If you are like this author, you may be saying, "Please Medicare, no more reimbursement change announcements!" However, after working in the medical industry reimbursement environment for the past 50 years, this author is sure of one thing besides death and taxes: Reimbursement legislation, regulation, and guidance documents are always changing. Therefore, we must continue our vigilance and read and implement all reimbursement changes that pertain to the business of wound care. This article will review 3 recent Medicare announcements that wound care professionals, providers, and suppliers may have missed.
Revised CMS-1500 Paper Claim Form
Although most durable medical equipment (DME) suppliers submit electronic claims, some DME suppliers are still using CMS-1500 paper claim forms. If you are a DME supplier using CMS-1500 paper claim forms, be sure that you are using the correct version: The version number 02/12 should be on the top of the claim form and in the lower right-hand corner of the claim form. Effective August 30, 2017, any other claim form version will be returned to DME suppliers.
Suppliers are responsible either for purchasing their own CMS-1500 claim forms from print vendors or for printing their own forms. If the DME supplier purchases claim forms, they should be sure to order the 02/12 version: Medicare will accept any type (ie, single sheet, snap-out, continuous feed, etc). If the DME supplier prints its own forms, it should follow the specifications developed by the National Uniform Claim Committee. Note: Photocopies of the CMS-1500 claim form are not acceptable.
Revised Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN) Form
Effective June 21, 2017, wound care professionals/providers who provide care to original Medicare (fee-for-service) beneficiaries should be using the revised ABN Form CMS-R-131 that displays the expiration date of 03/2020 on the bottom of the form. The only revision on the ABN Form is language that informs beneficiaries (1) of their rights to the Centers for Medicare & Medicaid Services (CMS) nondiscrimination practices and (2) how to request the ABN in an alternative format if needed. If your wound care practice has not implemented this revised ABN Form, you must do so immediately; the previous version is no longer valid.
Even though Payment Strategies has discussed ABNs numerous times, some new wound care professionals/providers may be wondering, "When should I use an ABN?" The answer is quite simple. Wound care professionals/providers should give an ABN to patients when Medicare normally covers a service/procedure/product, but you believe coverage will be denied for this patient. The ABNs advise beneficiaries, before services/procedures/products are furnished, that Medicare is likely to deny payment. For example, if a physician orders a cellular- and/or tissue-based product for skin wounds that is indicated for the patient's wound type, and the Medicare Administrative Contractor (MAC) in that jurisdiction covers that cellular- and/or tissue-based product for some wound types but not that patient's wound type, the wound care professional/provider should give an ABN to that patient.
Remember that wound care professionals/providers can complete some parts of the ABN in advance (Sections A, D, and F). Before giving the ABN to the patient, take time together to complete Section E with the patient-specific reason Medicare may not pay. Be sure to use words that the patient will comprehend. Then give the ABN to the patient and allow her/him to select one of the options in Section G. Reminder: Wound care professionals/providers may discuss the Section G options with the patient, but may not select the option or tell the patient which option to select.
When a patient is notified in advance that a service/procedure/product may be denied as not medically necessary, the wound care professional/provider must annotate this information on the claim (both paper and electronic) by reporting (with the service/procedure/product) either modifier GA, waiver of liability statement on file, or modifier GZ, item or service expected to be denied as not reasonable and necessary. This author has spoken to numerous wound care professionals/providers who provided ABNs to their patients, who still wanted the service/procedure/product and selected that option in Section G. However, the wound care professionals/providers failed to report modifier GA on their claim forms and had to assume financial responsibility for the denied service/procedure/product. Modifier GZ may be used in cases where a signed ABN was not obtained from the patient, but the wound care professional/provider assumes financial responsibility if the service/procedure/product is denied.
For more information about the use of ABNs and the use of appropriate ABN modifiers on claims, Chapter 30, Section 50, of the Medicare Claims Processing Manual provides complete instructions at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-CMS-M. Reproducible copies of the revised ABN (in English and Spanish) are also available at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.
New Targeted Probe and Educate Medical Review Strategy
Most wound care professionals/providers will probably agree that the way Medicare currently audits claims can be a burden, especially if the professionals/providers are doing everything right. The CMS uses MACs to review clinical documentation to prevent improper payments. The MACs choose claims for review based on many factors, such as the service-specific improper payment rate, data analysis, and billing patterns of the provider.
To improve this process, the CMS announced its new Targeted Probe and Educate (TPE) Medical Review Strategy. Rather than conducting reviews of all professionals/providers who submit claims for a particular service, the MACs will focus on professionals/providers who have (1) the highest claim error rates or (2) billing practices that vary significantly from their peers. These professionals/providers and specific items/services will be identified by the MAC through data analysis. This will eliminate the burden on professionals/providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.
The TPE process will consist of up to 3 rounds of claim reviews. Each round (referred to as a probe) will review 20 to 40 claims per professional/provider, per item or service, and will be followed by 1-on-1 provider-specific education to address any errors found in reviewed claims.
* Professionals/providers with moderate and high error rates in the first probe will continue to a second probe of 20 to 40 claims, which will be followed by additional provider-specific 1-on-1 education.
* Professionals/providers with high error rates after round 2 will continue to a third and final round of probe reviews and education. In addition to education after each probe review, MACs will also educate professionals/providers throughout the probe review process, when easily resolved errors are identified. This education should help professionals/providers avoid additional similar errors later in the process.
* Professionals/providers who have continued high error rates after 3 rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a recovery auditor, and so on.
* Professionals/providers may be removed from the review process after any of the 3 rounds of probe review if they demonstrate low error rates or sufficient improvement in error rates as determined by CMS.