System error caused claims to incorrectly process through ...



021 office E/M changes and E/M worksheet updatesEffective for dates of service on and after January 1, practitioners will have the choice to document office/outpatient evaluation and management (E/M) visits via medical decision making (MDM) or time. CMS is adopting the American Medical Association’s (AMA's) revised CPT guidance, including deletion of CPT code 99201. The E/M code and guideline changes are specific for office and other outpatient visits and apply to codes 99201–99205 and 99211–99215. Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, as clinicians may choose the E/M visit level based on either medical decision making or time; both CPT code 99201 and 99202 require straightforward medical decision making, therefore the decision was made to delete CPT code 99201.To assist providers with this change, the?E/M worksheet?has been updated. The updated worksheet will function based on the date of service and type of visit. If the date of service is on and after January 1, and related to an office or outpatient services visit, the worksheet options will align with the AMA guidance to determine the level of E/M service performed. If not related to office or outpatient services, or the date of service is prior to January 1, the worksheet options will remain based on the 1995 or 1997 guidelines. Helpful resources and tips will be available within the tool as an added resource to guide providers in determining the level of E/M service.E/M interactive worksheet: User agreementEvaluation and management (E/M) services refer to visits furnished by physicians and qualified, licensed, non-physician practitioners. Billing Medicare for a patient visit requires the selection of the code that best represents the level of E/M service performed. The purpose of this interactive worksheet is to assist providers with identifying the appropriate E/M code based upon either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services or AMA CPT E/M Code and Guideline Changes for 2021 (effective for office/outpatient visits only for dates of service on and after January 1, 2021).Since the 1995 and 1997 guidelines or AMA CPT E/M Code and Guideline Changes for 2021 (effective for office/outpatient visits only for dates of service on and after January 1, 2021) each specify different criteria to determine the level of E/M service performed, only one set of guidelines may be used to document a specific patient visit. This interactive worksheet offers providers the option to select either their preferred set of guidelines (1995 or 1997) or to select both for the purpose of comparison.To emphasize the importance of medical necessity when reporting E/M services consider the following: all E/M services reported to Medicare must be adequately documented so the medical necessity is clearly evident because federal law requires that Medicare not pay for services for which the documentation does not establish such. For E/M services medical necessity of a visit as well as the CPT “level” of the service must both be documented. Per the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1 A, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.", as we proposed, we are using our authority under section 1833(t)(2)(F) of the Act to apply an amount equal to the sitespecific PFS payment rate for nonexcepted items and services furnished by a nonexcepted off-campus provider-based department (PBD) of a hospital (the PFS payment rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act. We will be phasing in the application of the reduction in payment for code G0463 in this setting over 2 years. In CY 2019, the payment reduction will be transitioned by applying 50 percent of the total reduction in payment that would apply if these departments were paid the sitespecific PFS rate for the clinic visit service. In other words, these departments will be paid 70 percent of the OPPS rate for the clinic visit service in CY 2019. In CY 2020 and subsequent years, these departments will be paid the site-specific PFS rate for the clinic visit service. That is, these departments will be paid 40 percent of the OPPS rate for the clinic visit in CY 2020 and subsequent years. In addition to this proposal, we solicited public comments on how to expand the application of the Secretary’s statutory authority under section 1833(t)(2)(F) of the Act to additional items and services paid under the OPPS that may represent unnecessary increases in OPD utilization. The public comment we received will be considered for future rulemaking. ? Expansion of Clinical Families ofSystem error caused claims to incorrectly process through local editingIssueFrom July 2019 through April 2020, claims were not processing through local policy editing. As a result of this system error, there are services that may have paid that should have been denied based on a local coverage determination (LCD) editing or the need for records that were not requested.The Fiscal Intermediary Shared System (FISS) corrected the issue on January 6, 2020.ResolutionFirst Coast has identified approximately 348,000 claims that will be adjusted. The adjustments will allow the claims to process through any local edits that may have been missed due to the system error.Depending on how the claim was reported:??Claims may be adjusted with no change to payment if the coding on the claim meets the medical necessity of any local editing that is in place.??Previously paid claim lines may deny against LCD editing or an entire claim may be denied.??Providers may receive requests for records of previously paid claims.The adjustments related to this issue can be identified with a type of bill (TOB) ending with “J” on the remittance. We will begin initiating adjustments for impacted claims on November 6, 2020.Status/date resolvedOpenProvider actionNo action required by providers to initiate the adjustments. Please respond to record requests that you receive for the previously paid claims. If the adjustment resulted in a line level or claim level denial for incorrect or missing diagnosis code that should have been reported on the initial claim, submit a clerical error reopening request, listing the appropriate diagnosis code for the service to add or change a diagnosis code.Current processing issuesHere is a link to a table of?current processing issues?for both Part A and Part B.For more information about submitting clerical reopening requests, review the?identifying medically reviewed adjudicated claims?article. ................
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