Provider Outreach and Education Advisory Group (POE AG) Meeting Minutes - September 12, 2023

Roll Call

POEAG Member or Other (CMS) Attendees

JE: Cheryl Bradley, Mitchel Kaye, Luci Hendrickson (substitute for Rob Sikorski), Susan LaPadula, Tameka Island, and Beckie Northwood

JF: Anna Gauslow, Dawn Davidson, Jana Weis, Lisa Davies, Mindy Gale, Mollie Brooks, and Kimberly Sattler

Noridian Attendees

Teresa Cirelli, Cheryl Hanson, Erin Swaidner, Jan Ervin, Katie Wik, Kim Phillips, Miriam Funderburk, Tammy Ewers, Tim Morrissey, Val Cavett, Kathryn Grueneich, and Tracy Schutt

POEAG Mission and Goals

The primary function of the POE Advisory Group is to assist Noridian in the creation, implementation and review of our provider education and training strategy and efforts. 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 were 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. 09/13/22. Skilled Nursing Facility (SNF) Demand Bill Education.
    1. Topic was not conducted in previous SNF Noridian education and outreach. Noridian will work to educate on the regulatory privileges for all Medicare beneficiaries, include the right to demand a bill to be sent to Medicare.
    2. 03/14: Noridian is producing an Education-on-Demand Tutorial. The tutorial was expected by the end of 2022 and has been moved to the end of March 2023.
    3. 06/13:  Noridian continues to work on this education and is confirming information included in the CMS manual. A POEAG member offered to help with this education.
    4. 09/12: Demand Bill education was included in the SNF Fundamentals 102 webinar that was held on August 3. The recording of the webinar is available on the Part A website under Education and Outreach. The tutorial will be available soon.
  2. 09/13/22. 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.
  3. 03/14: Request training sessions for End Stage Renal Disease (ESRD) Billing to include the use of modifiers.
    1. Modifiers AY, JW, and JZ were mentioned.
    2. 09/12: The ESRD webinar was presented on August 16. The recording of the webinar is available on our website under Education and Outreach, Webinar on Demand Recordings. Modifier AY was included in the education. For drug wastage modifiers JW and JZ, Noridian includes information on the website under Topics; Drugs, Biologicals, and Injections; Drug Wastage - JW and JZ Modifiers.
  4. 06/13: 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. Expect to have an update in the next quarter.
      2. POE Part A holding TPE webinar September 13.

Agenda Items

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

  1. Questions have been received regarding telephone call CPT code 99441-99443.
    1. Should modifier FQ be added?
    2. Should the Place of Service (POS) be where the patient would have been seen through December 2023?
    3. Noridian response: Modifiers FQ and FR are for mental health telehealth only. (Source: CR12549)
      • Through the Consolidated Appropriations Act (CAA) 2023, CMS has extended the following Telehealth waivers and flexibilities until the end of 2023.
      • Services temporarily added to Medicare Telehealth will be available through 2023.
      • Providers may continue to use the POS they would have used if rendering the service in person with modifier-95 appended until end of 2023.
      • Question: Phone codes are considered telehealth with audio only? Questioning modifier 95.
      • Noridian response: For CMS, FQ is recognized for mental health codes only. MLN901705 contains additional information on telehealth services. CPT codes 99441-99443 are currently listed on the Telehealth Services for 2023.
  2. Physician Supervision of Dialysis for Acute Kidney Injury Billing and Coding Article
    1. The "Please Note" section of the article indicates end stage renal disease may be a covered condition. However, the approved covered diagnoses do not include N18.6 - End stage renal disease.
      1. JE A55992
      2. JF A55996
    2. Noridian response: The Medical Review department is in the process of updating the article and appreciates this being brought to their attention. Diagnosis N18.6 will be added, and the article posted by next week.
  3. Suggested Evaluation and Management (E/M) Education:
    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
      • 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?
      • 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?
      • 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.
        Suggestion to develop an article.
  4. Suggestion to provide written copy of pre-submitted questions along with the corresponding answer, similar to a Frequently Asked Questions (FAQ) document. The Ask the Contractor Meetings include a published Q&A.
    1. Noridian response: We have made a change in our webinars and will now include a transcription option with the webinar recording. This will only be applied to new recordings published on or after September first. Reps are encouraged to read aloud the question and answers that are written in the chat so that they are included within the transcript.
  5. Update from the Medicare Medical Review Department with the most common errors in Part A chart reviews.
    1. MR Part A posts our highest trending error rate results of the service topics on our Noridian provider websites. This site is updated quarterly and refreshed with the top three trending service topics that currently are under review. Along with the service topic and trending current payment error rate, there is educational information on the specific trending errors when you click on the review results link.
  6. Education for end of the Public Health Emergency (PHE) - suggestion received from March 2023 POEAG.
    • Has anyone encountered a waiver or flexibility that has ended and was not able to find a resource to reference?
    • Are there any areas Noridian should be aware of that may be causing questions at your facility?
    • We want to hear about experiences from POEAG members.
      • Question: Does POE have guidance from CMS on new COVID vaccine and administration codes released by the AMA a couple of weeks ago? Which codes are still in existence and what is changing? The CMS website doesn’t reflect any of the new codes yet. When will the MACs be ready to process the new codes?
      • Noridian Response: The COVID page was last updated on September 6. Teresa will research between the time difference of AMA posting and CMS website updates.
  7. Education request received through surveys: Portal Education - Reviewing options for resources and education for providers to learn how to use the Noridian Medicare Portal (NMP).
    • Which options would POEAG members recommend:
      • Live - offered multiple times throughout the year
      • Recorded and available at all times
      • Other options
  8. MAC Customer Experience (MCE) Satisfaction Survey Update: Surveys reflect the webinar presentation content is informative. We review the survey comments and look for opportunities to improve educational topics, webinar materials and presentation skills. Here are a few recommendations for future education:
    1. Cardiology
    2. On-line portal codes 99421-99423
    3. Shared or split guidelines following 2024 final rule
    4. Endoscopic procedure coding and billing
    5. Modifier 25 with examples showing what does or does not meet criteria
    6. Wound care
    7. Advanced Practitioners Incident to for procedures
    8. Auditing, conversation with providers for implemented changes
    9. Pathology billing and modifiers
    10. Skin substitutes
    11. Provider types not allowed to bill like physicians
    12. Ears, nose and throat
    13. Plastic surgery
    14. Psychotherapy billed with E/M codes
    15. Facility observation charging
      Noridian Question: How can Noridian promote the surveys and make them more engaging? Do you take the surveys? Note: All MACs are required to use the same surveys.
      • Surveys are redundant with the same questions so sometimes it’s skipped.
      • Another member figured enough other people were taking the survey. They will make it a point to take the survey going forward.
      • When there is more than one presenter, we can’t evaluate each person.
      • It seems like people would make a point to complete a survey if they had some negative experience so maybe you’re not getting a lot of completion because everything was fine.

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

"Hitting a Home Run with Medicare" - Virtual Two-day Symposium - September 20 and 21

Six educational sessions offered each day. Guest speakers include CMS, Comprehensive Error Rate Testing (CERT), Durable Medical Equipment (DME), Supplemental Medicare Review Contractor (SMRC), Provider Audit, along with the Provider Outreach and Education team.

2023 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 22 (Part A), April 19 (Part B), August 30 (Part A), and October 11 (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 2023 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. Question: ESRD providers are experiencing an issue with the CPT code 90999 paying in cents instead of dollars in FISS. Are there any updates? We are wondering what we are supposed to do with the claims.
    Noridian response: All MACs are affected and are awaiting direction from CMS.
  2. Suggestion: It would be great to get an interpretation of completing Medical Decision Making (MDM) in its entirety from the Medical Directors. Providers are asking if each and every diagnosis covered in the MDM must be reviewed to meet the definition of 'entirety'.
    Noridian response: We suggest asking this question to the AMA at their November conference. CMS is usually in attendance.
  3. Question: Regarding shared medical appointments where there is one physician with multiple patients, what are Medicare’s thoughts on this?
    Noridian response: We have not received anything from CMS regarding this. We’ve heard providers want to do group annual wellness visits, or diabetic management, etc. We can reach out to CMS to request guidance on group visits.
  4. Question: This question has come up more often recently. There are two providers with one patient at the same time due to clinical need to benefit the patient. Example: Neuro and gastro specialists seeing the patient at the same time. Is this acceptable as long as each note stood alone and based on time that doesn’t overlap? Is there any guidance that Noridian can publish?
    Noridian response: We suggest asking this question to the AMA at their November conference. CMS is usually in attendance. Noridian will also reach out to CMS. If both physicians are in the shared appointment that lasted 20 minutes total, each physician could only count 10 minutes if billing based on time. If billing based on MDM, each physician would need to document their full history, exam and MDM related to their portion of the E/M service.

Upcoming Meetings

Meetings for 2023

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

  • December 12

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

Last Updated Dec 20 , 2023