phone and I can use it 24/7? So that's what the portal does. Anything you can ask of the IVR can be done and found in the NGSConnex portal. There will be some functionality that will be removed from the IVR and only be available in the NGSConnex portal. As we learn more about this, we'll send it out.
Podcasts: I know we've mentioned this in the past, looking at using this for Part B and Part A. Our HHH team is using it now, sharing information about HHH. My questions for you are: Do you use podcasts? Do you listen to podcasts? Do you find them beneficial? We'll be looking to expand into the podcast realm, and you know we to make it more interesting, we may be asking l providers, billers, advisory group members to join us and a be part of it. We may set up some time and ask you to join with us. Yes, we will add additional topics, we will look for any topic we can come up with that we think will benefit the provider community.
Member Feedback: Yes, they use them, listen to them, find them beneficial and can listen while driving.
Outsourcing: We’ve discussed outsourcing in the past, and what do we mean by outsourcing, you know, many of us are using outside billing companies, service bureaus, external billers, whatever you want to call it, even clearinghouses. What we are finding is that some of them are using an additional outsource. The vendor calls on your behalf and some of them have really bogged down our telephone lines with nonsense calls, meaning, they call us as a question that doesn’t really matter, and ask for a reference number. We think what they're doing is they're saying oh as part of our service level agreement with the provider we called X number of times, and you owe us X number of dollars for that service.
We’ve been working with CMS and looking at these outsourced providers to see how we can prevent this from continuing. In some cases, they are offshore, meaning they are outside of the U.S., we’ve been locking those calls out so they cannot connect to us. Some providers we spoke to were not even aware that their vendor was using an outsourced group outside the U.S.
One other thing it is also extremely beneficial to make sure that your provider enrollment applications that you have with us are up to date with the authorized officials that we can talk to. We're looking at them more and more when these calls come in. If it’s not the authorized official calling, we will not talk to them. This is something you’ll be hearing more about.
Member Feedback: How would it be a proper workflow that Medicare know we're using an offshore vendor for denial management. Exclusively?
NGS: The EDI enrollment process requires you to sign up to submit claims electronically. They use the provider portal and so on. This has to be authorized by the authorized official, and the provider on the enrollment screens. That’s how we manage it.
If you're using an offshore company, you should know whether or not patient information or data is leaving the U.S. That's something you really want to be careful with. And also, when you're using an offshore person for billing for denial management, do you have a service level agreement with them as to what they can and cannot do in dealing with the Medicare Program, and how they go about it? Some of the large groups that we've seen get paid for every phone call they make to us. In our conversations with other health insurers, Elevance, Humana and so on and so forth, they're all experiencing this.
Mental Health/Depression Screening
Lori Langevin POE Consultant, NGS
This was added to the agenda per member request.
Deliver the screening in primary care settings with staff-assisted depression care supports in place to ensure accurate diagnosis, effective treatment, and follow-up. NCD 21.09 Screening for Depression in Adults.
Member Question: I’m asking if our providers are noting that they’re providing depression screening, but I don't see documentation that can really suggest that we can bill for these services. I’m looking at the documentation that's required and it's the risk factors. The Patient Health Questionnaire, the description of the laws, and the plan of care. If these components are not in the documentation, can we still bill for it? We are using this new tool called notable. These forms are sent to the patient, the patient fills the forms out, then they are transferred to the medical records. Is this considered documentation? It doesn't really support the documentation that's required, so I'm not sure what to do with this.
NGS: I heard a couple of the compliance officers hit the floor on this call, so I don't know.
Member Comment: I’m sorry. Don't kill the messenger.
NGS: I wanted to include the NCD, and I don't know if you've had a chance to review it but it's pretty specific in there about what they're looking for. The description of the code and then the medical documentation has to support that, in order for the service to be payable. Although I can appreciate any new tool or whatever is out there, the service needs to be documented, it has to have an accurate diagnosis, effective treatment and follow up that's per the code. I don't know if anybody else has anything that that they want to add to this or if they bill these codes and you know what type of struggles or success they’ve had. A couple of comments in the chat box mention providers don’t bill for this.
Member Question: I guess the next question would be and for the providers who are on here, I apologize, but our providers are just so difficult They will tell you that they did the depression screening and there’s nothing else that they can do, and I'm looking at the documentation and I'm thinking there is a lot more that you need to do to make that a billable service. So how do we get through to the providers? Has anyone had that issue?
NGS: It comes down to getting the physician to understand. what needs to be in the medical record in order to bill for it. Saying it is fine but not writing it is not. If there's something we can do to help, by providing information to say this is what a sample record should look like that's really what it should come down to. Again, if it's not in the chart it wasn't done.
Member Feedback: That would be truly helpful Jim to have a sample of what the records should look like. I think that would be helpful.
NGS: We I'll see if we can find something for him.
NGS: Anybody else have anything else you'd like to discuss?
Member Question: Who's going to be the primary intended audience for podcasts and the information on LinkedIn. Would NGS be identifying availability in their current communications listen to podcasts, but not during work hours?
NGS: What we'll be doing is, our podcasts are going to be provider centered. So, we'll work with providers, billers and so on. That's what I mean by provider centered. It'll be geared toward billers compliance officers, physicians, nonphysician practitioners. It's not going to be open for the beneficiary population. As far as when you can listen to these, we'll be putting them on platforms like Apple and Spotify. You'll be able to listen to them at your leisure. That's how we'll work on this.
Member Question: Will we be able to use this podcast for training other staff? Not providers, just all staff.
NGS: Sure. If we put that out there and you find it beneficial, sure. I know many of you use our Medicare University or computer-based training programs. You use those as part of your compliance programs or your staff as education. Please feel free to do that. We’ll be creating more and more YouTube videos as well. If there's something you need to take be our guest. But I would ask you just let me know so I can say, oh, this is working. We'll continue doing it.
Member Question: We’re getting a lot of questions and we live on your site of course, and it's always an interpretation. We have a couple of geriatric docs that are going out to their society, and I had said that I would present it today. I think I did email Lori. But then of course it's snowballed. So, I have a question and it's regarding if the patient is unable to make a decision due to delirium or other healthcare status change and the physician has a discussion with the family about the goals of care. Would this support 99497?
And then we have two caveats- does the family member have to be listed as the legal health care representative? I'm on a previous directive by a patient. Or can it be another family member? And if there's a previous directive, if the hospital saw a patient come in and they were always a full code and there may be a directive on file at the skilled nursing or PCP or through the health proxy and if our docs don't know, can they bill out advanced care planning or should they be reaching out to find out if there's one on file?
I guess that's our $1,000,000 question today. I've spent 15 hours, trying to give them the right answer, I can put it in the chat.
NGS: Send it off to Lori and Jim. We may have to bring our medical directors in on a couple of things, so we'll take a look at it.
NGS: POE is offering our care management series on 10/3/2023 and 10/10/2023. On 10/3/2023 we have Advance Care Planning, Cognitive Care and Psychiatric Collaborative Care Management/ Behavioral Health Integration and on 10/10/2023 we have Principal Care, Chronic Care and Transitional Care Management Services. Our lead clinician here in POE, Cathy, developed an Helpful Reminders on Advance Care Planning and we have the Advance Care Planning web page that provides helpful information.
Member Question: One of my clients recently received the comparative billing report which really outlined couple of codes that he uses with the graph, and I was wondering if you could talk about that. Is this something that's being done more now because I haven't seen one of these?
NGS: Yes, we send them out on a regular basis. Years ago, we did this more globally, but now, we do more targeted versions of them. CMS also sends them out. What it does is show the provider how they're billing a particular service or services against their peers. It's sometimes used as a heads up, ‘do you know you may be doing this more than your peers by X percent’, just to make sure your documentation is up to date etc.
NGS: (Nadine Riccobene, Medical Review, NGS) When we send out those CBRs it’s just like Jim said, it's an instance where maybe you look different than your peers. It doesn't mean you're doing anything wrong. It's meant to be a tool to let you know this is what we're seeing. Perhaps you want to look at your billing., see if there are any issues. Maybe you want to look at the LCDs and policies that are out there just to ensure that you have documentation that supports those services. When you receive the CBR, it doesn’t mean you’re on review. The CBR letter has our email address, if your provider wants to reach out to us we are happy to speak to them about it.
Member Comment: Thank you. I did that, and in the letter, it also says if you want us to review a couple of claims and discuss it with you. I thought maybe that would be good because he stated that his documentation is excellent. I thought it would be a good training tool for him.
NGS: I will tell you, sometimes it works the other way. You know, people think automatically I am doing something wrong. Many years ago, I had a physician who was billing all his beneficiaries with 99211 and 99212 and he was subject to a comparative billing report. Then when we looked at the documentation, he was not billing appropriately. He could have been billing 99213 to 99214 and then some cases 99215, so we were able to show him what he was doing correctly and incorrectly as far as what he was billing versus what he was documenting. He was able to change his billing around so that he was billing with the appropriate level of service. So, it works both ways. Not only like we're on a witch hunt going after you, but it works both ways.
Member Comment: Ok, thanks a lot.
NGS: (Dr. Boren, CMD) Several times I have seen that at a prior contractor. Situations that looked funny, but there was a good reason. One was a physician who had enrolled as whatever. I forgot what specialty but enrolled in a completely wrong specialty. So, consequently, he really stood out compared to everyone else. We explained to him he better change the way he was enrolled. The other time in a small town in Illinois, there was an anesthesiologist who was doing an awful lot of EKGs. It turns out she was also doing general practice. So that is why she stood out and there was nothing wrong with what she was doing. She looked different because her practice was actually different.
Member Question: The last time we spoke about that report, I said that I have never seen one.
So I was wondering, do you send it to the provider group, or do you send it to individual providers? Because if you send it to individual providers, we don't get that feedback from them at all.
NGS: It is sent to the billing provide, whoever submits the services. It’s similar to what we do for TPE reviews. We'll go through their enrollment, and we'll see what address is on file for them with their enrollment. It would go to that address. And remember, there is a way on your enrollment application where you can designate an address, a specific address where you want things like medical record requests to go to. CMS now gives you that capability on the enrollment form to designate another address.
Member Comment: Something that maybe we could put on a future agenda. I was recently at a conference where they were talking about you using AI for documentation and some of the discussion was very scary. It was scary to hear the types of ways practitioners are using this AI. I think that that's probably something that's going to need to with regulatory guidance in the future, but also, I know Medicare has, your site has a great discussion about cloned documentation, but I think that providers are going to need to understand the cloned versus AI versus copy and paste and the limitations and what's acceptable. The other thing is what are the HIPAA restrictions on using that like chat. GPT is all the rage right now, and providers will type in I'm doing a colonoscopy with a removal of a polyp by snare technique. Can you give me an Op report for that?
NGS: We are taking note of this and will bring it out to CMS as well. Doctor Boren and our medical review staff have heard this as well. We would definitely need guidance from CMS for this.
Anything else from anyone? Thank you all very much for today. Appreciate the feedback, the great dialogue today we did get a lot of information from you. That's really what we look for. If there's anything that you feel you need to bring out to us, don't hesitate to reach out to myself, Lori, or Chris. We’d be happy to help. If you have ideas, any feedback that you would like to provide to us, send it to us. We're always looking for it, and as I said, I look for many of you during the course of the year for assistance on specific topics and I will probably continue that into 2024. So, I do thank you very much for your help on behalf of Lori and Chris, the entire POE staff, and everybody here in NGS, thank you very much for joining us today. Our next meeting is scheduled for December 14th. We might move that up a little depending on when we get the final rule, but that's where we'll be because I would like to get that into your hands as soon as possible.
We just want to thank everyone for attending and all the feedback.
IX. POE Advisory Meeting Schedule
Lori Langevin NGS POE Consultant
Members were thanked for their input and attendance. They were reminded of the final meeting date for 2023, 12/14/2023.
Meeting adjourned
Posted 10/19/2023