Free Continuing Medical Education for Physicians from CMS

Attention Physicians:

CMS is providing free Continuing Medical Education through the completion of online training modules.  All modules apply to Medicare Fee-for-Service Quality Payment Programs.  CMS sent the email below to subscribers to Medlearn Matters.  If you would like to receive future notifications directly, you can sign up one the Medlearn Matters Electronic Mailing List Page.

Learn More About MIPS and Earn CME Credit with These 2019 CME Modules

CMS has posted 6 continuing medical education (CME) modules on the Merit-based Incentive Payment System (MIPS). You can access them by logging into your Medicare Learning Network (MLN) account or creating one here. Once logged in, type the name of the module into the search bar at the top of the website to find it.

The new MIPS CME modules include:

• Quality Payment Program 2019 Overview – Provides information on the origin and objectives of the program as well as an overview of the MIPS and Advanced Alternative Payment Models.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Participation in 2019 – Details MIPS eligibility and participation options, including the new opt-in policy, and how to report MIPS data.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Quality Performance Category in 2019 – Explains the requirements, data submission and collection types, and scoring for the Quality performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Promoting Interoperability Performance Category in 2019 – Provides information on reporting requirements, measures, and reweighting for the Promoting Interoperability performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Improvement Activities in 2019 – Explains the requirements, reporting steps, and scoring for the Improvement Activities performance category.
• Quality Payment Program Merit-based Incentive Payment System (MIPS): Cost Performance Category in 2019 – Provides information on new measures, attribution, and scoring for the Cost performance category.

For More Information

• Visit the CMS.gov MLN Web-Based Training webpage and log in to MLN to access the modules.

• Visit the QPP Resource Library to review new and existing QPP resources.
• Contact the Quality Payment Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222). To receive assistance more quickly, consider calling during non-peak hours—before 10 AM and after 2 PM ET.

SNF Billing Guide

Recently, we've noticed that there are a number of Skilled Nursing Facility claims/encounters rejected by CMS due to the following reasons:

1. Skilled Nursing Facility Claims required Health Insurance Prospective Payment System (HIPPS) codes not present on the claim.
2. HIPPS Codes and Revenue Codes conflict 
3. Hospital to Skilled Nursing Facility within 24 hours.

All of these issues can be remedied, by following the Centers for Medicare and Medicaid Services guidelines for billing of Skilled Nursing Facility guidance, including the correct use of HIPPS codes.


Although CMS allows Medicare Advantage plans to provide services which may not meet the coverage criteria in Fee-for-service (FFS) Medicare, provision of services and submission of an encounter data are two distinct things.   So, while coverage may be extended in some cases when FFS guidelines are not met, encounter  data must meet FFS billing requirements in order to be processed.  And CMS does require that all services must be submitted as encounter data, whether or not CMS covers them.

In order to ensure your encounter data is processed correctly, you should follow the instructions contained in the CMS Skilled Nursing Facility (SNF) Billing Reference.  For complete instructions on HIPPS Codes, you should review the HIPPS code page on the CMS website as well.
Finally, in order to ensure that your claim/encounter for a SNF transfer within 24 hours, be sure to use Condition Code 40 on the encounter.

The importance of correct encounter data cannot be stressed enough. In order for CMS to have an accurate and complete picture of the services provided to our members, encounters must be processed to completion.  By and large, that means they must meet the requirements of FFS medicare when they are sent to health plans. This ensures that they will be correctly processed, and that CMS can more accurately assess the care provided to MA members.

If you have questions regarding CMS Encounter Data, contact Michelle Nguyen of our Encounter Data team at MNguyen3@scanhealthplan.com.

Importance of Submitting Complete Encounter Data

As you know, CMS now uses a combination of RAPS (Risk Adjustment Processing System) data and encounter data submitted thru EDPS (Encounter Data Processing System) as inputs into the payment system for projecting RAFs (Risk Adjustment Factors), which is a key input to payment model for MAPD (Medicare Advantage Prescription Drug) health plans.  CMS requires that all encounter data be submitted by MAPD health plans, including services not covered by CMS in Fee-For-Service (FFS) Medicare.

Due to the growth of payment strategies such as capitation in MAPD, providers are no longer financially incentivized to provide complete data as they were in the traditional claims billing process.  This has been a widely identified trend in MAPD professional data, but also occurs in the inpatient setting which often contains more robust information then other places of service.  Missing encounter data and the growth of the gap in these data (between MAPD and FFS) has a number of important ramifications for MAPD:

• ·        It causes inaccuracies in payment because treated conditions are not reported and therefore not loaded into the payment model
• ·        It suggests a distorted picture of members’ true disease burden as being lower than the actual
• ·        It suggests incorrectly to CMS that MAPD members are receiving fewer services than beneficiaries in traditional Medicare (FFS)

Some possible drivers for this under-reporting are:

• ·        Failure to submit data from sub-capitated providers, including hospitals
• ·        The purposeful filtering of encounter data submitted to the plan with the goal of providing only incremental HCC model data
• ·        Downstream data that medical groups processes as claims are not always extracted and reported. This is especially true when the groups’ encounter data and claims data are on different platforms.
• ·        Selective reporting from providers of only risk adjustable diagnoses in MAPD and only providing a single E&M procedure code so that the encounter will process
• ·        Submitting reporting from providers of only diagnoses “linked” to a procedure code for traditional Medicare claims or only the minimum needed for the claim to process

While there are no mechanisms in traditional Medicare at present to submit additional diagnosis data (maximums are currently <=8 diagnoses for professional, <=25 diagnoses for institutional), it’s important to submit all documented diagnoses and procedures for both programs.  In traditional Medicare where there are more diagnoses then 8, we would suggest that the provider or biller first choose linked diagnoses followed by the diagnoses that most accurately reflect the need for the visit and evaluations conducted at that service.  Similarly, reporting all CPT/HCPCS codes is important since it is the only way that CMS can gain an accurate picture of procedures performed with the goal of trying to understand and compare value between the programs. 

At present we believe that there are a number of systematic biases that are impacting the accuracy of the view CMS has on the health status of the entire Medicare population, biasing towards fewer CPT/HCPCS for MAPD and fewer ICD codes for traditional FFS.

NOTE:

Remember, SCAN’s Encounter and Risk Adjustment provider team is here to assist you.  Please reach out to Michelle Nguyen at MNguyen3@scanhealthplan.com for assistance.

Special Guest Posting by Coding Quality Specialist, Megha Patel, CCS, CPC- Official Coding Guideline Changes

Good afternoon, all.  Today, we're lucky to have a special guest post, by one of SCAN's Coding Quality Specialists, Megha Patel, CCS, CPC.  Megha has done a lot of hard work for us, compiling all the significant changes to the Official Guidelines for Coding and Reporting, beginning with the switch from ICD-9-CM to ICD-10-CM:

ICD -9 to ICD-10 Official Coding Guideline Updates

1.      10/01/2015:

ICD-9 to ICD-10 updated October 1, 2015.

·         CAD with Angina: Use combination codes for CAD with Angina, A causal relationship can be assumed in a patient with both Atherosclerosis and angina pectoris. It is not necessary to code Angina Pectoris separately.

·         Sequelae of CVA: Weakness due to previous CVA should be coded as Hemiplegia/Hemiparesis.

·         Sequelae of CVA: Hemiplegia/Hemiparesis/Monoplegia identify whether the dominant or non-dominant side of affected.  If provider didn’t documented dominant or non-dominant, the default is to assume the right side is the dominant side. If left side affected, the default is non-dominant.

·         DM with Hyperglycemia: Uncontrolled DM, Inadequately Controlled, Out of controlled, Poorly Controlled should be coded as Hyperglycemia.

·         Diabetes Ketoacidosis: ICD-10 CM does not provide a specific code for Type II diabetic Ketoacidosis. Assign code E13.10 Other Specified Diabetes with Ketoacidosis as per Coding Clinic First Quarter of 2013.

2.      03/18/2016:

·         DM with Complications Assumed relationship. The guidelines published in the first quarter 2016 issue of AHA Coding Clinic on pg. 11. According to this clarification, the subterm “with” in the index should be interrupted as a link between diabetes and any of those conditions indented under the word “with”.

** The linkage between diabetes and Osteomyelitis used to be assumed in ICD-9 but it is not assumed in ICD -10 (10/01/2015-10/01/2016 Not coded). There is no assumed relationship till October 1, 2016.

3.      10/01/2016:

·         Uncontrolled DM: Uncontrolled DM is classified by type and whether it is hyperglycemia or hypoglycemia. There is no default code for “uncontrolled DM”. Effective Oct. 1, 2016, uncontrolled diabetes can be referenced as Hyperglycemia or Hypoglycemia.

·          Hypertension with CHF: Presumes a causal relationship between hypertension and heart involvement. 

·         COPD with Asthma: COPD with asthma only coded as J44.9. If type of asthma not documented J45.909 should not be coded.  “Unspecified” is not type of asthma.

4.      10/01/2017:

·         Diabetic Ketoacidosis: October 1, 2017 updated with new codes for Diabetes Ketoacidosis (Type II). E11.10 Type II DM with Ketoacidosis w/o Coma and E11.11 Type II DM with Ketoacidosis w/ Coma.

·         COPD, Emphysema and Chronic Bronchitis all documented: Assign J449 only, because J43.9 Emphysema has Exclude 1 note (Emphysema with chronic bronchitis). J44.9 has Include note Chronic Bronchitis with emphysema. (J439 is Emphysema without Chronic Bronchitis) (J449 is Emphysema with Chronic Bronchitis).

·         COPD with Emphysema: J43.9 Emphysema assigned as Emphysema is specific type of COPD.

·         Emphysema with an Acute Exacerbation of COPD: Assign J43.9. Both codes have Exclude 1 note to each other. J439 is without Chronic Bronchitis and J449 is with Chronic Bronchitis. Emphysema is type of COPD so Acute Exacerbation of COPD is covers in J43.9.

Thanks, Megha--for doing all the heavy lifting!

Remember, you can always download the full text of the ICD-10-CM guidelines on our website, at http://hccuniversity.com/asset/154d663f-95bf-4a59-a1fd-a6e4eb7c8477

An Important Reminder From our Encounter Data Team

Hello SCAN Provider Partners,

The January CMS Encounter Data Sweep deadline has been extended! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) and requires the submission of encounters for DOS range 01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

Additionally, TODAY is the CMS Final Deadline Date for the March CMS Encounter Data Sweep, which requires the submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee for Service blended risk score based on 2017 DOS.

SCAN has one date for you to manage towards for the January 2018 sweep (2016 DOS):

Ø  SCAN Deadline for Provider Partners: EOB Friday, April 27, 2018 – RAPS only

o   After this deadline, SCAN will NOT process any RAPS files received for the January CMS sweep

*Note: 2016 DOS EDS deadline has been extended to September 2018

SCAN has two dates for you to manage towards for the March 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018 – closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018 – closed

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. March reports were uploaded to the SCAN Encounter Data Portal on 3/2/2018. The next ESRs will be uploaded the first week of April 2018.

2.     Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

  

3. Review your SCAN All DX Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of May 4, 2018 for the January Sweep (RAPS only) and March 2, 2018 for the March Sweep.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until April 27, 2018 to upload your 2016 DOS files for the January Sweep (RAPS only). Additionally, please do not wait until February 23, 2018 to upload your 2017 DOS files for the March Sweep.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports
4. Invalid DX rejection reports
5. ICE File Pend reports

f.     POS 21, 22, and 23 reports

What are the Timelines?

1. Last day to submit all 01/01/2016 -> 12/31/2016 DOS encounters for RAPS to your Clearinghouse: 04/27/2018
2. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 -> 12/31/2016 to SCAN: 04/27/2018
3. January CMS Sweep RAPS deadline for SCAN: 05/04/2018
4. Submit all 01/01/2017 -> 12/31/2017 DOS encounters to your Clearinghouse: 02/23/2018
5. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 -> 12/31/2017 to SCAN: 02/23/2018
6. March CMS Sweep deadline for SCAN: 03/02/2018

* Remember: SCAN has two dates for provider partners to manage towards for the January and March Sweep:

Ø  January Sweep SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017- closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  January Sweep SCAN Deadline (RAPS only) for Provider Partners: EOB Friday, April 27, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

Ø  March Sweep SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018- closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  March Sweep SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018- closed

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s HCI Representative:

o   Michelle Nguyen: MNguyen3@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects

RAPS Submission Deadline Extension Memo

The memo below was shared with our provider partners today explaining the CMS extension for filing RAPS for Payment Year 2017.a

Important Reminder from Our Encounter Data Department

Hello SCAN Provider Partners,

The January CMS Encounter Data Sweep is coming to a close. TODAY is the Final Deadline Date to submit the remainder of your 2016 DOS Encounter Data! This is the FINAL CMS sweep impacting 2016 DOS (2017 payment) and requires the submission of encounters for DOS range 01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

Additionally, we are now 4 weeks away from SCAN’s Final Deadline Date for the March CMS Encounter Data Sweep, which requires the submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee for Service blended risk score based on 2017 DOS.

SCAN has two dates for you to manage towards for the January 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017 - closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

SCAN has two dates for you to manage towards for the March 2018 sweep:

Ø  SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

1. Review your SCAN monthly Encounter Submission Reports
1. January reports were uploaded to the SCAN Encounter Data Portal on 1/5/2018. The next ESRs will be uploaded the first week of February 2018.

2.     Review your SCAN Encounter HCC Reconciliation Reports

1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

  

3. Review your SCAN All DX Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§ QUESTION: What is the All Diagnoses (DX) Reconciliation report?

§ ANSWER: A report containing all diagnosis codes received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017.

2. This report can be leveraged along with the HCC Reconciliation report to match up to your database and ensure all of your encounter data has been sent to SCAN.

4. Review your SCAN PCN Reconciliation reports
1. This report is available to you monthly. If you would like to utilize this report for the January and/or March Sweep, please access the EDP SCAN Documents tab -> HCCs and Encounters.

§  QUESTION: What is the Patient Control Number (PCN) Reconciliation report?

§  ANSWER: A report containing a list of all the PCNs received from your group for dates of service 01/01/2016 -> 12/31/2016 and 01/01/2017 -> 12/31/2017. The PCN field provides you with the ID received from you for each encounter (a.k.a. claim ID). You may reconcile the list of PCNs against your system to ensure that SCAN has received all of your PCNs. If any are missing on our list that exist in your system, then you can identify those as needing to be submitted to SCAN immediately

2. If you are already reconciling against the PCN report, then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help you ensure that all possible encounter data for SCAN members has been sent to SCAN to meet the CMS health plan cut-off date of January 31, 2018 for the January Sweep and March 2, 2018 for the March Sweep.

Additional Steps:

5. Work your clearinghouse rejections via OfficeAlly, Ability Network, or Change Healthcare

6. Upload all ICE alternative submission files to SCAN via the Encounter Data Portal (providerportal.scanhealthplan.com) using the File Transmission link
1. It is your responsibility to ensure that the file uploaded is processed successfully. Due to the larger number of files received during sweep timeframes, it becomes very difficult to provide 1:1 attention on these files. Please refer to the SCAN ICE file specifications located on the SCAN Encounter Data portal or you may email me to request the documents to ensure the success of your file upload.
2. Send these files sooner than later; please do not to wait until January 26, 2017 to upload your 2016 DOS files for the January Sweep. Additionally, please do not wait until February 23, 2018 to upload your 2017 DOS files for the March Sweep.
3. ICE files should only be used to submit additional DX codes or deletes of DX codes.

§ SCAN expects to receive all original encounter data records via your normal clearinghouse workflow.

7. Follow up on additional cleanup requests (contact your respective HCI representative with your direct questions)
1. Provider Name Mismatch (PNM) rejection reports
2. Rendering Provider/Entity (RPX) rejection reports
3. EDS Full Encounter Data rejection reports
4. Invalid DX rejection reports
5. ICE File Pend reports

f.     POS 21 reports

What are the Timelines?

1. Last day to submit all 01/01/2016 -> 12/31/2016 DOS encounters to your Clearinghouse: 01/26/2018
2. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2016 -> 12/31/2016 to SCAN: 01/26/2018
3. January CMS Sweep deadline for SCAN: 01/31/2018
4. Submit all 01/01/2017 -> 12/31/2017 DOS encounters to your Clearinghouse: 02/23/2018
5. Last day for ICE file submissions of additions/deletions of DX codes for 01/01/2017 -> 12/31/2017 to SCAN: 02/23/2018
6. March CMS Sweep deadline for SCAN: 03/02/2018

* Remember: SCAN has two dates for provider partners to manage towards for the January and March Sweep:

Ø  January Sweep SCAN Target Date for Provider Partners: EOB Friday, December 29, 2017- closed

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  January Sweep SCAN Deadline for Provider Partners: EOB Friday, January 26, 2018

o   After this deadline, SCAN will NOT process any files received for the January CMS sweep

Ø  March Sweep SCAN Target Date for Provider Partners: EOB Friday, January 26, 2018

o   This target date ensures that SCAN has adequate time to complete processing prior to the health plan cut-off date by CMS

Ø  March Sweep SCAN Deadline for Provider Partners: EOB Friday, February 23, 2018

o   After this deadline, SCAN will NOT process any files received for the March CMS sweep

Please be prepared for continued communication from SCAN. We look forward to supporting and working with you during this upcoming sweep period!

  

If you have any questions or concerns, please feel free to contact me directly or reach out to SCAN’s HCI Representative:

o   Michelle Nguyen: MNguyen3@scanhealthplan.com

Best regards,

Christina Cabiltes

Supervisor, HCI Projects