Saturday, August 22, 2015

Difference between ICD 9 – ICD 10

Difference Between ICD 9 - ICD 10
Basic Information about ICD 9: The United States Implemented ICD 9 in 1979. But most of the countries moved to ICD 10 several years ago, it’s time for United States medical history to reflect modern Medical terms. 

Code set differences

ICD-9-CM codes are very different than ICD-10-CM/PCS code sets:
  • There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3
  • There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM
  • ICD-10 has alphanumeric categories instead of numeric ones
  • The order of some chapters have changed, some titles have been renamed, and conditions have been grouped differently
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
No Laterality
Laterality –
Right or Left account for >40% of codes
3-5 digits
  • First digit is alpha (E or V) or numeric
  • Digits 2-5 are numeric
  • Decimal is placed after the third character
7 digits
  • Digit 1 is alpha; Digit 2 is numeric
  • Digits 3–7 are alpha or numeric
  • Decimal is placed after the third character
No placeholder characters
“X” placeholders
14,000 codes
69,000 codes to better capture specificity
Limited Severity Parameters
Extensive Severity Parameters
Limited Combination Codes1 type of Excludes Notes
Extensive Combination Codes to better capture complexity

2 types of Excludes Notes


Saturday, August 8, 2015

Coding guidelines for part b hospice GV and GW

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his terminal illness during the period his hospice benefit election is in force, except for professional services of an “attending physician” who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. Professional services of an “attending physician” are submitted with the GV modifier if all conditions are met (description below). Any services provided to a patient enrolled in hospice that are not related to the treatment and management of the patient’s terminal illness are submitted with the GW modifier (description below).

For purposes of administering the hospice benefit provisions an “attending physician” is defined as follows (must meet all requirements):

An individual who is a doctor of medicine, doctor of osteopathy or a nurse practitioner.
Is identified by the beneficiary as having the most significant role in the determination and delivery of his medical care at the time hospice coverage is elected.
Is not an employee of the hospice and does not receive compensation from the hospice.
The following applicable modifiers must be used when billing for services of a patient enrolled in hospice. The appropriate modifier usage will depend on who is providing the service, what services are being provided and if the services are for/related to the reason the patient is enrolled in hospice.
GV Modifier
Attending physician not employed or paid under arrangement by the patient’s hospice provider
This modifier should be used by the attending physician when the services are related to the patient’s terminal condition and are not paid under arrangement by the patient’s hospice provider. Also, this modifier must be submitted when a service meets the following conditions, regardless of the type of provider: 
The service was rendered to a patient enrolled in a hospice.
The service was provided by a physician or non-physician practitioner identified as the patient’s attending physician at the time of that patient’s enrollment in the hospice program. 
Do not submit the GV modifier in the following conditions:                        
The service was provided by a physician employed by the hospice.
The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his attending physician.

GW Modifier
Service not related to the hospice terminal condition
This modifier should be used when a service is rendered to a patient enrolled in a hospice and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when:
The service(s) provided are unrelated to the patient’s terminal condition.
Claims are submitted for treatment of a non-terminal condition to the Part A MAC with condition code 07.
The following charts should be used to determine when the services of a hospice patient should be covered and when to report the appropriate modifiers.

Medicare pre-authorization

Recently, Novitas Solutions has received numerous requests to provide pre-authorization for surgery scheduled to occur within days. Traditional Medicare does not provide pre-certification or pre-authorization of a surgery. Medically necessary services should not be withheld or delayed.

Medically necessary services that have been provided to the patient are billed to Medicare for consideration and processing. If a service is denied, the provider and the patient have a right to request a redetermination of the denial.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meet all technical requirements for coverage, but are determined to be any of the following:

Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used;
Not proven to be safe and effective based on peer review or scientific literature;
Not medically necessary in the particular case;
Furnished at a level, duration or frequency that is not medically appropriate;
Not furnished in accordance with accepted standards of medical practice; or
Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
To be considered medically necessary, items and services must have been established as safe and effective. That is, the items and services must be:

Consistent with the symptoms or diagnosis of the illness or injury under treatment;
Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational);
Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; and
Furnished at the most appropriate level that can be provided safely and effectively to the patient.

Thursday, July 2, 2015

Internet based PECOS submission

Medicare Novitas is currently receiving a high volume of duplicate certifications/signatures for Internet-based PECOS (Provider Enrollment, Chain and Ownership System) CMS-855  submissions.  This is a result of customers submitting both an electronic signature and a hardcopy/paper certification.  When submitting an application via Internet-based PECOS, please elect only one method of submitting your signature; electronic OR hardcopy.  For additional details, please review Novitas educational article titled “Internet-based PECOS Signature Submissions” on our website in the Enrollment Center.  

When submitting an application via Internet-based PECOS, please elect one form of signature submission.

1. Electronic Signature: Internet-based PECOS allows for the provider or Authorized/Delegated Official to electronically sign the application submission. Utilizing the electronic signature process will ensure faster application submission, resulting in an earlier effective date.  This feature does not change who is required to sign the application.


2. Hardcopy Certification Statement: After the ‘Submission Receipt’ page appears, the user will be notified to print the 2-page Certification Statement to be signed, dated and mailed to the Medicare Administrative Contractor. Please do not submit your certification using the certification pages from the paper CMS-855 enrollment applications.

Tuesday, September 2, 2014

Claim rejected for DME length of Medical Necessity

DME is equipment that can withstand repeated use, is primarily used for a medical purpose, and is not generally used in the absence of illness or injury. Examples include hospital beds, wheelchairs, and oxygen delivery systems. Medicare will cover medical supplies that are necessary for the effective use of DME, as well as surgical dressings, catheters, and ostomy bags. However, Medicare will only cover DME and supplies that have been ordered or prescribed by a physician. The order or prescription must be personally signed and dated by the patient's treating physician. 

DME suppliers that submit bills to Medicare are required to maintain the physician's original written order or prescription in their files. The order or prescription must include: 

o the beneficiary's name and full address;
o the physician's signature;
o the date the physician signed the prescription or order;
o a description of the items needed;
o the start date of the order (if appropriate); and
o the diagnosis (if required by Medicare program policies) and a realistic estimate of the total length of time the equipment will be needed (in months or years). 

For certain items or supplies, including supplies provided on a periodic basis and drugs, additional information may be required. For supplies provided on a periodic basis, appropriate information on the quantity used, the frequency of change, and the duration of need should be included. If drugs are included in the order, the dosage, frequency of administration, and, if applicable, the duration of infusion and concentration should be included. 

Medicare further requires claims for payment for certain kinds of DME to be accompanied by a CMN signed by a treating physician (unless the DME is prescribed as part of a plan of care for home health services). When a CMN is required, the provider or supplier must keep the CMN containing the treating physician's original signature and date on file.
Generally, a CMN has four sections:
  • Section A contains general information on the patient, supplier, and physician. Section A may be completed by the supplier.
  • Section B contains the medical necessity justification for DME. This cannot be filled out by the supplier. Section B must be completed by the physician, a non-physician clinician involved in the care of the patient, or a physician employee. If the physician did not personally complete section B, the name of the person who did complete section B and his or her title and employer must be specified.
  • Section C contains a description of the equipment and its cost. Section C is completed by the supplier.
  • Section D is the treating physician's attestation and signature, which certifies that the physician has reviewed sections A, B, and C of the CMN and that the information in section B is true, accurate, and complete. Section D must be signed by the treating physician.Signature stamps and date stamps are not acceptable.
By signing the CMN, the physician represents that:
o he or she is the patient's treating physician and the information regarding the physician's address and unique physician identification number (UPIN) is correct;
o the entire CMN, including the sections filled out by the supplier, was completed prior to the physician's signature; and
o the information in section B relating to medical necessity is true, accurate, and complete to the best of the physician's knowledge.

Saturday, August 30, 2014

Unemployment Insurance (UI)

September 1st 2014 is the US labor day, The Department of Labor's Unemployment Insurance (UI) programs provide unemployment benefits to eligible workers who become unemployed through no fault of their own, and meet certain other eligibility requirements.

In the United States unemployment benefits generally pay eligible workers between 40-50% of their previous pay. Benefits are generally paid by state governments, funded in large part by state and federal payroll taxes levied against employers, to workers who have become unemployed through no fault of their own. This compensation is classified as a type of social welfare benefit.

Eligibility :

In order to receive benefits, a person must have worked for at least one quarter in the previous year and have been laid-off by an employer. Workers who were temporary or were paid under the table are not eligible for unemployment insurance. If a worker quits or is fired they are not eligible for UI benefits. There are five common reasons a claim for unemployment benefits are denied: the worker is unavailable for work, the worker quit his or her job, the worker was fired, refusing suitable work, and unemployment resulting from a labor dispute. In practice, it is only practical to verify whether the worker quit or was fired.

Generally, the worker must be unemployed through no fault of his/her own although workers often file for benefits they are not entitled to; when the employer demonstrates that the unemployed person quit or was fired for cause the worker is required to pay back the benefits they received. The unemployed person must also meet state requirements for wages earned or time worked during an established period of time (referred to as a “base period”) to be eligible for benefits. In most states, the base period is usually the first four out of the last five completed calendar quarters prior to the time that the claim is filed. Unemployment benefits are based on reported covered quarterly earnings. The amount of earnings and the number of quarters worked are used to determine the length and value of the unemployment benefit. The average weekly in 2010 payment was $293.

Medicare Immediate Recoupment

Whether the provider, Novitas Solutions, or another entity identifies an overpayment, the overpaid funds must be reimbursed to Novitas Solutions in one of the following ways:

A.  Immediate Recoupment as a Means to Repay Medicare Debt - Part A and Part B

The immediate recoupment process is for providers who have received an overpayment demand letter and are actively billing Medicare.  Immediate recoupment is not an alternative for sending a voluntary refund to Medicare.

You may elect to have your overpayment(s) repaid through the immediate recoupment process and avoid paying by check or waiting for the standard recoupment that begins automatically on day 41 from the date of the initial demand letter.  A request for immediate recoupment must be received by Medicare in writing no later than 16 days from the date of the overpayment demand letter. You must specify whether you are submitting: 

1. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments
2. A request for all invoices included in only the current overpayment demand letter received
The immediate recoupment process is optional and for your convenience.   You may find savings in check printing and postage since you are requesting to have your Medicare overpayment(s) withheld from your future Medicare claim payments.
Any principal balance remaining after the initial immediate recoupment attempt will continue to accrue interest and continue in the recoupment process and other collection activities until the overpayment is satisfied.   You may fax your immediate recoupment request directly to the following fax numbers:
Part A fax line: (412) 802-1836 
Part B PA/NJ/MD/DC/DE providers may fax to: (717)-728-8722 
Part B AR/CO/LA/MS/NM/OK/TX providers may fax to: (717)-728-8728 
As stated above, there are two immediate recoupment request options available: 

3. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments
4. A request for all invoices included in only the current overpayment demand letter received

If you select option 1 above, for future overpayments the immediate recoupment process will automatically begin on day 16 from the demand letter dates (assuming the provider has paying claims).  The 16 day timeframe allows for the 15 day rebuttal period. 
If you select option 1 above, you can later fax or mail a written request to Medicare to discontinue participation in the immediate recoupment process at anytime.  Allow Novitas Solutions, Inc. 10 business days from receipt to stop the immediate recoupment process. 
If you select option 2 above, please note that the immediate recoupment process will occur at the demand letter level through our  current process which will not allow offset to begin until day 16 from the demand letter date (assuming the provider has paying claims).  The 16 day timeframe allows for the 15 day rebuttal period. 
A request for immediate recoupment must be in writing and may be submitted by fax or regular mail.  We do not currently offer the option for you to email us your request.  Novitas Solutions, Inc. preferred method is to recommend utilization of the fax process to insure efficiency, timeliness, and to decrease costs.  Please refer to the fax numbers listed above including separate fax numbers for Medicare Part A versus Medicare Part B.   Your request for immediate recoupment must include the following when submitting your request:

Your name and contact phone number (include area code)
Your Provider Transaction Account Number (PTAN)
Your National Provider Identification (NPI)
Your Provider signature or CFO’s signature authorizing the request
The Overpayment Demand Letter number located on the 1st page, at the right top of page
Identify which option you are requesting. 
Your request must specifically state you understand you are waiving potential payment of interest pursuant to Section 1893(f)(2) for overpayments.   Such interest may be payable for certain overpayments reversed at the Administrative Law Judge level or subsequent levels of appeal (935 Overpayments).