Provider Advisory Groups

1. Greg Hart, Professional Relations, Arkansas Blue Cross
2. Lori Langevin, Professional Relations, RI Medicare Services
3. Carol DeMelo, RI Medicare Services
4. Cindy Cote, Senior RN, RI Medicare Services
5. Rocco Bruno, RI Medicare Services
6. Mickey Lourenco, Kent County Hospital
7. Lynne Gauvin, Kent County Hospital
8. Carol Foldes, Landmark Medical Center
9. Paula Poirier, Landmark Medical Center
10. Kathleen Petrarca, Women & Infants Hospital
11. Robin Neale, Women & Infants Hospital
12. Godiva Laliberte, Eleanor Slater Hospital
13. Jan Sayer, Lifespan
14. Katherine Viveiros, Roger Williams Medical Center
15. Nilda Mendoza, Roger Williams Medical Center
16. Arleen Palazzo, South County Hospital
17. Lisa Randall, South County Hospital

1. Welcome and Introductions
   The meeting was called to order at 9:10 am. Lori Langevin invited the audience to introduce themselves. She welcomed and thanked the members for attending the meeting.

The minutes from the July 29, 2004 meeting were accepted with no changes.

2. New Business

PCOM Advisory Group Focus (Handout)

To remind members of the primary focus of the PCOM Advisory Group, Lori explained that the group meets to assist in the creation, implementation and review of providers/supplier education strategies for future workshops, publications and notices. We need your input to accomplish this task. We need for you to let Medicare know how we can better educate you on specific topics so that you can get your job completed. The intent of this meeting is not for individual problems but to focus on areas that would affect all hospitals. Lori advised that once the meeting is adjourned, to feel free to present individual concerns.

1. FISS & Part A Updates ~ Lori Langevin

Lori Langevin advised the next call is schedule for 11/3/04. However, the Claims Department will take over this call as the existing issues are claims related. Lori Langevin and Lisa Baxter, Ark EDI DEPT. will also participate on the call. Lori advised as soon as the Claims Dept. confirms this date and who will moderate the call that she will email the group.

The top 10 FISS reason codes were discussed and Lori Langevin asked the group what additional training that they would need to avoid getting these reason codes on their claims:

1. Patient name or initial do not match bene record - 30715. Since the conversion to FISS, this has been the top reason code that claims are returned to providers. The problem is that if the name, middle initial or spacing is not exact to the Common Working File, you will receive this code. The group felt they understood what they have to enter to avoid getting this error.
2. Revenue Code invalid for this type of bill – 32206.
3. Invalid procedure code – W7040
4. Provider requested adjustment to original claim - 37541
5. Inpatient & Outpatient claim within 4 days – W7K01
6. Incorrect value or occurrence code – 31346
7. Inpatient admission within 3 days – 38045
8. Missing modifier 25 – W7021
9. More than one condition code – 30950
10. No appropriate modifier - 31905

This CR will change the current structure for handling provider inquiring and education.

Greg informed the group that a study was conducted for all Customer Service Units for Medicare Fee-for Service business. The study determined that there was a need to improve Customer Service and divide the Customer Service Reps. so that certain ones will only service providers and others will service the patients. This will allow the Reps. to become more knowledgeable when assisting the providers.

As part of the Medicare Modernization Act effective January 1, 2005, contractors will be restructuring their Provider Customer Service areas in an effort to provide better customer service. The customer service areas will be structured into tiers, the first tier will handle very general question…the 2nd tier will handle more specific calls and 3rd tier will handle very complex questions that may need research.

Greg also advised that providers will be directed to the IVR (Interactive Voice Response) for status on a claim. This will take place sometime in April 2005. This system will address claim status and eligibility inquiries. For correspondence, Medicare will still have 45 days to respond in accordance with CMS standards, this would include emails as well as general mail.

For the provider side for education and training, this CR will expand on our use of the website for Frequently Asked Questions (FAQ) and Web-based training courses. Another aspect of Provider Education will be to target small providers. This would not apply to hospitals, however Greg asked for input on current teleconferences and the Open Door Forum calls. Greg asked specifically for the frequency and topics that the hospitals would like to see. Greg advised to forward suggestions to Lori.

Greg spoke about the Medicare website and making the website technically self sufficient for providers to find the information as quickly as possible. You will also see a breakdown of just Part A issues. Greg reminded the group again to forward any ideas or suggestions to Lori on improving the RI website.

• Upcoming Workshops

Upcoming Hospital workshops will include annual updates (March 2005) and general billing of the UB92 form (end of the fiscal year 2005). These dates will be announced through newsletters and our website. Greg also mentioned the Inpatient Psych PPS training that CMS will mandate and announce very soon. Lori advised the group to provide input on what topics they would like to see at these workshops.

2. RI Medical Review Issues ~ Cindy Cote, Senior RN

• Documentation Requirements – Complex Review Edit Reason Codes

Cindy reviewed the website to be implemented as Arkansas has for documentation requirements and advised that very soon you will these guidelines on our RI website. A concern was made from Kent Hospital that hospital staff that would need this information would most likely would not have internet access. However, the hospital thought his was a good idea and perhaps they could recommend that certain Medical Records.  Staff could get access to the web.

 2.  LCD Transition – Draft Policies – Update:

• 3 policies for Consolidation
• 10 policies are new to Rhode Island
• Eye Policies - Comment Period 10/13/04-12/13/04           

        Draft Policies presented in September:

• Physical Medicine and Rehabilitation, AC-02-059
• Accelerated Breast Irradiation (APBI), AC-04-003             
• Anti-Cancer Drugs, AC 01-024
• Debridement of Toenails, AC-30-003
• Infrared Coagulation of Hemorrhoids, AC-04-004
• Insertable Loop Recorder (ILR), AC-99-529
• Magnetic Resonance Angiography (MRA), AC-03-010
• Routine Foot Care, AC-02-043
• Stereotactic Radiosurgery / Fractionated Stereotactic Radiotherapy, AC-02-018                              

A concern of the hospitals was the bone density tests and the recent ADR letters (10/1/04) that are generating for proof of the last bone density test. Cindy advised that she would review the letter to ensure it is asking for the appropriate information. Cindy advised that the ADR should not be for frequency since the system would edit for test that were done before the allowable time. However, an ADR letter may be requested if the diagnosis code warrants the test before the 23 month allowable time. Lori suggested that maybe the ADR letter needs updating.

           C.) Open Discussion

• Website ~ Medicare updates daily

Medicare’s website is updated on a daily basis and we encourage providers to use more frequently in order to receive the most recent changes, deletions and updated Medicare information. Also, we have free-of -charge courses for which you can receive credits. We use a pop-up screen to address critical issues. As a reminder the minutes to this meeting are posted to our web. You can find them by clicking on the Provider Information and looking to the left side of the page if you scroll down to PCOMAG Info, this is where you would double click. We also post the dates and times of these meetings. We still intend to get the FY 05 schedule posted on the web; however we need to make travel plans with other states involved. We also have Listservs specifically for Hospitals. Lori referred group to the handout on Part A Listservs and the website as it exists now with Part A and Part B of Medicare separated for easier access.

• HIPAA ~ Lori encouraged group to convert to HIPAA versions as soon as possible, including the electronic remit formats. Lori advised group to contact Arkansas EDI @ 1-866-582-3247 for EDI assistance. Lori also referred to the HIPAA Report User Guide that can be found on the Web.

• Medicare Newsletter ~ Effective January 1, 2005, these newsletter will only be available electronic. There will be a $100.00 yearly fee for paper copies.

• Medicare News ~ Lori gave an overview of the following items:

Medicare Beneficiaries will soon be able to resolve Medicare appeals faster due to CMS awarding contracts to 8 QIC’s (Qualified Independent Contractors). These QIO’s will perform reconsiderations, or second level claims appeals, of denied Medicare fee-for-service claims. This is a key step in helping Medicare beneficiaries resolve their appeals more quickly and efficiently. Also the ALJ’s will now be under Health and Human Services, which will mean they will have to follow the same guidelines as CMS. This process should be in place by October 1, 2005.

• Medlearn Matters MM3260 ~ Invalid Diagnosis Code Editing ~ Second Phase

New edits will be added to the Medicare claims processing system to prevent acceptance of inbound claims with invalid diagnosis codes. Effective April 2005

• Medlearn Matter MM3311 ~ Override of Medicare System Edit for Observations Services Exceeding 48 Hours.

This article relates to the current Medicare system edit that does not allow claims to be paid for observation services greater than 48 hours. Effective April 1, 2005, changes will be made to the Medicare system to allow this edit to be overridden when the additional observation hours are reasonable and necessary. ABN’s must be given if you submit a claim for observation services greater than 48 hours. Lori will get clarification on this.

• Medlearn matter SE0464 ~ Important News about Flu Shots for Medicare Beneficiaries

Due to the flu vaccine shortage, Medicare beneficiaries are being encouraged to obtain the flu vaccine from their regular physician. This shortage does not include the pneumococcal. The Centers for Disease Control and Prevention is recommending that individuals be given priority for getting the flu vaccine who are in high-risk category.

• Medlearn Matters MM3416 ~ New Policy and Refinement on Billing Non-Covered charges to Fiscal Intermediaries

This article relates to CR 3416 and services to effect compliance with the HIPAA in ensuring all services not covered by Medicare may be submitted and accepted on Medicare claims, which in turn can be crossed over to subsequent payers.

Issues brought to our attention by the hospitals during open discussion:

• Genetic modifiers listed in the 2005 CPT book and when they are effective for certain HCPCS. Lori will get clarification on this.
• LMRP’s and the retiring of them to LCD’s was mentioned. Cindy Cote explained the process will take some time but the goal is to follow the same protocol as Arkansas. You can view this on the website as they transition and we will post when a LMRP is retired.
• The hospitals requested that when EDI issues affect their claims being processed that they would like to be notified by an email since all the hospitals are on an email address group with Ark EDI. Lori advised that EDI would post these issues on the web
• Paper remits are to be eliminated January 2005 so what plans are in place so that the hospitals can post their money, since the electronic remits are not readable. Will there be a replacement file sent once the paper remits are eliminated? Lori will inquire with ARK EDI.
•  
• Lori brought up the issue that when EDI gets a file and the file is accepted why would the claims not get into FISS. Lori has a new Part A provider with this issue now.
• Eleanor Slater mentioned electronic remits and when they are available. Lori advised this remit should be available on Wednesday’s after the Tuesday night payment cycle runs.
• Landmark Medical mentioned that when they call Customer Service they are advised that a certain claim can not be adjusted or processed due to a system problem. The hospitals would like the information communicated to them so they are aware of the system problems, if any. Lori advised that that is what we try to do with the Part A issue log. Greg suggested posting FISS issue to our website.
• Landmark Medical Center brought up an issue with some claims that are just not getting through FISS and the use of A-3 when the patient’s days are not exhausted. Lori advised she would follow-up with JoAnne Hernandez, Supervisor of Claims Dept.
• The hospitals are not satisfied with the CMS feedback on SNF CB with Emergency Room services that extend after midnight. CMS advised on a SNF CB conference call that the hospital should bill all services regardless if the service were done after midnight with the same date the patient was admitted to the Emergency Room. The hospitals all agree that the instructions only apply to revenue code 450 not other services rendered. They also are concerned with compliance issues of billing services with a date of service that is not consistent with then the actual services were performed. Lori advised that she asked Cathy Sullivan if CMS would be putting something on writing to clarify other revenue codes services done after midnight. Cathy advised that per the SNF CB conference that CMS advised the FI’s to refer the providers to the OPPS manual on Emergency Room billing after midnight. Greg suggested that the issue be addressed in writing and than the written request can be forwarded to CMS for further review. Carol Foldes advised that she will send her concerns in writing to Lori Langevin. We can discuss with Cathy Sullivan again and work with CMS from there.
• Hospitals questioned location SMSPR1 and why do lab claims have to suspend in that locations. This will also be an action item.

D. ) Next meeting & agenda Items

FY05 ~ 1^st Quarter

Lori Langevin advised the next meeting is scheduled for January 21, 2005 9-11 am Warwick Public Library. This date is subject to change but the meeting will be held this same week.

Lori also encouraged members to submit agenda items for the next meeting and to provide input on Medicare topics that you would like training and education on.

• Lori Langevin to advise the group on the date, time and dial-in-number for the Part A issue log call as soon as Cathy Sullivan can provide this information.

• Cindy Cote to review the ADR letter for Bone Density Tests to ensure the appropriate information is being requested. We believe the diagnosis code is triggering the ADR letter for medical records.

• Genetic Modifiers were mentioned and the group would like clarification on when these modifiers will be effective for certain HCPCS.

• Will another report replace the paper remits that will be eliminated on January 1, 2005? Lori to follow-up with ARK EDI.

• Why would claims that are accepted electronically not get into FISS?

• Location SMSPR1 on FISS. Lori will get clarification on why lab claims suspend in this location.

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