Provider Outreach and Education Advisory Group (POE AG) Meeting Minutes - September 10, 2024

Roll Call

POEAG Member Attendees

JE

Angela Amey, Becky Clearwater, Gloria Beazley, Mitchel Kaye, Sara Jasper, Stacey Singer, Susan LaPadula

JF

Anna Gauslow, Carol Self, Dawn Davidson, Jana Weis, Lisa Davies, Mollie Brooks, Nicole Bratlie Sarah Luther

CMS

Kathy Browley

Noridian Attendees

Teresa Cirelli, Cheryl Hanson, Dani Aasen, Jan Ervin, Miriam Ocampo-Funderburk, Tammy Ewers, Val Cavett, Jennifer Joyce, Julie Schroeder, Daylann Robertson, Emily Salvatore, Erica Westbrock, Gretchen Kirklewski, Kate Petersen, Marci Eckroth, Tanisha Barnhardt, Tracy Farahmand, 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. 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. 09-10: Draft article shared. POEAG members appreciate the article.
      1. Member question: Once published, does Noridian plan on sharing with other MACs to see if they would like to also post an article? Some of the MACs have already published information.
      2. Noridian response: Noridian will research on sharing the article.
  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? The CPT book states same or related problem. The diagnosis code would not be the only determining factor.
      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? It doesn't state one way or the other and CMS is silent on this.
      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. 9/10: Discussions have taken place and a final draft version is not ready currently.
  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 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 will be included in the Noridian SNF Prove Review webinar on Thursday, June 13, 2024.??????? https://attendee.gotowebinar.com/register/2102102843986534491
    8. 9/10: Update on Medical Review findings for the SNF 5 claim review.
      1. Noridian continues to post quarterly updates from the reviews on our Part A webpages. The trending errors continue to look similar or the same. The next update is planned for the end of September.

Agenda Items

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

  1. Noridian website home page accessibility using screen reading technology for a person with visual impairment. The homepage has many text boxes that include vertical lists with multiple links. A screen reader may not be able to follow and require assistance from someone.
    Noridian response: We are in communication with our technology team to review and working with the external vendor to update the page.
  2. Should CPT code 45390 be included in the LCD article A57343 for Diagnostic and Therapeutic Colonoscopy?
    Noridian response: Yes, 45390 should be included in the article mentioned. We have quarterly updates needed to this article as well so 45390 will be added at the same time. Providers can expect to see the update, notification, etc., by end of September.
  3. Procedures with KX modifiers for gender changes (diagnosis F64.0) deny provider responsibility (example 19325), not covered; should this deny as patient responsibility or should obtain an Advance Beneficiary Notice of Noncoverage (ABN)?
    Noridian response: Yes, this would deny. For a Patient Responsibility (PR) denial, the provider should obtain ABN and bill with the GA modifier which will result in PR denial. Coverage for gender reassignment is a case-by-case coverage decision by MACs without a CMS-issued a national policy.
    1. Member question: Do providers assume it's not covered, obtain the ABN, and if the procedure is covered, the claim is paid with the GA modifier?
    2. Noridian response: The claim would process through the system and the modifier would not be considered if the procedure would be covered.
  4. Skilled Nursing Facility (SNF) Education Requests
    1. Skilled Nursing Facilities SNFs are requesting a Comprehensive Medicare Denial Letter education specific to Part A and Part B within the SNF. They seek comprehensive samples of the current CMS versions of these letters, along with detailed explanations of the purpose, timing, and required content that must be presented to the Medicare Beneficiary or Responsible Party in a timely manner.
    2. Provide information on Appointment of Representative options and statutory guidelines for a beneficiary unable to sign the notice. Kindly include links for students to the CMS websites displaying the current full letters. In the SNF setting, multiple CMS denial letters are utilized, each supported by CMS regulations.

      A "deeper dive with comprehensive content coverage" would be greatly appreciated. This is an important subject for both Beneficiaries and Provider's Liability. Therefore, we recommend focusing solely on this subject matter in one training for attendees and students of Skilled Nursing Facilities SNFs.
      Noridian response: We will work to create a presentation including all SNF notification for Part A and Part B.
  5. Top five inquiries to Provider Call Center (PCC)
    1. Part A
      • Missing or Invalid Code - over 2,000
      • Payment explanation or calculation
      • Contractual obligation not met
      • Status of claim
      • Claim overlap
    2. Part B
      • Coding errors or modifiers - over 3,000
      • Interactive Voice Response (IVR) or Noridian Medicare Portal (NMP) referral
      • Medical necessity
      • Medicare Secondary Payer (MSP)
      • Status of claim

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 in March

Watch for information to be posted soon.

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.

  • Refresher on endoscopic procedures
    • Noridian response: We are updating the presentation; however, the tutorial has been updated on our website under Provider Outreach and Education > Education on Demand.
  • New Social Determinants of Health - CMS put out a recent MLN article, but clarification has been given since then. Can additional education be provided on this?
    • Noridian response: We will look into providing this education.
  • 2025 Final Rule codes promoting health equity - Although these benefit patients, it's difficult to determine all of the elements.
    • Noridian response: The Federally Qualified Health Center (FQHC) Part A page has a detailed page and we will work on adding all of this information to the Part B site as well.
  • New add-on codes appear to be expanding. Once the Final Rules are out, many providers will need help with documentation, when they can or cannot be used, etc. This could be a topic for education.
    • Noridian response: Some codes are implemented immediately and some we need to wait for guidance. Sometimes rules are effective January 1, 2025, for example, but implementation is not until later in the year. We educate as soon as possible.
  • CMS was going to release clarification on the G2211 but I haven't seen anything yet. Do you have information on this?

Training Topics for Call Center

  • We have Licensed Professional Clinical Counselors (LPCCs) who have called the Contact Center to ask about enrolling, and they are told they are not eligible to enroll. I believe this is incorrect, can training be provided?
    • Noridian response: Yes, they may enroll as an LPCC, must have masters or doctoral degree, need 3,000 hours of clinical supervised experience post-degree, include license number and effective date. Training will be provided to the Provider Contact Center.
    • Review the CMS Internet Only Manual, Program Integrity Manual, publication 100-08 Chapter 10, Section 10.2.3.18 - Mental Health Counselors (MHCs); pages 145-148.

      C. Further Information

      1. Other Titles - Individuals who meet all applicable statutory and regulatory qualifications to be an MHC --- even though they may be licensed or certified by their state under a different title to furnish mental health counseling --- may enroll as an MHC. This includes mental health professionals who otherwise meet the requirements of § 410.54(a). (While a clinical psychologist, for instance, must possess a doctoral degree in psychology to enroll as such in Medicare, only a master's degree is required for MHC enrollment.) In short, the individual's specific title under state law for purposes of mental health counseling is less important than whether the requirements of § 410.54(a) are met. As an example, addiction counselors, ADCs, and licensed professional counselors (LPCs) may enroll as MHCs if they meet the MHC requirements. They cannot, however, enroll as addiction counselors, ADCs, or LPCs, for Medicare does not recognize such supplier types.

General Questions

  • Is there a way to get numbers from Noridian on how many California Marriage and Family Therapists (MFTs) have enrolled or opted out through the MAC to date?
  • In respect to the ordering and referring. How can we identify who is enrolled as an Opt Out provider?
  • Regarding Marriage and Family Therapists, what is the policy if someone doesn't take action on their enrollment? For example, one patient ages into Medicare, what are the consequences if that person doesn't enroll?
    • Noridian's response: If a provider bills but is not enrolled, there is a monetary penalty. That provider must either enroll or opt out of Medicare. In the latter case, a private contract with the beneficiary must be made. Providers must understand the requirements on enrolling and the fines that may occur.
      • Are there any trainings on this?
        • Information on enrolling and opting out is available on the Noridian website under Provider Enrollment. Also, there are several tutorials available on NMP functionality.

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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