POE Advisory Group Details

8/8/2024 J6/JK Part A and FQHC POE Advisory Group Meeting

Meeting Minutes

Meeting Time: 9:30-11:30 a.m. ET

Member Attendees: Mary Altieri, Louise Bertrand, Kimberly Bischel, Corey Bowe, Kafi Cook, RaeAnn Couture, Amy Fanelli, Matthew Felton, Nancy Fleenor, Christine Leibold, Vera Loftin, Sara Luther, Catherine Nolin, Nancy Richman, Anna Santoro, Joanne Schade-Boyce, and Liz Salnier

National Government Services Associates: Ola Awodele, Connie Arszman, Stephanie Boucher, Laura Brown, Adela Deal, Michael Dorris, Emily Fox-Squairs, Andrea Freibauer, Jeanine Gombos, Christine Janiszcak, Casey Jones, Nathan Kennedy, Laura Kiker, Cheryl Papalia, Jean Roberts, Susan Stafford, John Stoll, Auburn Sutton-Puckett and Michelle Vannatter-Johnson

Agenda

  1. Welcome, Introductions and Approval of Minutes from Previous Meeting
  2. Updates
  3. Review of Educational Material
  4. POE AG Member Suggestions for Education and Open Forum
  5. Upcoming Events and Additional Education
  6. 2024 Part A and FQHC POE AG Meeting Schedule

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I. Welcome, Introductions and Approval of Minutes from Previous Meeting

Jean Roberts, POE Consultant, NGS

Jean welcomed everyone to the meeting. She advised that Christine Janiszcak and other NGS staff are on the line, everyone received a link to the handouts and an agenda is in the webinar handout box. She asked for questions/comments on the 4/4/2024 meeting minutes and received none.         

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II. Updates

Part A CERT Update

Laura Brown, POE Consultant, NGS

Laura reviewed Handout 2, the CERT Update slides, and reminded everyone not to share any internal unofficial error rates outside of the meeting: 

  • On slide 2 is the J6 CERT data for the 11/2024 reporting period (claims received 7/1/2022-6/30/2023).
  • On slide 3 are the J6 error codes, code definitions and number of claims for each error.
  • On slide 4 is the JK CERT data for the 11/2024 reporting period (claims received 7/1/2022-6/30/2023).
  • On slide 5 are the JK error codes, code definitions and number of claims for each error.
  • On slide 7 is a picture of the envelope for the letter CERT uses to request medical records. You can post this in your offices so everyone can identify and route these requests to the correct person/area in your facility.
  • On slide 8 is a picture of page 1 of the CERT letter. CERT assigns each claim they select CID, which is the tracking number for the claim. Page 1 briefly describes the CERT program, identifies the claim’s CID, provides the reason for record submission, medical records required, due date and consequences if you do not send them. 
  • On slide 9 is a picture of page 2 of the CERT letter. Page 2 starts with special instructions about the records and informs you of the ways to submit records to CERT. You can direct questions about the medical records requested to the CERT Documentation Center; their contact information is at the bottom of the letter.
  • On slide 10 is a picture of page 3 of the CERT letter. It contains the claim information, patient’s information, DOS and services on the claim that were selected. Review this page since you must submit all medical records for all DOS and procedures indicated.
  • On slide 11 is a picture of page 4 of the CERT letter, the barcoded coversheet. This must be on top when you are sending the CERT contractor medical records. Providers can complete the section to indicate who CERT can contact if they have questions about the medical records. This sheet may have a list of documents that may be required for the services. At the bottom of the page is the CERT Documentation Center address.
  • On slide 13 is a link to CERT’s C3HUB website and a view of the front page of the website. 
  • On slide 14 is a list of the CERT topics on the C3HUB website. Once you receive the original request, you can contact CERT and ask them to send future letters, for that same claim, to a certain person or unit. And if you have a large group and want all original requests to be sent to a certain person or unit, you can join the chain address program information found under the Letter and Contact Information. The status of the claim selected is under Claim Status Search, which is where you can determine if CERT received the medical records or if their review is complete.  If complete, it also identifies the MAC CERT Team member name and number you can use if you have questions about the next step. The CERT Documentation contractor contact information is at the bottom.
  • On slide 15, we explain how to do a claim status search on the C3HUB website. To find the status of the claim or medical records or to find the MAC’s CERT team member’s name and number, enter the CID number from the CERT letter on the Claim Status Search tool.  
  • On slide 16, we explain documentation lists. If you are unsure what documentation should be submitted, review your letter.
  • On slide 17 is a sample of a documentation lists. The document description will be in English and Spanish. Review the list and send in all medical records for the services on the claim.  
  • On slide 19 is the CERT contact information. You may use the mailing address, fax number or medical record email address to respond to the CERT ADR. If you have questions about the documentation CERT is requesting or want requests sent to a different address, contact the CERT contractor; information is on the C3HUB website. 
  • On slide 21 is information about our website. We have a dedicated page for CERT material with CERT alert articles, tools as well as documentation submission responsibilities. A CERT Task force consisting of the CMS, CERT contactor and all Part A & Part B MACs was created. We met and created articles to post nationwide to help prevent CERT errors. The CERT Denial Reason Finder tool will provide details of the CERT errors if you enter the CID number.  
  • On slide 22 is a view of our CERT web page. 
  • On slide 23 is a view of our CERT Denial Reason Finder tool. The tool, once you enter the CID number will display if there is an error or not and provides the details.  
  • On slide 24 is an example of the CERT Denial Reason Finder results. If it states review completed and NO under Claim in Error, there is no error. If it states review completed and YES under Claim in Error, the details about the error follow. When you receive the additional payment or overpayment letter, both are considered errors.  You can use the tool, determine if you agree or disagree with the error and appeal using the Medicare appeal process.    
  • On slide 26 is information about the role of providers. We begin with some tips to assist you in the CERT process. Providers should determine who in the office will receive and respond to the CERT requests, verify all addresses are current in the Medicare enrollment records so letters are sent to the correct address. Note that updates to the enrollment record can be made electronically using the Provider Enrollment, Chain and Ownership System (PECOS) or by submitting a paper application. Providers should also respond timely to the CERT documentation request, preferably within 45 days.
  • On slide 27 are additional tips. First, be familiar with documentation requirements for the services billed. We provided several links to identify different areas on websites that explain the documentation requirements for certain services billed. Also, submit all documentation to support all services and DOS on selected claims. You may need to obtain documents from third parties, some records are housed at other sites so either send the CERT request to that facility so that facility can send you the medical records or respond directly to the CERT. You may also contact CERT and give them the contact information of that other facility.
  • On slide 27, we explain that if you reviewed the details of the error on the CERT Denial Reason Finder tool and disagree with the CERT decision of the overpayment or underpayment,  you may appeal using the normal Medicare appeal process and have the error removed.
  • On slide 29, we ask the POE AG, to continue to review the material on our website and forward any suggestions and/or comments to us to improve our dedicated page for CERT material.  

Laura asked for questions. One provider asked how they can send in records via email securely and Laura advised the provider the email must be encrypted and referred them to the CERT website. Jean added that providers could use esMD in addition to the methods Laura had described. Another provider asked why they received some CERT letters in white rather than hot pink envelopes and Laura confirmed the envelopes are white. Jean added that we use hot pink for our MR ADR letters.

Part A Provider Enrollment Update

Susan Stafford, POE Consultant, NGS

Susan reviewed Handout 3, the PE Update slide with the members: 

  • There is no new information for Part A providers. For Part B, there has been an expansion of dental specialties added to the specialty codes as well as for epileptologists on 7/1/2024. 
  • The CMS-855A form, 9/2023 version, now includes REHs as a specialty type including Indian Health REHs. 
  • We suggest you sign up for email notifications on our website to stay up to date with important news and opportunities for educational events. 

Susan asked for questions and received none. 

Prior Authorization: Outpatient Department Prior Authorization Program Update

Stefanie Boucher BSN, RN, Clinical Review Nurse Senior, Clinical Operations, NGS

Stefanie reviewed Handout 4, the OPD PA Program Update slides with the members: 

  • On slide 2 are the most frequent rejection reasons for prior authorization requests which include missing TOBs or invalid TOBs, missing paired botulinum procedure code, invalid Part A PTAN/NPI combinations and unsubstantiated expedited requests.  
  • On slide 3 are details for 2024 ADRs including the number of providers exempt in JK and J6. 
  • On slide 4 are common reasons for pre-ADR withdrawals including change in TOB on the claim vs. what was required on PA requests, Botox claims without PA administration codes, no claims billed, cancelled claims and valid UTN on claims. 
  • On slide 5 is what is expected for exempt providers through 2024. For pre-ADR withdraw letters, the exemption remains in effect for the calendar year. For ADRs, monitor ADR locations and the due dates provided (45 days from issue). The self-service exemption tool will be updated by 12/10/2024. And, withdrawn providers will be able to submit PARs on 12/1/2024.
  • On slide 6 is what to expect for exemption in 2025. New exempt providers are determined by PAR affirmation rate for cases received 1/1/2024-9/30/2024 and exempt notifications will be sent by 11/2/2024. Also, the self-service exemption tool will be updated by 12/10/2024.  
  • On slide 7 is a list of upcoming educational webinars.

Stefanie added that, effective 8/16/2024, CMS is removing two CPT codes from the OPD Facet Joint Injection list of codes: 64492 and 64495. Refer to Removal of Facet HCPCS Codes Prior Authorization Outpatient Department Update.  Also, a new cervical fusion policy went into effect for services on/after 8/1/2024. 

Stefanie asked for questions and received none. 

Medical Review and Case Management Team Update

Cheryl Papalia, MR Nurse Senior and Nurse Educator for Part A CMT, NGS

Cheryl reviewed Handout 5, the MR and CMT Update slides with the members: 

One provider commented that they have received requests from NGS in white rather than pink envelopes and asked if something has changed? Cheryl explained we are still sending our MR requests in pink envelopes but will look into this.  Update: We learned that TPE notification letters and results letters are being mailed in pink envelopes. However, ADR letters were recently mailed out in white envelopes.  We are changing this back to pink envelopes and apologize for any inconvenience this may have caused. We appreciate you bringing this up. The documents are mailed according to the address, not the information within the ADR; therefore, you may get ADRs for multiple TPEs in the same envelope if they were printed/mailed on the same day and going to the same address.

New Provider Education

Jean Roberts and Laura Brown, POE Consultants, NGS

Jean reviewed Handout 6, our Guide for New Providers, with the members.  She explained that we send this document to new providers but that it may also be beneficial to new Medicare staff members at your facilities because it includes information on various topics and resources such as the Fundamentals of Medicare, manuals, guides, FAQ, LCDs/NCDs, forms, general information and education.  Jean asked for comments on the document and received none.  

CGS Durable Medical Equipment Medicare Update

Jean Roberts, POE Consultant, NGS

Jean reviewed Handout 7, the CGS DME Medicare Update slides, with the members as Denise Winsock, Provider Relations Senior Analyst, from the CGS - DME MAC Jurisdiction B was not able to attend this meeting: 

  • On slide 3 is the revised coverage criteria for the lower limb prostheses LCD.  This LCD was recently revised to allow for coverage of the electronic/microprocessor-controlled knee system for Level 2 beneficiaries. Previously, these codes were only applicable to Level 3 beneficiaries and higher.  This revision is effective for claims with DOS on/after 9/1/2024. 
  • On slide 4 is information on the treating practitioner evaluation of the blood gas study for oxygen. One of the criteria for coverage is that the treating practitioner has evaluated the oxygen test results. The DME MACs have recently seen a large number of errors regarding this requirement. To help address this issue, all four DME MACs published an article on 7/3/2024 titled Treating Practitioner Evaluation of the Blood Gas Study for Oxygen.  Some examples to ensure this requirement are met are listed on the slide.  
  • On slide 5 is information on SWO for PAP and RAD masks. The DME MACs received many questions regarding what needs to be included on the order since the beneficiary often switches between either full-face mask or nasal cannula. The medical directors from the DME MACs provided clarification of this issue via the “Dear Physician” letter. The order for PAP or RAD masks may be a general description. 
  • On slide 6 is information about DME MAC and A/B MAC collaborative education.
  • On slide 7 is information about the Community Coach Program. This program is unique to Medicare and provides an unparalleled level of education through collaboration with other MACs. Within each DME MAC jurisdiction, there are a number of A/B MAC contractors. At Jurisdiction B, CGS has aligned members of our POE team with A/B MAC partners to extend education related to prescribing and ordering provider/supplier relationships. If you have questions, you can email Denise.Winsock@cgsadmin.com.         

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III. Review of Education Materials

Quarterly Review of Top Part A Claim Errors

Andrea Freibauer, POE Consultant, NGS 

Andrea reviewed Handout 8, the Top Part A Claim Errors PowerPoint, with the members.  She explained we are conducting quarterly webinars that include the top claim errors which we have now been able to drill down to specific provider types. She explained that not all providers experience all errors but we do look for common threads so we can discuss as many reason codes as possible with a variety of provider types attending these webinars.  She asked the members to review each slide and provide feedback on the format and content and to advise us if they have attended. One provider indicated she did not attend but commented she feels this format is very informative and very helpful to providers.  

Jean suggested that members sign up for our emails to receive notifications about our events. 

Federally-Qualified Health Center Basics 

Jean Roberts, POE Consultant, NGS 

Jean reviewed Handout 9, the FQHC Billing Draft PowerPoint, with the members as Mimi Vier was unable to attend this meeting.  She asked for comments or suggestions and received none. Jean added that members could email her with any feedback. Jean added that there will be an upcoming webinar on FQHC billing in which this presentation will be used.  

Idea/Discussion: NGS Batch Claim Submission 

Jean Roberts, POE Consultant, NGS 

Jean advised the members that we are looking into allowing our Part A providers submit multiple or batch claims in NGSConnex and wanted to know if anyone would be interested. One member responded that she is unsure of what their billing department would think of this option but will ask them and send Jean an email. Another provider asked if this is for a short time period such as only through the end of the year. Jean replied that we are just exploring this option with no particular timeline. Another provider asked what a batch is and if the providers would key the claims. Jean explained it is like an EDI batch submission of claims. The provider indicated their facility would probably like to have this option especially if they have problems with their clearing house.  Jean asked the members to email her with any feedback. 

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IV. POE AG Member Suggestions for Education and Open Forum

Jean Roberts, POE Consultant, NGS

J6 and JK POE AG Education Tracker

Jean reviewed Handout 10, the POE AG Education Tracker, with the members:

  • We have received some great ideas in the last few meetings.
  • For CAH Method II billing education, we are working on this request and apologize for the delay.
  • For the SNF PDPM calculator, we felt, rather than including this on our website, this would be better as a global tool and have submitted a request to the CMS asking them to consider updating their version to include the provider’s suggestions.  We will keep you updated.  
  • For the additional suggestions, we had sent requests for more details but did not receive responses and we have closed out the requests.  We will open the requests once again if we receive the requested details.  You may email me the information.  

Member Ideas for Education and Next Virtual Conference 

Jean asked for new suggestions for education including topics for our Fall Virtual Conference.  

One member requested post-PHE education on behavioral health, physical therapy and nutritional therapy as sometimes it is not clear if the CMS is speaking to hospitals or physicians in their instructions. Jean asked the provider to send her the CMS resources she feels are unclear. She also referred the provider to the resources slides of the post-PHE webinar she conducted in 2023 which the provider indicated she had attended. 

Another provider had requested education on the LCD retirement process as well as on the off-label drug LCD. Jean explained we will be conducting education again on LCDs/NCDs and she will ask the consultants to include information on the retirement process. She explained CMS is conducting national education on LCDs/NCDs including the retirement process which is very helpful. The provider then clarified that they would like to suggest education on the medical use of chemotherapy. Jean will add this to the education tracker. 

Another provider explained she is having trouble finding information on add-on codes for different procedures which are matched, and which are not matched.  She looked at the CMS’ NCCI list and explained that there are three different types of add-on codes and type two states the MAC is supposed to create their own list of matched codes yet, she cannot find this information on our website.  Jean added that we will be doing another NCCI webinar. However, she added that the provider can send the reference to her for review. 

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V. Upcoming Events and Additional Education

Jean Roberts, POE Consultant, NGS 

Jean explained that rather than listing all of our upcoming educational events in our agenda, she is asking everyone to routinely check our website events page for educational events. 

VI. 2024 Part A and FQHC POE AG Meeting Schedule 

Jean Roberts, POE Consultant, NGS

Jean reminded everyone the next meeting will be held on 12/5/2024, 9:30 a.m.–11:30 a.m. CT/10:30 a.m.–12:30 p.m. ET. She explained the meeting will be held via Teams with no pre-registration and members can attend even if you do not have Teams because we provide you with a dial-in number.  

Jean then reviewed the rest of the references listed on the agenda. 

Meeting adjourned