1. Medicare Changes April 08, 2011 WSOPP Presented by: Chris Duprey
Carrie Romandine

2. 2010-2011 Highlight Changes Agenda Medicare Policy Billing Rules
Compliance Changes and Notifications
Appeal Process

3. Medicare Policy Changes
Prosthetics and Orthotics Ordered in a Hospital or Home Prior to a Skilled Nursing Facility Admission
CMS Ordering/Referring Provider Report Updated (PECOS)
Healthcare Provider Taxonomy Codes April 2010 Update
Auto Denial of Claims with GZ Modifier

4. Prosthetics and Orthotics Ordered in a Hospital or Home Prior to a Skilled Nursing Facility Admission – October 2010
P&P regarding circumstances a supplier may deliver DME, prosthetics, and orthotics, but not supplies to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary’s home.
SNF consolidated billing (CB) provision of the Balanced Budget requirement under which the SNF itself is responsible for billing Medicare for all services that its residents receive.

5. Responsibility Grid
Transfer from IPH to SNF Part A
Requires an Orthotic or Prosthetic Device
Facility where medical need occurred is responsible for billing
If device is medical necessary occurs at time beneficiary in IPH
Device is not delivered until the beneficiary has arrived at the SNF
Facility remains responsible for billing the item, not the SNF
If device medical necessity occurs after the beneficiary is transferred from IPH and enters SNF Part A
SNF is responsible for billing of the prosthesis or orthothis
Most prosthetics and all orthotic devices are subject to the SNF CB
Item would be included within the global per diem payment unless
specifically excluded from SNF consolidated billing.

6. Who Bills? If
And
Then
Need for these devices were established while in SNF,
Supplier is to bill the DME MAC
When prosthesis or orthosis is required while patient is in the home
Is entered into a SNF for covered Part A stay
DME MAC should be billed by the party which supplied the device, not the SNF
If beneficiary enters SNF for a non-covered stay
Develops a medical need for a customized device which the SNF orders
SNF would bill the DME MAC for the item since SNF CB rules do not apply

7. CMS Ordering/Referring Provider Report Updated (PECOS)
Effective January 3, 2011 DMEPOS suppliers will not receive payment from Medicare for items that are ordered if you do not have a current enrollment in the PECOS.
Providers who can order DMEPOS items include:
Applicable to O&P
Others
Medicine or Osteopathy
Dental Medicine or Dental Surgery
Nurse Practitioner
Certified Clinical Nurse Specialist
Physician Assistant
Optometry

8. Healthcare Provider Taxonomy Codes April 2010 Update
Taxonomy codes are required for X Professional and Institutional Implementation Guides
NUCC updates the code set twice per year effective April 1 and October 1.
Taxonomy for Prosthetics and Orthotics is 335E00000X – this should be included on your file when electronic billing or box 31(rendering provider), 32 (rendering facility) and 33 (billing location)

9. Auto Denial of Claims Submitted with a GZ Modifier
The Health and Human Services Office of General Counsel (OGC) has provided guidance that Medicare contractors that process both institutional and professional claims have discretion to automatically deny claims billed with the GZ modifier.
Effective for dates of service on or after July 1,
In addition, line items denied due to the presence of the GZ modifier will reflect a claim adjustment reason code of 50 and Group code of CO – meaning provider/supplier liability.

10. Billing Changes
Reimbursement
Billing
Policy

11. 2010-2011 Billing Changes New Uses of the KX, GA, GZ, and GY Modifiers
Patient Responsibility – PR Group
Use of Upgrade Modifiers
Therapeutic Shoe Policy Revision /Documentation
Timely Filing Requirement
Top Error Codes

12. New Uses of the KX, GA, GZ, and GY Modifiers Effective 5-01-2011
Definitions:
KX – Requirements specified in the medical policy have been met
GA – Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file)
GZ – Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary, no ABN on file)
GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit

13. Tips to Understand About Modifiers
Claim lines will be rejected if the proper use of the modifiers are not used according to the LCDs
If the claim line is rejected for an incorrect or missing modifier – you may resubmit that single claim line with the corrected modifier vs. reopening of the claim Effective 5/1/2011
GA, GZ and/or GY may not be used on the same claim lines
GY and KX are inappropriate to report on the same line

14. Modifier KX
Serves as an attestation by the supplier that the requirements for its use that are defined in the particular LCDs are true for that specific beneficiary – requirements vary from policy to policy
Therapeutic Shoes For Diabetics Only
Ankle-Foot/Knee-Ankle-Foot Orthoses
Orthopedic Footwear
Suppliers may only append the KX modifier when all requirements for its use have been met
Adding the KX modifier without ascertaining that all requirements specified have been met could be viewed as filing a false claim and potential abuse of the Medicare Program (fines can be 3x value of the false claim, plus from $5,500 to $11,000 in fines, per claim)

15. Modifier GA
When an item or service that is provided to a Medicare beneficiary does NOT meet the coverage condition outlined in the medical policy, it is the responsibility of the supplier to notify the beneficiary in writing through use of the ABN before the item or service is delivered or purchased
Example: L3020
Use of the GA modifier indicates the supplier has a waiver of liability statement on file.
Modifier GA must not be appended to the claim line if the supplier did not properly execute an ABN

16. Modifier GZ
Item or service that is provided does not meet the coverage criteria outlined in the medical policy, an ABN must be executed.
When the ABN is not properly executed the GZ modifier would be used to append the claim.
Denial will be received as not medically necessary
Review criteria within LCDs for use
Ankle-Foot/Knee-Ankle-Foot

17. Modifier GY
An item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
Some LCDs require use of modifier GY to indicate when an item or service may be excluded from coverage in a specific situation.
Example:
Orthopedic Footwear Policy
Therapeutic Shoes for Diabetics Only

18. Impacts of Incorrect Modifier Usage
PR – Patient responsibility:
Amount may be billed to the beneficiary or to another payer on beneficiary’s behalf.
Examples:
Patient’s deductible or coinsurance
The patient assumed financial responsibility for the service not considered reasonable and necessary (ABN)
Charge denied as a result of the patient’s failure to supply primary payer other information
Patient is responsible for payment of excess non-assigned charges

19. Patient Responsibility – PR Group
Charges that have not been paid by Medicare and/or are NOT included in a PR group – beneficiaries not responsible
Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code, regardless if it is assigned or unassigned.
Examples:
Late filing penalty (reason code B4)
Excess charges on an assigned claim (reason code 42)
Excess charges attributable to re-bundled services (reason code B15)
Charges denied as a result of the failure to submit necessary information
Services not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements

20. Patient Responsibility
Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code, regardless if it is assigned or unassigned.

21. Use of Upgrade Modifiers – April 2011
Definition of an Upgrade:
Item goes beyond what is medically necessary under Medicare’s coverage requirements
Fact:
Considered an upgrade even if the physician has signed an order for it
Item does not meet coverage criteria stated in LCD – supplier can still obtain partial payment at time of initial determine with upgrade modifiers

22. Upgrade Modifiers
GK: Reasonable and necessary item/service associated with a GA or GZ modifier
Practitioner ordered: L3020 vs. A5513
GL: Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN

23. Claim Example EOR Example DOS POS HCPCS MOD CHG 2-4-2011 11 L3020 GA
120.00
A5513 GK
80.00
EOR Example
DOS
HCPCS
MOD
CHG PD
L3020 GA
120.00
PR-96
A5513 GK
80.00
CO-45
16.00
64.00
PR-2
40.00
Beneficiary liability will be the sum of (a) difference between the submitted charge for the GA claim line and the submitted charge for the GK claim line and (b) the deductible and co-insurance that relate to the allowed charge for the GK claim line. Supplier may charge U&C fee for the upgraded item that is provided.

24. Upgraded Item – Supplier’s Decision
An upgraded item may be provided by a supplier at their discretion with no ABN on file—however, this upgrade must be free of charge
To bill the following modifiers would be used:
GL modifier to the item that is covered based on the LCD. In this situation, the supplier does not bill the HCPCS code that describes the item that was provided.

25. Beneficiaries Decision to Upgrade
Supplier decides to provide it at no additional charge, no ABN is obtained.
On one claim line supplier bills with a GZ on the item that was provided.
Second claim line, supplier bill with a GK modifier and the HCPCS code that describes the item that is covered based on the LCD.
Claims for upgraded modifiers must be billed in this order.

26. Therapeutic Shoe Policy Revision /Documentation Sept 2010
Addresses two main areas:
1). In person fitting and delivery addressed by Article by May 2010
II). Certification Statement required by the physician managing the patients diabetes

27. Summary of Requirements
Activity
Responsible Person
Timeframe 1
Visit to document diabetes management2
Certifying MD/DO
Within 6 months prior to delivery 2
Visit to document qualifying foot condition2
Certifying MD/DO, other MD/DO, DPM, PA, NP, CNS 3
Completing Certification Statement
After visit(s) to document diabetes management and qualifying foot condition
After Certifying Physician reviews and signs report of visit documenting qualifying foot condition by other MD/DO, DPM, PA, NP, CNS – if applicable
Prior to initial provision of shoes and inserts
For subsequent provision of shoes and inserts, required if delivery is > 1 year after most recent certification statement 4
Providing dispensing order to supplier4
Prescribing Physician
After visit with Prescribing Physician
Before delivery

28. Summary Requirements, Con’t
Activity
Responsible Person
Timeframe 5
Signing detailed written order
Prescribing Physician
After visit with Prescribing Physician 6
Selection Visit
Supplier 7
Delivery Visit
After selection visit
After receiving dispensing order or detailed written order 8
Submitting claim
After delivery
After receiving detailed written order
After receiving Certification Statement
1 If the table states that one event needs to occur “before” or “after” another event, both could occur on the same date if that sequence was followed
2 Effective for dates of service on/after 1/1/2011
3 Applicable if qualifying foot condition is not documented on visit with certifying physician
4 Separate dispensing order not needed if detailed written order received by supplier prior to delivery

29. Timely Filing Requirement
Reminder timely filing for Medicare has been reduced to 1 year; all extensions have been exhausted.

30. Top Error Codes 2010
CO-13 – The date of death precedes the date of service
CO-16 – Claim/service lacks information which is needed for adjudication
CO-18 – Duplicate claims
CO-22 – Payment adjusted because this care may be covered by another payer per coordination of benefits
OA – 109 – Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor

31. Compliance Changes and Notifications
CEDI Recertification Process – Effective January 2011 recertification will be required annually (13,000 trading partners are affected)
Schedule is as follows:
January 2011 – Trading Partner ID A08
February 2011 – Trading Partner ID D08
March 2011 – Trading Partner ID C08
April 2011 – Trading Partner ID B08
Process is expected to be completed by August 2011

32. Medicare – April 08, 2011
Question/Answer