Provider Outreach and Education Advisory Group (POE AG) Meeting Minutes - March 12, 2024

Roll Call

POEAG Member or Other (CMS) Attendees

JE: Angela Amey, Avery Malate, Candice Kahue-Antone, Cathy Atkins, Cheryl Bradley, Greg Labow, Mitch Kaye, Rob Sikorski, Sara Jasper, Susan LaPadula, Tameka Island, Wendy Alfaro, Luci Hendrickson, and Gloria Beazley

JF: Anna Gauslow, Dawn Davidson, Jana Weis, Lisa Beyer, Lisa Davies, Mindy Gale, Mollie Brooks, and Susan Albaitis

Noridian Attendees

Teresa Cirelli, Cheryl Hanson, Dani Aasen, Erin Swaidner, Jan Ervin, Katie Wik, Kim Brantley-Phillips,  Miriam Ocampo-Funderburk, Tammy Ewers, Valerie Cavett, Jennifer Joyce, Julie Schroeder, Aspen Schiermeister, Daylann Robertson, Marci Eckroth

POEAG Mission and Goals

The primary function of the POE Advisory Group is to assist Noridian in the implementation and review of our provider education and training strategy and efforts such as webinars, tutorials, and articles. The input received from these groups will affect the way educational materials and correspondence are presented, the content contained in them and how Noridian can best provide resources for the provider community.

Prior Meeting Minutes

The prior meeting minutes for the last two years are distributed to POEAG members and published to the website(s).

Prior POEAG Member Recommendations

Below are the POEAG member prior meeting recommendations and the progress or resolution for each item.

  1. 9/13/2022. Evaluation and Management (E/M) translation of ‘prescription drug management’ meaning for the 2023 guidelines.
    1. People are getting hung up is on the translation of ‘management’ and that the MDM column 3 is now ‘risk of test or treatment to the patient management’. There is a mindset that because it says prescription (RX) management, if a provider prescribes, then they get credit for this area.
    2. Noridian’s Response: One drug is not the same as the next. Prescription drug management documentation would need to show the work and/or risk involved by the billing provider when managing a prescription. Is the prescription something that could be harmful to the patient’s health? Will it interact with other drugs the patient is taking? Is the prescription a non-complex drug for a patient with no allergies or complications? Example – a patient taking anticoagulants. Did the patient have a stroke? Is there a risk they may bleed out?
    3. POEAG recommended this would be one of the best topics for planning upcoming webinars. POE will take this to the Medical Directors to pursue with CMS or publish specific by Noridian. The member stated there should be more structure with managing these services.
    4. 12/13: POE is working with Medical Directors for educational opportunities.
    5. 03/14: POE is working with our Medical Directors to see how we can put together this educational opportunity. It may be an opportunity to put together another webinar or an article and include the Prescription Drug Management.
    6. 06/13: Draft article continues to be discussed with Medical Directors. We are looking at ways to incorporate POEAG member suggestions:
      1. Providers are looking for specific documentation requirements. Compliance staff find a challenge educating clinical staff without specific documentation guidance. Other MACs have posted specific documentation requirements.
      2. Internally, staff is looking for the condition requiring medication management.
      3. Members requested including scenarios that would not support medication management. Example: provider refilling medication that is more preventive and the provider is not managing a condition. Medicare is based on lab results.
      4. In the spirit of burden reduction and documenting less, providing documentation guidance for prescription management would benefit providers.
    7. 09/12: Active discussions have taken place, and a final draft version is not ready currently. We will have something soon to share.
    8. 12/12: Active discussions have taken place, and a final draft version is not ready currently. We will have something soon to share.
    9. 03/12: On hold at this time.
  2. 9/12: Suggested Evaluation and Management (E/M) education articles
    1. Copy and paste in Electronic Health Record (EHR) – Some providers copy and paste the history and exam since it is no longer required to choose the E/M level. Old habits are hard to change, and this is not discussed in the current E/M guidelines. Suggestion to develop article with the Noridian Medical Directors.
    2. On-line digital E/M services – 99421-99423
      1. There is specific language within AMA CPT about on-line evaluation and management within seven days of a previous E/M for same problem is not reportable. Would the same problem mean same diagnosis as reported on the claims?
      2. The CPT code book states that all professional decision making and assessment or subsequent management by physicians or qualified health professionals in the same group practice contribute to the cumulative time of the digital on-line E&M. Would this include same provider and provider specialty?
      3. Lastly, would the date of service be the date the on-line inquiry was initiated by the patient? Sometime the messages can span over multiple days so keeping track of the seven days is critical.
    3. 12/12: Those discussions will be had with our CMDs. I couldn’t find all the answers, so it may be something we need to bring to CMS.
    4. 03/12: On hold at this time.
  3. 06/13: New Part A Skilled Nursing Facility (SNF) Five Claim Probe and Educate
    1. CMS Change Request (CR) 13164 provides guidance on the strategy to reduce improper payments for SNF claims and educate providers on correct billing.
    2. Medicare Administrative Contractors (MACs) will sample five claims from each SNF under all jurisdictions.
    3. Global and one-on-one education will be available.
    4. 09/12: POEAG member requested an update on Part A findings for the SNF Probe and Educate review.
      1. MR Part A started the required review of SNF providers for the 5-Claim Probe and Educate reviews in June. Each provider receives a written notice at the time their facility is being implemented. At this time, due to provider response timeframes and MR review timeframes we do not have any trending to share on the providers that were started June-August.
    5. 12/12: For the SNF 5-claim reviews, here are pieces of documentation that are most commonly missing from provider ADRs submissions:
      • Certifications or Re-certifications, and reason for delay if late
      • Signature logs
      • Signed physician orders for skilled services
      • Signed copies of physician H&P or Progress notes
      • Therapy treatment notes and logs
      • Nursing treatment logs
      • All documentation for the entire SNF admission to support the Minimum Data Set (MDS) coding of the Health Insurance Prospective Payment System (HIPPS) billed on the claim.
    6. 3/12: Review findings and checklist
      • SNF Checklist – Draft checklist is available internally and has been discussed to add an additional link to show where the ABN can be located. Not finalized yet.
      • Timeframe for the SNF Probe review will continue until all SNFs have been reviewed in the jurisdiction.
      • Medical Review (MR) is including trending information from SNF review results on the Noridian website under MR Review Results. Once you open the links you can click on the SNF PPS review criteria and link of "view results". Can only be found on Part A pages.
      • JE Part A Medical Record Review Results
      • JF Part A Medical Record Review Results
      • Clarification of the 3.5% error rate. Is this a payment rate or claim error rate?
        • Noridian’s response: This is an error rate, not a claim error rate.
  4. 12/12: New Complexity Code G2211 – Is there any opportunity for additional education on this new code? We are struggling a bit on how to use this code and the necessary documentation. If you’re hearing anything from CMS on that code, I think there’s a lot of interest into properly capturing it. Would like to know how it applies to new patient codes as an add-on code. It’s unclear due to the ongoing contact with the patient. Examples would be helpful.
    1. 3/12: A lot of questions based on what has been published so far. CMS working on an FAQ document, no timeline given, we are still waiting. CMS MLN MM13473 - How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211, addresses the new complexity code, however, leaves a few gray areas.
      • How would this code be used in a teaching setting where a family practice residency provider has established patients. Would the residents use this code assuming the team approach to the patient’s care? How would this work for moonlighting?
      • Would this be applicable to FQHC’s and RHC’s?
      • Noridian’s response: During a Physician Open Door meeting on January 24, 2024, CMS indicated the documentation must support the longitudinal relationship and reason the visit was determined to be complex. There wouldn’t be templated language because each medical record should be unique to that particular patient and current encounter.
        1. There was a teaching physician question and answer provided:
          Primary care exemption teaching resident is allowed to bill a low-level E/M. If they are the focal point for that person's care, that patient's care and all the evidence again in the medical record, again, assuming the interaction between the physician and the resident one could bill a G2211 if all those other things are true.
        2. We have not received CMS guidance on if this code could be included in the encounter for RHC or FQHC.

Agenda Items

Prior to the meeting, Noridian solicited agenda topics from members and evaluated significant program changes to discuss.

  1. MFT and MHC - Recommendation for Provider Outreach and Education to provide comprehensive webinars for Marriage and Family Therapist (MFT) and Mental Health Counselor (MHC) providers. This is a new benefit that started in 2024. We’ve included webpages for Part B below. There are two CRs CMS has published. Provider Enrollment has provided education on getting these providers enrolled and Webinar on Demand recordings have been published.
    1. JE Part B - Marriage and Family Therapist (MFT) or Mental Health Counselors (MHC)
    2. JF Part B - Marriage and Family Therapist (MFT) or Mental Health Counselors (MHC)
    3. CR13346
    4. CR13469
  2. Jimmo Settlement has been a source of confusion for Skilled Nursing and Skilled Therapy
    1. Noridian has been following the guidelines included in the Jimmo Settlement. The guidance that CMS published on February 13, 2024, appears to be directed to Medicare Advantage plans. If you have anything indicating we’re not following it, please let us know. The PCC is the best way to get that information out because they can take a look at specific claims that may not be processing correctly. No examples available during our meeting.
  3. Clinical Trials or Research related accounts – When a patient is covered under a Medicare Advantage plan, when should the claim be billed to original Medicare?
    1. Clinical trials are covered under National Coverage Determinations (NCD)
    2. It is mandatory to report a clinical trial number on claims for items or services provided in clinical trials, studies, registries, or under coverage with evidence development (CED). This is the number assigned by the National Library of Medicine (NLM) ClinicalTrials.gov website when a new study appears in the NLM Clinical Trials data base. This number is listed prominently on each specific study’s page and is always preceded by the letters "NCT." Contractors verify the validity of a trial, study, or registry by consulting CMS’s Coverage Website at:
      CMS Medicare Approved Facilities/Trials/Registries
  4. G0136 – Social Determinants of Health (SDOH) Risk Assessment
    1. Health Equity MLN doesn’t mention if ‘incident to’ could be billed. The 2024 physician final rule included language that would allow billing practitioner’s auxiliary personnel to perform during a patient interaction.
    2. Assuming this requires "direct supervision" as this code is not specifically mentioned as a designated care management service. SDOH risk assessment may be reported when provided as part of the AWV with no -cost-sharing. We are exploring opportunities for the RN/clinical staff to provide as part of the AWV when SDOH needs are addressed by the care team in collaboration with the patient’s treating provider.
    3. Auxiliary staff could give the patient a questionnaire, important it’s not ignored, go through that with them and identify any risk. CMS Prevention webpage indicates the removal of cost share for the risk assessment when included within AWV, will be implemented later this year. Watch that webpage for any updates.
    4. A member indicated they will wait for further guidance from CMS. There is desire to use that code within the context of primary care. We have nurses who are under physician oversight. We’re trying to understand the need of the risk assessment in a plan of care, and incident to. Hopefully there will be some clarification from CMS.
    5. Noridian Response: We are waiting for a change request from CMS and will see if there is any other additional guidance out there, and if incident to being discussed within.
    6. MLN9201074 - Health Equity Services in the 2024 Physician Fee Schedule Final Rule
  5. Caregiver Training – Would be helpful to have an FAQ for this topic.
    1. The Health Equity MLN mentioned above includes Caregiver Training guidance. If this doesn’t answer your questions, we would love to hear from you what caregiver guidance training would be needed to further develop education. We’ve worked with associations on what type of person is eligible. The codes are set up for only the caregiver, the patient does not need to be present.
    2. A member mentioned the code says that the patient can be there, but if you’re using them as a demonstration to the caregiver, you should not use the caregiver code, but can bill that time as if it were treatment. Example: Range of motion for extremity, you can bill for therapeutic exercise code 97110 as if you’re doing it with the patient. If the patient is there, but the info given to the caregiver is solely instruction without demo, you would use the caregiver code. The MLN resource also indicates the caregiver would be someone that is not paid. Can be a friend, but not a professional caregiver. It has to be free.
    3. A member asked to provide the source for the non-paid vs paid caregiver.
      MLN9201074 - Health Equity Services in the 2024 Physician Fee Schedule Final Rule (cms.gov) – Page 2
  6. Change Healthcare Cyberattack
    1. Can you please confirm Noridian Medicare will still be accepting and paying Medicare claims? This is affecting people across the nation.
    2. Noridian’s Response: Yes, we will continue to process and pay for Medicare claims. We have an Alert for the cyberattack posted on our website. As we receive updates from CMS, the Alert will be updated. Our Electronic Data Interchange (EDI) has also provided an update that will simplify any changes requested when switching to a different vendor. If you are a provider struggling financially, you have the opportunity to request an accelerated (Part A) or advanced payment (Part B) request.
    3. Article Detail #10521 - JE Part A - Noridian
    4. Article Detail #10534 - JE Part B - Noridian
    5. Article Detail #10529 - JF Part A - Noridian
    6. Article Detail #10534 - JF Part B - Noridian
    Member discussion: As a Change Healthcare customer, we can utilize other technology and get claims submitted to Noridian. Now we’re faced with receiving payments but do not have access to the 835s (electronic reports). We need access to the Noridian Portal. Is there a contact to assist with expediting additional facilities to our Noridian administrator account? We have an account, it just doesn’t have all our facilities, and we have over 1000 locations. Is there someone you can provide a name that we can work directly with, send a spreadsheet?
    We’ve been hearing that the 835s that were currently with Change will be gone. Will Noridian be able to reload those?
    Our challenges are not necessarily with new patients but mitigating the 270-271 response to make sure the patient still has Medicare for existing patients.
    We do not have our eligibility function through Change.
    The Change Healthcare issue is very big, and we are feeling very lost.
    Noridian response: The best advice is to reach out to our EDI team for the electronic report questions, they might be able to help you. We have a team internally working to alleviate these types of issues affecting facilities and providers. We need to funnel through this team to make sure we’re all getting the same answers. Does anyone else have anything to add?
    EDISS Notice - Electronic Data Interchange (edissweb.com)
  7. Top five inquiries to Provider Call Center (PCC)
    1. Part A
      1. Missing or invalid code(s)
      2. Payment explanation or calculation
      3. Contractual obligations not met
      4. Referral from self-service on the Interactive Voice Response (IVR) or Noridian Medical Portal (NMP)
      5. Coding errors and modifiers
      6. Claim Overlap
    2. Part B
      1. Coding errors and modifiers
      2. Claim form 1500 item
      3. Medicare Secondary Payer (MSP) questions
      4. Medical necessity
      5. Claim Overlap

Upcoming Education and Training Events

Providers can view Ask the Contractor Meetings (ACMs), webinars, and related training opportunities by visiting the "Education and Outreach/ Schedule of Events" section of our website.

Webinars and Schedule of Events

Virtual Two-day Symposium Coming April 17 and 18
The events have been posted. Registration is open. There is a banner on the home page that will take you directly to the Symposium page.

2024 Ask the Contractor Meetings (ACMs)
CMS requires quarterly ACMs (formerly ACTs). Noridian offers a question-and-answer portion within each webinar to help streamline applicable topics, audience, and questions for experts.

  • March 20 (Part A), April 10 (Part B), August 28 (Part A), and November 6 (Part B) from 3-4 p.m. CT, 2-3 p.m. MT, and 1-2 p.m. PT
  • Submit questions in advance through the Pre-Question Process on our website.

Please share recommendations for any timing, frequency, size, topics, and provider type(s) for the 2024 ACM schedule.

Provider Contact Center Training
CMS approves training for Customer Service Representatives (CSRs) for up to eight hours per month. The training improves consistency and accuracy, understanding of issues, and knowledge retention. POE participates in training Customer Service Representatives each month.

POEAG member recommendations for PCC training topic or related recommendations are welcome.

Electronic Mailing List (Listserv)
Noridian’s email list is routinely distributed Friday mornings with a CMS-authored MLN Connect sent out each Thursday. Noridian’s providers will benefit by seeing outreach opportunities and register as those events are available.

New POEAG Suggestions and Recommendations

During each meeting, all POEAG members are asked to provide suggestions on ways to increase education, improve training methods, CSR training topic recommendations, or elaborate on topics discussed during the meeting.

  1. MFT and MHC members would benefit from hearing from Noridian on:
    • Licensed in California, performing telehealth only services, and live in a state other than where they’re licensed. Running into problems because they’re not licensed in the state they’re working out of. Education regarding provider enrollment. Maybe it doesn’t go into the weeds in enough detail.
    • Noridian Response: Telehealth is billed depending on where the provider is sitting, they need to be licensed in that state. Some providers maybe have California plus other states and only register in the state they are rendering from. That is the guidance we’ve received from CMS.
    • Follow up discussion: Great clarification, we will disseminate that. If they’re living and providing services out of somewhere they’re not licensed, would that render the provider as Medicare-ineligible and they should not try to opt-out?
    • Medicare does not allow PT, OT, Speech therapy to opt out once they’ve opted in. We’re trying to get legislation for therapists to opt out. I don’t know about other professions, but it’s a problem with us. Once you’re opted out, you’re opted out in all settings for two years.
    • For telehealth, one area we follow is the Center for Connected Health Policy (CCHP), they have a lot of good info regarding crossing state lines for telehealth. They also follow recent changes. Home | Center for Connected Health Policy (cchpca.org)
    • Noridian Response: To opt-out, the provider would need to be an eligible Medicare provider. CMS limits the provider types that are eligible to opt-out. Refer to CMS Internet Only Manual (IOM) publication, 100-02, Chapter 15, Section 40. We will provide additional clarification on enrolling vs opting out. Thank you for sharing the telehealth resource.
    • Providers who are both MFTs and MHCs
    • Noridian Response: Providers that are both MHC and MFTs would have two enrollment records and would need to enroll separately. Both of their licensure and backgrounds would be listed within the application data portion.
  2. Therapist Medical Records: When reviewing therapist medical records, there are many therapists that will discharge the patient once they reach the $3,000 Medicare threshold. My colleagues stress during in-services and webinars that it’s not an automatic discharge point. Could Noridian consider an article, association letter, or other education? Therapists worry they will be audited if they submit claims over the threshold limit. For KX modifier, the threshold used to be $3,700, it was a mandated review. Many therapists are paranoid about being audited by Medicare and they choose to discharge the patient from therapy. Is there any data on the percentage of people who are audited based on that threshold.
    • Noridian Response: The decision to continue therapy treatment is based on need and medical necessity of the patient, not a dollar threshold. There are reviews on physical therapy, but it’s usually not based on KX modifier. The reviews are looking for outliers, someone billing therapy five times a week over a long period of time. The need is based on necessity to continue therapy when using KX modifier. Claims can be reviewed. Providers can execute maintenance therapy. We can provide an article or other education.
  3. Conversion factor for Medicare Physician Fee Schedule (MPFS) increase in the beginning of March.
    • Noridian Response: Yes, congress passed an increase in the MPFS that took effect March 9, 2024. This increase will not be retroactive to January 1, 2024. Noridian has two fee schedules posted on the website for the different time periods in 2024, based on the date of service.

Upcoming Meetings

Meetings for 2024

We continue to meet four times per year.
When: All meeting times 2-3 p.m. CT, 1-2 p.m. MT, and 12-1 p.m. PT

  • March 12
  • June 11
  • September 10
  • December 10

Thank you for attending today’s meeting. We look forward to working with all of you again.

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