Provider Outreach and Education Advisory Group (POE AG) Meeting Minutes - June 11, 2024

Roll Call

POEAG Member or Other (CMS) Attendees

JE

Angela Amey, Avery Malate, Becky Clearwater, Mitchel Kaye, Susan LaPadula, Tameka Island, Luci Hendrickson, and Stacey Singer

JF

Anna Gauslow, Carol Self, Dawn Davidson, Jana Weis, Lisa Beyer, and Mollie Brooks

Noridian Attendees

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

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. 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. 6/11: 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. 6/11: On hold at this time
  3. 06/13: New 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 is available
      • 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".
      • 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.
    7. 6/11: Review findings, review timeline, top education takeaways
      • CMS started the SNF reviews in June 2023 and will continue until all SNFs have been reviewed. CMS expected this to complete in about a year time frame, however, it may need to be longer until all SNFs have been reviewed.
      • The review findings and top education takeaways presented in the Noridian SNF Probe Medical Review webinar on Thursday, June 13, 2024. Webinar on Demand recording will be available until December 24, 2024.
  4. Change Healthcare Cyberattack As of 5/28, there continues to be a print service disruption affecting the printing and mailing of SPRs. Information can be downloaded from the Noridian Medicare Portal (NMP).

Agenda Items

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

  1. 2024 update of the excluded from Medicare Part A Consolidated Billing in SNFs (up-to-the-minute including proper billing)
    1. Mental health counselors (for services provided on or after January 1, 2024);
    2. Marriage and family therapists (for services provided on or after January 1, 2024);
      https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/consolidated-billing
      Noridian Response: CMS has published to Change Requests (CR)
      CR13576 - July 2024 Quarterly Update to HCPCS Codes Used for SNF Consolidated Billing (CB) Enforcement
      CR13661 - October 2024 Quarterly Update to HCPCS Codes used for SNF CB Enforcement
  2. Nurse Practitioner (NP) and Physician Assistant (PA) practicing as a specialist in group practices. New patient visits may be allowed if seeing a new specialist.
    Noridian Response: Article available on website to follow guidance developed with POEAG suggestion in 2021. The article provides guidance to include information in item 19 of the 1500 claim form to indicate the provider is seeing a new patient for that specialty, and the claim should process. One of the POEAG members encouraged discussion on this topic again and make everyone aware that the article is available on the website. The issue was initially brought to POEAG in 2021 and our CMDs agreed it was important.
    Member discussion:
    1. Providers requested to have this verbally confirmed through POEAG that they would be able to put the specialist information in item 19 of the 1500 claim form. For example, the cardiologist would put their specialty code to bill that as a new patient assuming they haven't been seen by cardiologist in the past three years.
    2. We see a similar issue in our Ohio market, the largest of our three markets. Another Medicare Administrative Contractor (MAC), CGS, provided similar instruction. We still see claims auto deny even with the information is in item 19. Are you also experiencing this at Noridian, are we needing to address this on the backend as a denial?
    3. Noridian Response: We had some issues in the beginning but worked with our Adjudication and Claims teams and feel like they are processing correctly.
      Member response: We are seeing a few denials, but not as many as in the past. We also look internally to verify the claim included the correct information. We've been using it for a while, and it seems to be going smoothly.
  3. Top five inquiries to Provider Call Center (PCC)
    1. Missing or invalid codes or modifiers
    2. Payment explanation or calculation
    3. Contractual obligations not met
    4. Number of days
    5. Credit balance or account receivable

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 September 18 and 19

Watch for information to be posted soon. Our reps planning the event are using compliance theme: Cracking the Medicare Compliance - A Detective Insight. We have a variety of outside speakers. By July, we will start to post on social media such as Facebook and LinkedIn. Spread the word and we're looking forward to having you join us at this event.

Our website will include the variety of education session the first part of August. It'll be a very exciting time!

Webinar Question and Answer Promo

Each presenter makes every effort to include pre-submitted questions. Of course, those who register day of or day before, we can't always include. We do everything we can to make sure we answer questions. If you listen or look at the recording transcript you can see those verbally asked questions and answers.

For events you join, you can download the questions log at the end of the event.

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.

  • Has Noridian heard anything from CMS on G2211? CMS indicated an FAQ would be coming with additional guidance and examples to ensure we're using that appropriately.
    • Noridian response: Yes, great question, we have a webinar on that tomorrow. We checked in with CMS about three weeks ago and they are still working on it. CMS is hearing from several associations and provider offices because they want to know if they're billing appropriately. Sometimes, it may be appropriate, but we don't have the documentation to educate. We are waiting also. One of the key elements in the documentation is to show longevity of care for the patient.
    • Another member had a meeting with Dr. Greenway and Dr. Wolfe at CMS. They hope to have the FAQ soon.
  • One POEAG member is presenting a webinar on coding for rural health, focusing on the regulatory side of RHC and FQHC. A lot of wild questions are received on how claims should look and certain instances of services not within the covered code list. Recommended a webinar that maybe focuses on those weird situations. It would be super well attended. The webinars that are on YouTube were reviewed and didn't see anything covering the unusual situations.
    • Noridian response: Our RHC specialty matter expert requested some of the examples so they could be reviewed. Noridian will look at opportunities to present a webinar in the future, and having examples would really help.
  • A question relative to TPE for SNF. Are there any plans from Noridian to conduct a training program with the audience being the physicians or non-physicians. I think it would be beneficial for the SNF space to have an in-service specific to the function of the physician or non-physician in this space. We could also use this part of our compliance program for our onboarding.
    • Noridian response: That is a lot of what we're planning for this webinar to cover. The biggest issues they see are certification and recertification. We'll review those specifics and what should be included, as well as main errors we've been seeing.
    • Member: If there is a webinar on demand that is carve out for 15 or 30 minutes. In order for service to be considered skilled, here is what you have to do. If a clinician is included in the education, it may insight the interest of providers to attend for the peer-to-peer interaction.
    • Noridian response: We could also do a tutorial for the Part B side that could be for those physicians and practitioners seeing the patients in the SNF.
  • Member: When patients don't meet inpatient criteria, the therapy portion for documentation is what they're concerned about. We thought they'd have to follow guidelines for in or outpatient because they don't know. If they didn't have the outpatient documentation guidelines.
    • Noridian response: These resources are easy to find. If you have more specific questions we can connect after the call and dig up some more resources for your teams.
  • Member: For Part B providers receiving medical records from nursing facilities, more specifically communication via EHR/EMR. There's a lot of questions and debates around whether or not a nursing facility can communicate an order for services via EMR with that order being electronically signed to incorporate an electronic signature to a downstream provider. That's a significant topic in a lot of industries. Is that something you have clarity on? Can that be a takeaway to look into?
    • Noridian response: EHR shared between ordering provider and facility?
    • Member: Electronically signing for diagnostic test, for that EMR communication via HL7 to the downstream provider. It might become a bigger topic. A lot of feedback from providers is that I electronically signed something, why do I have to sign paper now? It's becoming a hot topic as the years go by. I haven't seen an answer.
  • Member: The secondary question is about Part B provider going to the facility to pick up a specimen for laboratory services . Updates introduced by CMS on specimen collection and travel. What would be acceptable for phlebotomy formats? Is there already a plan to provide any type of clarity or have dialogue w/ providers along that particular area? I can send you more information if you'd like to point to what CMS is indicating. Has the website been updated since 2023?
  • Member: For Part A reason code guidance, every time we try to find one it's not on there. Are there certain ones you can't put on there? There's so and we get that aren't on there?
    • Noridian response: This will be something we can look into.

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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