POE Advisory Group

3/13/2025 Part B POE Advisory Group Meeting

Meeting Minutes

Meeting Time: 10:00 a.m.‒12:00 p.m. ET

Member Attendees: Doris Barnes, Aurelia Barraco, Brenda Bedard, Sheila Bembeneck, Madelon Berger, Todd Bergstrom, Kimberly Bischel, Mollie Brooks, Tami Carter, Bridget Charrier, Ilka Collier, Eileen Conlan, Renay Coonan, Pam D’Apuzzo, Lisa Dolbert, Elizabeth Fitzgerald, Darren Goodwin, Deborah Gregoire, Martha Harris, Christie Hewson, Stephanie Hirst, Cindy Kennedy, Kevin Kile, Jenny Kovich, Maud Lawrence, Vera Loftin, Sara Luther, Kristen McCormick, Natasha Moser, Ashley Mui, Sheila Mulka, Joyce Nurenberg, Marcia Pachon, Jane Pine Wood, Mark Polge, Gilbert Rosenblum, Tracy Ross, Debra Rossi, Ken Ryan, Allie Ruffolo, Amy Schaffer, Wendy Shreve, Ekaterina Spirin, Stephanie Thebarge, Kate Tieppo, Katie Watkins, Katie Werner

National Government Services Associates: James Bavoso, Christine Brauer, Laura Brown, Michelle Coleman, Jennifer DeStefano, Michael Dorris, Marc Duerden, Arlene Dunphy, Heather Fitzmaurice, Alicia Forbes, Nathan Kennedy, Linda Klug, Lori Langevin, Phyllis McAdams, Carleen Parker, Michele Poulos, Jean Roberts, Nena Rodrigues, Paul Root, Susan Stafford, Auburn Wheeler

Agenda

  1. Welcome, Introductions and Opening Remarks
  2. IVR Changes Effective 3/14/2025
  3. NGSConnex: Redetermination Notifications
  4. NGSConnex for Medical Review: Discussion and Feedback
  5. 2025 Telehealth Services
  6. Modifier Look-Up Tool: Discussion and Feedback
  7. 2025 Virtual Conference Topics
  8. Open Discussion
  9. 2025 Meeting Dates

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I. Welcome, Introductions and Opening Remarks

Lori Langevin, POE Consultant, NGS and Jim Bavoso, POE Manager, NGS

Lori welcomed the members to the meeting and thanked them for joining. Lori advised she was the facilitator for the meeting, along with Christine Brauer and Jim Bavoso, our manager. Other POE department staff and NGS staff are also on the call.

Lori stated members should have received the Teams invite with a link to the meeting and an email with the agenda and materials for today’s meeting. Lori reviewed the agenda and turned it over to Jim for opening remarks. Jim welcomed the members, thanked them for their feedback, and reminded them of the purpose of this meeting. Jim also reminded the members these meetings cannot be recorded or taped and AI note taking was not permitted, it is against federal regulations. If AI note taking was turned on, it needed to be turned off.

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II. IVR Changes Effective 3/14/2025

Jim Bavoso, POE Manager, NGS

Jim advised the members CMS requested MAC to remove eligibility and Medicare Advantage information from the IVR. However, this information is available in our secure online portal NGSConnex. This change is scheduled to go into effect 3/14/2025, and we do not foresee this being an issue going forward.

Lori added to get the word out, we included this information in our webinars and participating events. We have heard most providers currently use NGSConnex to obtain this information or they have an electronic transaction to do this. Members were asked if they foresee any problems with this change.

POE AG Member Feedback: No feedback was provided.

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III. NGSConnex: Redetermination Notifications

Carleen Parker, POE Consultant, NGS

Carleen advised the members we are instituting a new process that will streamline the appeals redetermination decision letters and asked members to share the information with their organization(s). Carleen shared a short presentation with the members. The members were reminded of the five levels of appeals, level one (redeterminations) is conducted by the MAC and levels two through five are not so please do not send those to NGS for processing.

The redetermination decision letters will now only be available to you via NGSConnex when you initiate a redetermination through the NGSConnex portal. If you continue to submit your redetermination request through the mail, you will receive a decision letter hard copy through the mail, this process is not changing. You can, however, still view that paper submitted redetermination letter in the portal. Beneficiaries will still receive a hard copy of the decision letter.

Decision letter types and outcomes include:

  • Dismissed Redetermination – Late or incomplete request will receive a letter with the reason for dismissal
  • Unfavorable Redetermination – Letter sent with explanation why the appeal is upheld
  • Partially Favorable Redetermination – Letter sent with explanation of what services were allowed and other services upheld
  • Fully Favorable Redetermination – No letter is sent as the remittance advice will show the full claim adjustment

How will you know when the decision is completed? You will receive a message notification advising the letter is available in the NGSConnex portal.

What is new in the NGSConnex portal pertaining to this streamlined process? New messages will display when a user initiates a redetermination in the portal, advising the letter will only be available in NGSConnex.

Before you submit your redetermination request you will be prompted to agree to receiving your letter in the portal, and you check that box (I agree) and then submit your redetermination request. This was added to remind the user they will not get a hard copy decision letter when redetermination requests are submitted electronically through NGSConnex.

Once your redetermination request has been submitted you also receive a verification message advising your request was successfully submitted. The message includes the date and a reminder your decision letter will only be available through the NGSConnex portal.

These changes will go into effect the end of the month. We remind you to allow 60 days for the appeal to process. If you cannot access the letter or do not see it, we suggest checking your browser to be sure you are using a compatible browser. Also, if your NGSConnex LSO has not approved access to your providers accounts you will not be able to see it. All users who have been granted access to the provider or groups accounts by their LSO can view the decision letter even if another staff member initiated the redetermination request.

Once the letter is available you do not automatically get a message at this time. You will have to go back and check on your own. Remember to allow 60 days for the redetermination request to be completed. You may want to make a note on your own calendar to go back and check.

As a reminder, the appeals process is not changing. The only change is if you submit your redetermination request through NGSConnex then you receive your decision letter in the NGSConnex portal.

Members were asked if they might see issues with this or how it might affect their day-to-day operations?

POE AG Member Feedback:

  • That is a great idea.
  • We feel this will benefit us as many of our teams are working remote. Few people in the office to go through paper mail.
  • If person A submits the request can person B see the result letter?
    • NGS Response: Yes
  • A lot of people work with paper. Is that going away?
    • NGS Response: No, if you submit the request by paper, you will still receive a hard copy decision letter in the mail.

Jim reminded members there must be an LSO to grant access to accounts. We recommend two LSOs in case one is out for the day or an extended period of time. The LSO needs to be sure the appropriate NGSConnex users in their offices have the appropriate access and when someone leaves, they need to be sure to remove their access.

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IV. NGSConnex for Medical Review: Discussion and Feedback

Heather Fitzmaurice, POE Medical Review, NGS

Heather addressed the members and requested feedback on Responding to Medical Review ADRs in the NGSConnex when:

  • Finding Letters
  • Looking at the status of medical review claims
  • Challenges
  • Changes or wish list items

POE AG Member feedback:

  • Can we access result letters in NGSConnex for TPE ADRs?
    • NGS Response: Yes, when we mail a letter, you can find it in NGSConnex once that review is complete.
  • Are the TPE letters identifiable in the portal?
    • NGS Response: ADRs are separated by claim ADRs or Medical Review ADRs. Currently all Medical Review ADRs are TPE, those are the only type of Medical Review ADRs right now.
  • It would be helpful if TPE can specifically be identified for ADRs.
    • NGS Response: NGS can suggest that to the NGSConnex team.

Lori asked if there were any questions related to the TPE process in general or would the members like to see the TPE process as a topic for the June meeting. Members agreed yes to add as a topic for the next meeting. Jim added that we do these webinars a couple times a year.

Lori added we could have someone from the NGSConnex team attend the TPE webinars and add more NGSConnex ADR training detail to the TPE webinars. Jen added we can add more step-by-step slides in the education we do for NGSConnex ADR webinars to show how to access and respond to claim or Medical Review ADRs.

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V. 2025 Telehealth Services

Nathan Kennedy, Lori Langevin, POE Consultants, NGS

Lori shared a slide outlining and advising of the Telehealth Extension through 3/31/2025, and what was not changing.

Jim added it will take an Act of Congress to extend this further. There is an extension in the current Budget Bill that would extend this through 9/30/2025 which the house has approved and now it is at the senate level. So, keep an eye on the news and be sure you subscribe to our Email Updates so you can receive updated information as we get it and send it out.

Nathan added that we have heard from a few groups that they have taken action making contingency plans to return to telehealth as it was prior to March 2020. We are wondering if anyone knows if the industry is planning for this?

POE AG Member feedback:

  • We have regular meetings and have manual processes in place. But I do have a question with respect to the behavioral health in person visit. This is all behavioral health providers, right?
    • NGS Response: Yes, anyone who bills behavioral health.
  • We are following this and have heard the extension may be for another six months through 9/30/2025. It is still unknown at this time whether that will pass. We are trying to make providers aware as some did not even know this.
  • Is there any information that says how a government shutdown may impact Medicare, providers and beneficiaries?
    • NGS Response: This usually does not affect the day-to-day processes.
  • A member asked if we do not hear of an update starting 4/1/2025, it goes back to pre-covid rules. Scheduling appointments right now is an issue as we are not sure to schedule telehealth visits.
    • NGS Response: We really cannot tell you what you should do that is something you will have to decide for your business or practice. It is like the fee schedule every year where we do not know if it will be changed or amended. We have to wait for Congress.

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VI. Modifier Look-Up Tool: Discussion and Feedback

Jim Bavoso, POE Manager, NGS

Jim advised that POE is looking to implement a look-up tool for modifiers, and we would like your thoughts or suggestions on this. We have looked at tools currently out on websites trying to decide which one is the best to utilize and what is really needed. Jim shared a number of different websites, including other MACs and what they currently have available as a tool. Jim also shared what we currently have pertaining to modifier education on the NGSMedicare website.

One tool you enter the modifier, key word or show all. It returns the long definition of the modifier and how it works. Another tool asks for modifier, procedure code, date, and type of service (which we really do not use), and if your query is Part A or Part B. It then returns a short description, modifier indicator, effective dates, units, payer indicator and assistant at surgery. These return details can currently be found on our website using the Fee Schedule Look-up tool we have.

Another tool asks for the modifier. The results display a hyperlink which contains a complete write up of the modifier and examples for use. If you choose the option to “Show all” instead of a specific modifier, it returns hyperlinks for each modifier that contain the complete write up and examples.

After looking at these different tools we are trying to decide what we need and how to make ours better than these. Tell us what you would like to see.

POE AG Member Feedback

  • Would like to see a list of all codes the modifier can be used with.
  • Just having the modifier and procedure choice would work.
  • Would like to see indicated if the modifier is a payment modifier and when using more than one modifier which should be listed first (order).
  • Would like fact sheets for each where the descriptions are given, and examples of appropriate and inappropriate use.
  • Less information is better to put in the tool; but do have the fact sheets. Put in the modifier and an explosion of data pops up.

Jim added it would need to be clear that just because you use the tool and get results does not mean your claim will automatically pay. We would have disclaimers attesting to this (yes, it is a valid modifier/procedure combination but not necessarily payable). Please continue to send us suggestions as we build this tool.

Another member indicated they use the AAPC tool, and you get all this information we talked about. So, do we really need this? Basically, we pay for these sites, and would you be opening up a can of worms where you give this for free to providers and others have to pay?

Jim stated that we work from a Medicare standpoint, but we do understand where you are coming from. We have a lot of providers and not everyone uses the AAPC tool. We are trying to create our own tool. We have to worry about our Medicare providers and what we provide. Your practice would have to decide what you use.

Lori also advised the group of the new NCCI Look-up tool we recently developed. We would like to know if you tried it or even know it is out there. Lori showed them where to find it on the website and demonstrated how to use it. We wanted to add this for some time, but we are not getting much activity on it yet.

Phyllis added you can access it from the NGSMedicare website home page under Education/Medicare Topics then choose NCCI. On this page it explains NCCI, contains hyperlinks to resources, edit files and add-on codes, and also has the NCCI Look-up tool explaining how to use it and an example.

We are also possibly looking at adding a look-up tool for MUEs.

POE AG Member Feedback

  • I did try it but had a little trouble it did not seem to give me the results showing when two providers are doing the code combination.
    • NGS Response: Jim indicated you have to remember NCCI edit tables show results where the same provider is billing services at the same operative session on the same beneficiary on a given day. The results we return from the tool are like CMS spreadsheet with the edits. It works the same way as when looking on CMS edit pages.
  • We should be able to put in more codes at one time.
    • NGS Response: The member was advised when you enter a code the results display a column list of the other codes that are included in NCCI edits, so you look through those for your other code(s) being billed.
  • A member stated that sometimes there are discrepancies between NGS and CMS.
    • NGS Response: This should not happen as now we will receive feeds directly from CMS website as it becomes available.
  • Providers did not know where or how to find this information on CMS website.
    • NGS Response: When we have webinars on this topic, we take them out to the CMS website and show them how to find it. This tool is just an extension to that, so we hope providers will use it and find it very helpful. Please be sure to continue to send us feedback on this or any of our tools we have.

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VII. 2025 Virtual Conference Topics

Lori Langevin, POE Consultant, NGS

Lori told the members we are looking for topics and themes for our next Virtual Conference.

Jim added we used to do live two-day in-person sessions and eventually we would like to do that again sometime but with the industry how it is, people cannot leave the office for long periods of time, so we do them virtually. We try to do them topic driven/situation driven.

What topics do you think the general population would be interested in learning and if we should do full day, two days, multiple days, what is best? We know there is such a turnover in office staff even fundamentals may be needed again. We will be doing this in May/June timeframe and will be deciding this over the next few days so if you think of anything else after this meeting, please send it on.

POE AG Member Feedback:

  • You have done such an excellent job covering 99.99% of topics we have brought up. Just more repetition as we do have new members coming in often, so maybe revolving topics.
  • Most people like virtual. It enables all of us to learn more quickly and efficiently, but we do miss in person.
  • E/M – data elements, decision making, split/shared rules and examples based on MDM, counting time spent, audit review of E/M services.
  • Clinical trials
  • Incident to
  • Critical care
  • Chronic care management
  • PIN services
  • Psych services
  • ABNs
  • NGSConnex specific to LSO (We do a number each month right now of different topics)
  • TPE
  • Labs/pathology – independent verses reference labs
  • Ophthalmology – comanagement services
  • Remote therapeutic monitoring
  • LCDs/NCDs
  • Top appeals- what categories/types are appealed most, avoiding appeals

We will take these topics into consideration. Thank you for all this feedback.

Jim added we look at appeals data every month and include that in training. It is usually a targeted provider, and we educate them. Our goal is for providers to get claims in correctly the first time. Top claim denials and rejections for Part B is duplicate claims. We advise these providers and what they need to do, yet they continually have the same issues month after month. We are trying to get them to stop.

Member has a question to the group concerning E/M and the AI modifier for NPPS as they cannot use it for admit/discharge services in a hospital. How are other organizations handling this? Are they not using it? No additional comments on this question from the group.

Nathan indicated this question was posed to CMS and we are waiting response. Everything currently published states it has to be the physician.

Another member shared their frustration with RAC requests and trying to resolve an issue that was paid correctly. The RAC said there was no waste and it was underpaid but it was not and now the money was recouped incorrectly. It is a lot of extra work for all involved. Jim advised we are in the process of setting up partner meetings with Performant and we can bring this up to them.

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VIII. Open Discussion

Lori Langevin, POE Consultant, NGS

Lori opened the floor for open discussion.

A member asked if there was any update to claims denying incorrectly when billed with G2211?

NGS Response: This is for 2025 dates of service and CMS did have an MLN talking about this change for using a 25 modifier on the E/M being billed with the G2211 and other certain Medicare preventive services. There is a production alert on the 2024 dates of service. Jim asked the member to send him claim examples and we will look at it.

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IX. 2025 Meeting Dates

Lori Langevin, POE Consultant, NGS

Lori reminded the members of the 2025 Meeting dates. Please place them on your calendars, and if you have any agenda items, please send them before the next meeting on 6/12/2025.

Remaining meeting dates for 2025:

  • 6/12/2025
  • 9/17/2025
  • 12/17/2025

Lori thanked members for their participation and feedback and the meeting adjourned.

Posted 4/7/2025