Important Encounter Data Reminders and Updates
Remember, effective July 2014, Medicare has implemented the 13
month processing window for timely filing of encounter data. Encounters older than 13 months will receive
an informational edit from CMS—but this will change to a reject, which could
happen at any time. Remember, that your encounter must be processed by SCAN
first, so it’s important that encounters be received in advance of that 13
month time limit. We expect to receive
notice from CMS prior to them beginning to reject encounters.
Adjustments are not subject to the 13 month window, but SCAN must submit them to CMS within 30
days of their adjudication.
Encounter Data Processing System
Both the Risk Adjustment Processing System (RAPS) and the
Encounter Data Processing System (EDPS) will be used in 2015. CMS will make an announcement prior to
discontinuing RAPS and moving to only EDPS for risk adjustment calculations.
CMS Announcement for new
HCPCS modifier codes to replace modifier -59. Effective January 1, 2015. Read
the full release HERE.
This information is important for
correct submission of encounter data.
Effective: January 1. 2015
there are four new HCPCS modifiers to define subsets of the -59 modifier, a
modifier used to define a “Distinct Procedural Service.” Modifier -59 identifies services which
normally are considered “bundled” in the main procedure.
Please make sure your billing
staffs are aware of the coding modifier changes. The new HCPCS modifiers are
collectively referred to as –X {EPSU} modifiers:
• XE- Separate Encounter- A
service that is distinct because it occurred during a separate encounter.
• XS- Separate Structure- A
service that is distinct because it was performed on a separate
organ/structure.
• XP- Separate Practitioner- A
service that is distinct because it was performed by a different practitioner.
• XU- Unusual Non-Overlapping
Service- The use of a service that is distinct because it does not overlap
usual components of the main service.
CMS will not stop recognizing
the -59 modifier but notes that CPT instructions state that the -59 modifier
should not be used when a more descriptive modifier is available. CMS will
continue to recognize the -59 modifier in many instances but may selectively
require a more specific - X {EPSU} modifier for billing certain codes at high
risk for incorrect billing. For example, a particular NCCI Procedure-To-Procedure
code pair may be identified as payable only with the - XE separate encounter
modifier but not the -59 or other - X {EPSU} modifiers. The - X {EPSU}
modifiers are more selective versions of the -59 modifier so it would be
incorrect to include both modifiers on the same line.
CMS
recommends the use of the new HCPCS modifiers in place of the -59 modifier
whenever possible. SCAN also encourages all physicians, providers and billing
staff to familiarize yourselves with these new HCPCS modifiers and implement them
into your billing systems as directed by CMS. Effective starting date of
service for use of HCPCS modifiers –X {EPSU} is January 1, 2015.
Encounter Data Submission
Timetable—The
timetable below shows the new submission requirements for Health Plans to CMS. It also includes the risk score run
dates. The Encounter Data Team will
notify you, in advance, when encounters are required to be sent to SCAN:
Risk Score Run
|
Dates of Service
|
Deadline for RAPS Submission*
|
2015 Initial
|
07/01/13--06/30/14
|
09/12/2014
|
2014
Final
|
01/01/13--12/31/13
|
01/31/2015
|
2015
Mid-Year
|
01/01/14--12/31/14
|
03/06/2015
|
2016
Initial
|
07/01/14--06/30/15
|
09/11/2015
|
2015
Final
|
01/01/14—12/31/14
|
01/31/2016
|
As we receive new information from CMS, we'll be sure to post it here.
