14. Ground Ambulance Scenarios: Beneficiary Death -Medically necessary level of service furnished -After pickup, prior to or upon arrival at the receiving facility -The provider’s BLS base rate, no mileage or rural adjustment; use the QL modifier when submitting the claim -After dispatch, before beneficiary is loaded onboard ambulance (before or after arrival at the point-of-pickup) -None -Before dispatch Medicare Payment Determination Time of Death Pronouncement
58. Effective 12/15/09 J13 Contact Information NY & CT 877-273-4334 EDI: National Government Services Part B Provider General Written Inquiries P.O. Box 7052 Indianapolis, IN 43207-7052 Correspondence: 866-709-1905 Fax on Demand: 866-837-0241 Provider Contact Center: 1-877-869-6504 Interactive Voice Response unit (IVR)
No COLA (Cost of Living Adjustment) 2010 Social Security checks will not increase
Simply applying a cardiac monitor does not qualify the transport for ALS payment. Ex- a patient tripped and fell. The monitor read NSR. A cardiac monitor is not indicated . Would downcode to BLS. Routine blood draws do not qualify as justification for ALS if it is part of protocol. With breathing treatment, would expect to see monitoring of breath sounds and POX checks When reviewing an ALS claim, check that the level is ALS then determine if it is R+n.Look for crew credentials..need to see EMT intermediate, advance, or paramedic
The three doses may be the same or different medications, but they must be three separate doses. If three separate medication doses were not administered, the provider may still receive payment at the ALSII level if one of the ALSII services were performed. The provider may also receive payment at the ALSII level if one of these procedures is attempted but unsuccessful, as long as the service was reasonable and necessary ie. Intubation attempt is unsuccessful during a cardiac arrest/ CPR in progress.
Limitations of Internet-based PECOS for Provider and Supplier Organizations There are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be available at a future date. These scenarios are: Changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855). • Changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). • An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B MAC to bill for Part B services. This must be done using the paper enrollment application (CMS-855). • Initial applications submitted by Federal Qualified Health Centers, Rural Health Clinics,and End-Stage Renal Disease Facilities.
Slide 60 provides the Enrollment Processing timeframes when you utilize the PECOS system. 90 % of the Internet Based applications are processed within 45 days of receipt. CMS requires that Medicare contractors process 80 percent of initial paper enrollment applications within 60 days, and 80 percent of paper changes and reassignments within 45 days. Also, for both paper and Internet Based Applications, there is a thirty day retrospective billing guideline meaning: The Providers effective date for billing is 30 days prior to the receipt of the application, or, the date the Provider begins practicing at the location. CR 6310 – IOM 100-08, Chapter 10, Section 6.1.4 In accordance with 42 CFR §424.520(d), the effective date for the individuals and organizations identified above is the later of the date of filing or the date they first began furnishing services at a new practice location. Note that the date of filing for Internet-based PECOS applications for these individuals and organizations is the date that the contractor received an electronic version of the enrollment application and a signed certification statement. In accordance with 42 CFR §424.521(a), the individuals and organizations identified above may, however, retrospectively bill for services when: • The supplier has met all program requirements, including State licensure requirements, and • The services were provided at the enrolled practice location for up to— 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§5121-5206 (Stafford Act) precluded enrollment in advance of providing services to Medicare beneficiaries. The effective date of billing for a physician/non-physician practitioner and physician/non-physician practitioner’s organization is the later of the date of filing or the date the physician or non-physician practitioner began furnishing services at the practice location. Example 1: Dr. Joe is establishing a new practice location on July 1, 2009, and submits his enrollment application on June 10, 2009. The effective date is July 1, 2009. Obviously, there is no period of retrospective payment, since Dr. Joe submitted his CMS-855 application prior to the start date. Example 2: Dr. Joe started working at his new practice location on August 15, 2009 and filed his enrollment application on September 1, 2009. While September 1, 2009 is the later of these two dates and is therefore the effective date of filing, the effective date for billing purposes (and for retrospective payment) is August 15, 2009. EXAMPLE: Dr. Joe started working on January 2, 2009 and submits his enrollment application on March 1, 2009. Dr. Joe’s effective date of filing is March 1, 2009, but his effective date for billing purposes is limited to the 30 days prior to March 1, 2009. In this case, Dr. Joe’s effective billing date is January 31, 2009. NOTE: This calculation includes 28 days for February. EXAMPLE 4: Dr. Joe’s Medicare billing privileges were deactivated due to 12 consecutive months of non-billing on October 1, 2009. Dr. Joe submits an enrollment application on December 15, 2009 to reactivate his billing privileges. In this case, Dr. Joe’s enrollment application indicates that he started seeing patients at this location on January 1, 1998. Dr. Joe’s effective date of filing is December 15, 2009, while his effective date of billing is November 16, 2009. Dr. Joe is precluded from receiving payment for services rendered between October 1, 2009 and November 15, 2009. In each scenario described above, the contractor shall enter the effective date of billing into sections 1 and 4 of PECOS. Note that for purposes of 42 CFR §424.520(d) and §424.521(a), a CMS-855 reactivation application is treated as an initial enrollment application. This means that a reactivated provider will have a new effective date (i.e., the later of the date of filing or the date it first began furnishing services at a new practice location) and, per §424.521(a), limited ability to bill retrospectively.
New diagnosis coding system to replace ICD 9. This is being implemented October 1, 2013.
Why ICD 10? ICD 10 offers more detailed information and the ability to expand specificity and clinical information in order to capture advancements in clinical medicine. CMS has sponsored many calls on this and will continue to have information regarding the implementation of ICD 10.
Time Limitation on Filing Part B Reasonable Charge and Fee Schedule Claims The time limit on filing claims for service furnished in the last 3 months of a year is the same as if the services had been furnished in the subsequent year. Thus, the time limit on filing claims for services furnished in the last 3 months of the year is December 31 of the second year following the year in which the services were rendered. Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, Federal nonworkday or legal holiday, the claim will be considered filed timely if is filed on the next workday.(NOTE – THIS HAS CHANGED) Example: an enrollee received surgery in August 2001. He must file a claim for payment for such services on or before December 31, 2002. MCM 3004.1 Extension of Time Limit Due to Administrative Error If the failure to submit the claim within the timeframes specified in 3004.A was due to “administrative error” (I.e. misrepresentation, delay, mistake or other action) of an officer Exceptions for filing claims late: Unusual or exceptional situations determined by the Medicare carrier; MSP claims when the primary payment sheet is sent to the beneficiary);and foreign claim. Add islided Jim sending on CPt Icd-9
What is a RAC? The RACS detect and correct past improper payments so that CMS, Carriers, FI and MACS can implement actions that will prevent future improper payments.
For the RAC review process claims are reviewed on a post payment basis and they use the same Medicare policies as the claims processing contractors. Such as LCD’s and NCD’s.
The RAc contractor for your region is Diversified Collection Services Inc. Be sure to respond to nay requests coming from this company. On this slide we have given you further information on how to contact the RAC.
There are 2 types of reviews: Automated and complex When an overpayment is identified a demand letter is issued by the RAC.
Your a/B MAC receives a demand letter from the RAC and uses the same process they have in place for overpayments.
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