KAREN STOLL BSN, RN, CPC-H MANAGER OF REVENUE CYCLE RECOVERY AUDIT WHEATON FRANCISCAN HEALTHCARE FISS Best Practice Is your hospital leaving money on the table?

Objectives 1.) Search for claims that the Fiscal Intermediary has pulled for review or denied. 2.) Monitor and track denied claims- CERT, OIG, Probes, Automated. 3.) Catch denials and appeal the claim earlier- You have 120 days to appeal a claim from the first denial. 4.) Know the reason for the denial and accurately appeal the claim.  line denial - LCD/NCD denial  claim denial - edit code 5.) Understand when to adjustment vs appeal. 6.) Tips on how to appeal some of the denials.

FISS Get access- You need to access FISS each month or your password will be revoked. Decide who should have access to FISS.  Someone who write appeals should have access. Copy the FISS Quick Reference guide and keep it handy.

Reference Material Go to Medicare University and sign up for:  Maximizing use of the Medicare Fiscal Intermediary Standard System Direct Data Entry Online System Inquiries Menu. (FISS slides copied from the webinar above.)

Finding claims Pull claims by placing the NPI and  S/Location  TOB  Drill down by limiting the dates of service Look for a specific beneficiary by placing NPI and HIC # and span dates of service.

Claim summary page Once in a denied claim, on bottom left corner of a page is the denial reason code. PF1 on the computer and one by one place the denial reason in the blank for an explanation for the denial. PF3 to get back to the previous page.

Scroll- located in top left corner of page  Scroll 13- revenue codes  Scroll 14- HCPC codes  Scroll 15- DX/Procedure codes  Scroll 17- Reason code description  Scroll 56- Claim Count Summary

Claim Summary page While on the claim summary page PF2 and you are able to pull each line up- one by one. PF6 to move from line to line. Look to see if denied and the denial reason. Look at the NCD# place for the NCD that was referred to in the review. PF3 to get back to previous page.

Remarks page This is where NGS will explain the pre-pay denial reason. Page 4 is where you write your “love notes” explaining why the claim should not have been denied. Include specific Medicare references when possible.

Example of NGS note on page 4 for CERT denial

You should be able to: Drill for new record requests by hospital and by S/Location TOB Open new requests to see what is being looked at-  CERT  OIG  Lab  Therapy

You should be able to: Drill for a specific claim by hospital, HIC#, & DOS. Know the status location of a claim- paid, denied, rejected. S B6001- ADR S M5REC- records received P B9997- payment D B9997- denied (watch for doc not received) I B9997- inactive (go to page 4- LOVE NOTES) Understand why a claim was denied. Track the claims through the appeal process. Know the dates a claim was received/denied.

You should be able to: Scroll to a page for information on a Revenue Code or HCPC and not leave the claim. Look on page 6 for the DRG- (was it changed?) Was the claim paid or was the money taken back.

Letter enclosed with probe results

APPEALS TIPS FOR GETTING DENIED CLAIMS PAID

REBILL TIPS 34 Follow the CR 8185 closely!! Call NGS with questions!! Research the process and the number of days it takes for your claims to get to EDS. (It may go thru a clearinghouse and take an additional 1-2 days before it reaches NGS.) Try to split the claim into 12X and 13X early. Don’t wait until day 180 to rebill. Sometimes one of these claims might get caught up in the system and you need to release the other to be timely. This may cause one claim being denied. Monitor FISS (Fiscal Intermediary Shared System) for the claim status of 12X and 13X rebill and the date. If a claim is RTP’d back to you and you fix it (remove the lab or revenue code from the claims), in FISS the receipt date changes and may lead to an untimely denial. At Wheaton, we check FISS daily. (Watch for RTP’d claims.)

REBILL TIPS 35 Watch for the reason the rebill was denied:  Untimely denial- Count the days from the last denial. There should be = or <185 days ( days for mailing)  Adjust the denied claim:  Copy the claim (so that you know what was billed)  On each line you need to DDDD over each revenue code and when at the bottom of the page then hit home and enter. (This erases any hidden message with that line.)  Then move non-covered to covered (take the info from your copy of denied claim).  Place D9 in condition code, OT in adjustment reason, check ATT Physician name and OPR Physician name not blank and in notes section write: Please bypass timely filing because CR8185 states the date of receipt of a determination, decision or notice is presumed to be five days from the date of the determination, decision or notice, unless there is evidence to the contrary. Due date should be 180 days plus 5 days this would bring our due date to xx/xx/xx.

REBILL TIPS 36 When a claim is denied untimely because the due date falls on a Saturday, Sunday, federal non-workday or legal holiday: Per Pub , Chapter 1, Section (Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, Federal non-workday or legal holiday, the claim will be considered filed timely if it is filed on the next workday.) Please bypass timely filing.

REBILL TIPS 37 When an entire claim has been denied due to one item being a duplicate or a modifier was missing on one line and the claim was filed timely, but due to fixing the problem now the claim is denied untimely…  This claim was submitted timely and accepted into CMS’s electronic temporary storage location. Per Pub 100-4, Chapter 1, The FIs should take the following actions upon receipt of incomplete or invalid submissions: If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.  This entire claim denied due to a “not required data element”-XXXXX (one duplicate lab).  Per the Medicare Manual, the FI should process the claim if the “required data elements are entered accurately and appropriately.” The basic requirements per 42CFR424.32(a)(1) states, “A claim must be filed with the appropriate intermediary or carrier on a form prescribed by CMS in accordance with CMS instructions.”  The required data elements were entered accurately. Please review this claim and process for payment.

REBILL TIPS Lab edit Send to in-house coder (usually need to add modifier 91) 82550, 82553, 80048, 84484, (Usually need to unbundle and make 2 lines) Copy the claim. DDDD revenue code only on denied line, hit home, and enter. Re-key lab information and change to 1 unit On the line with the second unit place modifier 91 (not modifier 59) 38038, Duplicate Call NGS 1 st and ask why it was denied. (Many claims from June-Sept were denied in error.) Get a ticket number and monitor. NGS will send the claim back for review.