How to Appeal a Medicare Denial

If you have received a claim denial from your Medicare contractor you do have the right to submit an appeal.  If you do not take assignment on the claim, your appeal rights can be limited.

  See section at the bottom on Clerical Reopening when an appeal is not indicated.

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration 

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ) 

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

By clicking here you will find information on the OMHA website.

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.

By clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.

Fifth level of appeal: Judicial review
If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.

• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Additional resources

Within the CMS websites you will find information related to the five levels in the Part A and Part B appeals process.

• CMS Appeals Web resources

• CMS Appeals process flowchart

CMS resource materials available for download

• MLN - The Medicare Appeals Process Brochure

CMS Internet-only manuals: Publication 100-04

• Chapter 29– Appeals of Claims Decisions

• Chapter 34– Reopening and Revision of Claim Determinations and Decisions

Minor errors or omissions on some Part B claims can be corrected for reprocessing using the clerical reopening process.

There are two ways to initiate this process:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone re-openings on certain claims.  For the IVR reopening request help sheet, click here

• For reopening requests in writing, use the clerical reopening .

Common clerical errors consist of:

• Mathematical or computational mistakes

• Transposed procedure or diagnostic codes

• Inaccurate data entry

• Misapplication of a fee schedule

• Computer errors

• Denial of claims as duplicates which party believes incorrectly identified as duplicate

• Incorrect data items such as provider number, modifier, date of service

“Incident to… “What Does That Mean?

Many terms used in the “rules” for medical billing seem like they belong more in a law book, than a billing guide.

 That is how I start to feel when reading about billing “Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service.”

 For my enlightenment and hopefully yours, I have attempted to glean the basics from about 10 pages in section 60 of the Medicare Claims Processing Manual, Chapter 15 “Covered  Medical and Other Health Services”.

 Let’s start with an easy concept: An incident to service or supply is a service or supply not covered in one of the other benefit categories.  The other benefit categories are:

·         Drugs and Biologicals
·         Sleep Disorder Clinics
·         Diagnostic X-Ray, Diagnostic Laboratory and Other Diagnostic Tests
·         X-Ray, Radium and Radioactive Isotope Therapy
·         Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
·         Durable Medical Equipment
·         Prosthetic Devices
·         Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
·         Therapeutic Shoes for Individuals with Diabetes
·         Dental Services
·         Clinical Psychologist Services
·         Clinical Social Worker (CSW) Services
·         Nurse Midwife (CNM) Services
·         Physician Assistant (PA) Services
·         Nurse Practitioner (NP) Services
·         Clinical Nurse Specialist (CNS) Services
·         Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech Language Pathology Services) Under Medical Insurance

 To see the details of services that fall into these benefit categories, you can access the Medicare Claims Processing Manual, Chapter 15 by clicking here.

Well, now that has narrowed things down quite a bit. Let’s look at the next part that makes a service or supply “incident to”.  It is considered:

·         Integral to the performance of the *physician’s professional service
·         Commonly rendered without a separate *physician fee and furnished in *physician’s offices or clinics

 Supplies commonly considered “incident to”: gauze, ointments, bandages, oxygen

·         Furnished by the physician or by **auxiliary personnel under the *physician’s *** direct supervision

 Services of auxiliary personnel are considered incidental to a physician service when they assist in rendering the service, and the charge is included in the physician’s bill.  This also applies if auxiliary personnel perform a subsequent service as part of a course of treatment initiated by the supervising physician.

*Physician: includes physician, physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, clinical psychologist.

**Auxillary Personnel:  personnel whether employee, leased employee, or independent contractor that acts under the supervision of a physician.  May include services by Non-physican practitioners: certified nurse midwives, clinical phychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialitsts.

***Direct supervision: the physican must be present in the office suite and immediately available to assist the auxiliary personnel in preforming the service.

Special Rules for Homebound Patients and Incident to Services

In medically underserved areas the shortage of medical personnel to provide certain medical services to homebound patients allows for an exception to the direct supervision rule.  In these circumstances, nurses, technicians and other physician extenders may provide these services under the *general supervision requirement instead of the direct physician supervision requirement.

*General supervision means that the physician is not physically present at the place of residence when the service is performed, but is under his/her overall supervision and control.

Services that can be covered incident to under general supervision: Injections, venipuncture, EKGs, therapeutic exercises, insertion and irrigation of sterile catheter, changing of catheters and collection of catheterized specimen for urinalysis and culture, dressing changes, replacement and/or insertion of nasogastric tubes, removal of fecal impaction, sputum collection for stain and cultures, paraffin bath therapy for hands and/or feet, teaching and training the patient for care of colostomy, ileostomy, or tracheostomy, testing urine, care of diabetic feet and blood pressure monitoring.

The specific criteria for “Service Incident to a Physician’s Service to Homebound Patients under General Physicians Supervision”:

·         The patient is *homebound

*Homebound: a patient is considered homebound if they possess a normal inability to leave home, such that leaving the home would require a considerable and taxing effort.

·         The service is an integral part of the physician’s service to the patient and done under general physician supervision.

·         The physician orders the service, maintains contact with the employee and upholds all responsibility for the service.

·         The physician or clinic has an associated expense and their bill includes the fee for the rendered procedure.

·         Any service performed is medically necessary and reasonable and unavailable by a Home Health Agency.

Medicare Incentives for EHR and PQRS

Ideally, the only responsibility of a physician is to provide the best care to his/her patients.    Unfortunately, medicine is a business, so the topic of reimbursement will always rear

its ugly head.

Providers of Part B services on the MPFS can increase reimbursement and avoid future penalties by taking advantage of Medicare incentives for EHR and PQRS reporting.  Below you will find guidance on

both of these programs to help improve your bottom line.

To qualify for Medicare PQRS incentive payments, EPs must sufficiently report on the applicable quality information measures.  In the PQRS 2013 program, there are several hundred measures.

 To help navigate through this complex process, you can access the “Getting Started” page of the CMS PQRS website by clicking here.

Advanced Practice management software like Iridium Suite, has an integrated PQRS claim scrubber.  The practice can configure the medical billing system to automatically request that the physician sets up PQRS measures for each patient. The claim scrubber also recognizes which billing codes are potential PQRS denominators and automatically suggests the PQRS numerator codes that should be added to the claim. The biller simply accepts these suggestions and the claim scrubber automatically adds the proper PQRS charge codes to the claim.

  To qualify for the Medicare EHR incentive payments eligible professionals (EPs) must utilize certified meaningful use EHR technology. Proof of meaningful use can only be demonstrated by reporting clinical quality measures (CQMs) as well as the meaningful use measures.

Providers wishing to purchase certified EHR software can access a list of options on the CMS site by clicking here.

 In 2013, EPs may satisfy the meaningful use objective to report CQMs to CMS by reporting them through:

• Medicare and Medicaid EHR Incentive Programs’ web-based Registration and Attestation System

EPs who choose to report CQMs through the CMS Attestation system must still report information on individual quality measures or measure groups using one of the four reporting options in order to also participate in PQRS.

• Participation in the PQRS-Medicare EHR Incentive Pilot, which utilizes the 2013 PQRS EHR Measure Specifications.

 EPs who participate in the pilot may submit their meaningful use objectives through the CMS Attestation system, and then complete a single submission of CQMs to receive credit for both programs.

EPs who successfully participate in PQRS and EHR can receive an incentive in 2013 and avoid the 2015 payment adjustment for both programs.

Participating in both the PQRS and EHR programs in 2014 and beyond is being simplified by CMS with the alignment of several of key components.

Here are the changes affecting PQRS and EHR in 2014:

• PQRS and EHR programs will align on the same set of eCQMs (64 total) and the same electronic specifications
• All Medicare-EPs beyond their first year of demonstrating meaningful use will be required toelectronically report their CQM data to CMS for the EHR program
• Submitting data electronically using 2014 certified EHR technology will meet the standards forboth EHR and PQRS programs
• Participating EPs will have the option to submit patient-level data (via QRDA I) or aggregate data (via QRDA III) using the same reporting mechanism for electronic reporting for both programs.

Click here to read about how your EHR can communicate with your medical billing software.

Get Your Comments Ready: Proposed Changes to the 2014 Medicare Physician Fee Schedule

The Proposed Rule that details changes affecting the Medicare PFS will be published July 19, 2013 in the Federal Register.  This begins the comment period that continues until Sept. 6, 2013.

If you want to participate in the comment process, you need to start somewhere.  The best place is here, with a brief description of the key elements in the proposal.

Telehealth Services: These services would be expanded to include areas designated as health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy.  Additionally, transitional care management services would be considered eligible telehealth services.

Revisions To The Practice Expense Geographic Adjustment:  PFS rates are calculated based on numerous factors as required by the Medicare law. The main goal is to adjust payments according to geographic differences in practice costs.  To accomplish this, CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice cost components of each of more than 7,000 physicians’ services.   The proposed changes to the GPCIs would be phased in over 2014-2015 and are:

• New GPCIs using updated data as required by law every 3 years.

• Changes to the weights assigned to each GPCI (work, PE and malpractice) consistent with the recommendations of the Medicare Economic Index (MEI) Technical Advisor Panel (see below) that increases the weight of work and reduces the weight of practice expense.

• The proposed GPCIs reflect the elimination of the work “floor” and as a result 51 localities will have a work GPCI below 1. 

Medicare Economic Index: MEI, the price index used to update the PFS for inflation, and sustainable growth rate are used in when calculating the total payment amounts in the PFS.  The proposal reflects 2012 recommendations by a Technical Advisory Panel CMS that will revise the calculation of the MEI as well as changes in the RVU and GPCI weights assigned to work and practice expense to align with the MEI.

   Miss-valued Codes: CMS as part of the ACA, has identified miss-valued codes requiring adjustment to payment rates.  There are more than 200 codes with proposed rate changes.  These codes currently reimburse higher for services performed in an office versus the fee paid in a hospital outpatient setting or ASC.  The proposed rates would reflect a PFS office place of service reimbursement that is equal to the sum of the reimbursement to the facility and practitioner when service are rendered in an outpatient hospital or ACS place of service.  There have been additional miss-valued codes identified by Medicare Contractors based on claim review that have proposed reimbursement changes.

Application of Therapy Caps to Critical Access Hospitals: They are proposing outpatient therapy services furnished in CAHs are added to the therapy cap limitations.  This would apply two per beneficiary of the following outpatient therapy services:

• physical therapy and speech-language pathology services
• occupational therapy services.

Future change for 2015 included in this proposal:

Primary Care and Complex Chronic Care Management: The proposal would provide for an additional, separate payment for a practitioner that provides non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more).  This is how it would work:

• Coverage is based on the physician development and revision of a plan of care, communication with other treating health professionals, and medication management
• Beneficiaries  would  be required to have an Annual Wellness Visit (or an Initial Preventive Physical Examination (IPPE), if applicable)
• Would apply to a single practitioner that agrees to furnish these services and that obtains the beneficiary’s consent to receiving these services over a one-year period.  
• Medicare would make the separate payment through two G-codes for establishing of a plan of care and furnishing care management over 90-day periods.

Included in the proposal are guidelines to develop practice standards that would support this payment.  This may include requirements like real time access to records via HER and written protocols detailing the care management process.

To access the CMS Fact Sheet click here.

To read the entire proposed rule click here.

July 17th is Bladder Cancer Awareness Day

As part of Bladder Cancer Awareness Day, take the time to get familiar with some general bladder cancer facts.  We will begin with the basic types of bladder cancer and go through symptoms, diagnosis and treatment options.

Bladder cancers can form in many locations in and around the bladder, including the ureters and the lining of the kidneys (called renal pelvis). Bladder cancer cells can penetrate through the different layers of the wall of the bladder.

Bladder tumors are also grouped into several types by the types of cells it contains:

• Transitional cell carcinoma: This is the most common form of bladder cancer, accounting for more than 90 percent of these cancers that begin in the cells lining the bladder.

 Cancer that is confined to the lining of the bladder is called non-invasive or superficial bladder cancer.

• Squamous cell carcinoma: A rare form, accounting for 5 percent of all bladder cancersbegins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation.

Though less common, squamous cell carcinoma can be more aggressive than transitional cell carcinoma.

• Adenocarcinoma: Although rare, these are very aggressive tumors accounting for 1-3 percent of bladder cancers which develops in the inner lining of the bladder as a result of chronic irritation and inflammation.

• Small cell: Extremely rare, approximately 1-2 percent of all bladder cancers.

Patients often are treated with similar therapies as those used for lung cancer.

 The most common risk factors for developing bladder cancer include:

• Smoking
• Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies
• A diet high in fried meats and fat
• Being older, male, or white
• Chronic bladder inflammation (recurrent urinary tract infections, urinary stones)
• External beam radiation
• Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
• Infection with Schistosoma haematobium (parasite found in many developing countries)

Symptoms of bladder cancer frequently consist of:

• Blood in the urine (hematuria) can either be macroscopic or microscopic

Microscopic is typically discovered when blood is found by urine tests done because of other symptoms or as part of a general medical checkup

• Change in bladder habits
• Frequent urination or feeling the need to urinate without being able to do so
• Pain during urination
• Lower back pain

Patients experiencing these symptoms should undergo a complete medical history and general physical exam as well as urinalysis.

If bladder cancer has not been ruled out by exam ad UA, further testing for definitive diagnosis may include:

• Cystoscopy - A urology doctor will insert a cystoscope (thin, lighted tube) into the bladder through the urethra to directly look and examine the lining of the bladder.

In patients with a negative cystoscopy (no evidence of bladder tumor), an intravenous pyelogram (IVP) can be performed.

• Bladder Biopsy - Asample of bladder tissue is examined under the microscope.

This can identify bladder cancers and tell what type of cancer (urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, etc.) is present and how deeply the cancer has penetrated.

• Chest X-ray - A chest X-ray is done to look for any mass or spot on the lungs that might be a metastatic tumor, if it is suspected that the bladder cancer has spread distantly.

• Ultrasound - This is a test that uses high-frequency sound waves creating echoes that are recorded and translated into video or photographic images that are displayed on a monitor.

• Computed tomography (CT or CAT) scan - This is a special X-ray that uses a computer to create a series of images, or slices, of the inside of the body.
• Magnetic resonance imaging (MRI) - This is a test that produces images of the inside of the body using a large magnet, radio waves and a computer.

The cancer treatment for bladder cancer depends on how deeply the cancer has penetrated into the bladder wall, the stage of the cancer (whether it is only in the bladder or has spread to other places), and the patient’s general health.

 Cancer treatments for bladder cancer include:

• Transurethral resection of bladder tumor (TURBT) - This is the most common cancer treatment procedure for early stage or superficial cancers where the tumor is removed via cystoscope.

This procedure can be repeated if patients have superficial tumor recurrences.

• Intravesical therapy - Cancer treatment that is placed directly into the bladder through a catheter is immunotherapy. Bacillus Calmette-Guerin (BCG) is considered to be quite effective for treating low-stage bladder cancer. BCG is placed into the bladder stimulating the body's immune system to destroy bladder cancer cells.

Other intravesical therapies include interferon (immunotherapy) and mitomycin C (chemotherapy).

• Cystectomy - When the bladder cancer has invaded the muscle wall of the bladder, the recommended cancer treatment is to remove the entire bladder and nearby lymph nodes.

In men, the prostate is also removed. In women, the uterus (womb), ovaries, a small portion of the vagina and fallopian tubes (tubes that connect the ovaries and uterus) are often removed with the bladder.

• Radiation therapy - This is a cancer treatment that uses high-energy rays (such as X-rays) to kill cancer cells. It is usually delivered from the outside of the body (external beam radiation), and it is routinely performed as an outpatient treatment. It is usually given daily (each session lasting for approximately 20-25 minutes) daily for up to five to seven weeks.

It can also be given with weekly chemotherapy (low-dose) with the goal of enhancing the killing effects of the radiation.

• Systemic chemotherapy - This therapy uses drugs that kill cancer cells via the bloodstream. Chemotherapy is most commonly used once the cancer cells have spread beyond the bladder to distant organs (i.e. lungs or liver).

 There is evidence to suggest that giving chemotherapy before or after removal of the bladder may decrease the likelihood of cancer spreading after surgery.