RCM eNews – July 2023

Starting June 27,2023, any new or renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or other substance use disorders. This new DEA requirement for new and renewing physicians comprises an 8-hour course that costs $80. Click here for further details.

Effective July 1, 2023, Medicare is requiring the JZ modifier to be reported on all claims that bill for drugs separately payable under Part B when there’s no discarded amount from single-dose containers or single-use packages. For the amount you administer, the claim line should include the billing and payment code, such as a HCPCS code, describing the given drug, the JZ modifier showing there were no discarded amounts, and the number of units administered in the units’ field.

There are no changes regarding the reporting of the JW modifier.

CMS is implementing the JZ modifier in phases:

• January 1, 2023: You may report the JZ modifier.
• July 1, 2023: You are required to use the JZ modifier on applicable claims.
• October 2, 2023: Claims editing starts when JW or JZ modifiers aren’t used correctly.

Do note that claims that bill for separately payable drugs under Part B from single-dose containers that don’t report the JW or JZ modifier on or after July 1, 2023, may be subject to audits. For further details about the JW and JZ modifiers, click here. For further information about this new requirement, click here.

From CMS:

When there’s an accident, another entity has responsibility for paying before Medicare for accident-related services. Sometimes, claims are mistakenly denied or rejected in these cases. Don’t deny your patient services, even if it takes some time to figure out who pays first.

Medicare Secondary Payer (MSP) is the term used when Medicare doesn’t have the primary payment responsibility. If you see no-fault, liability, or worker’s compensation MSP coverage information, including accident or injury related diagnosis codes, on the Medicare eligibility response, you must bill the primary payer first for services related to the accident or injury.

If there’s no MSP employer Group Health Plan coverage identified as primary, Medicare is the primary payer for those other services not related to the accident or injury.

If your claim is mistakenly denied or rejected, you can still get paid:

• Submit an appeal to your Medicare Administrative Contractor. Provide an explanation and any relevant reason codes to justify that the services performed aren’t related to the accident or injury on record.
• Part A providers: Submit adjustments with your appeal.

Find more information on how to get accident-related insurance claims paid in our MSP: Don’t Deny Services & Bill Correctly fact sheet.

From CMS:

CMS may reject or return Medicare Part A and Part B claims inappropriately if it appears there’s a mismatch between the procedure or diagnosis code and the reported sex of the patient. This is a reminder to institutional providers and clinicians that bill for Part B professional claims that a condition code/modifier are available to allow these claims to process correctly.

Effective July 1, 2023, the National Uniform Billing Committee revised Condition Code 45 to Gender Incongruence, defined as “characterized by a marked and persistent incongruence between an individual’s experienced gender and sex at birth.”

For any procedure codes often considered appropriate for only one gender, indicate on the claim detail line if the patient’s experienced gender is different than their sex at birth. For claims to process correctly:

Institutional providers: Continue to report condition code 45 (Ambiguous Gender Category) for inpatient and outpatient claims related to transgender, intersex, and gender-expansive systems issues.

Clinicians that bill for Part B professional claims: Report the KX modifier for any claims related to transgender, intersex, and gender-expansive systems issues.

Medicare Part B covers intermediate and intensive tobacco counseling for symptomatic and asymptomatic patients. Tobacco cessation counseling is a service that can be provided via telehealth.

The Consolidated Appropriations Act of 2023 authorized the extension of many of the telehealth flexibilities through 12/31/2024.

Health care providers may offer tobacco counseling services via telehealth to patients located in their homes and outside of designated rural areas.

The Centers for Medicare & Medicaid Services expanded the list of services that can be provided by telehealth. Some of these services will continue to be covered under Medicare through 12/31/2024.

Some types of telehealth services no longer require both audio and video, including tobacco counseling services – visits can be conducted over the telephone.

For details, see the List of Telehealth Services covered by Medicare.
The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that a primary care provider can do to help a tobacco user in a primary care setting.

If time is limited, the 2As and R (Ask, Advise and Refer) can also be effective. In this intervention, the health provider can refer a tobacco user to a quit line, cessation specialist, or other resource for quit plan development.

 

Types of Eligible Providers

Generally, any provider who is eligible to bill Medicare for their professional services is eligible to bill for telehealth during this period.

Documentation

Providers must ensure all performed services are claimed and supported by complete documentation. Smoking cessation documentation should reflect:

• Type or method of tobacco use (cigarettes, vaping device, chewing tobacco, etc.)
• Amount of use (assess if the use qualifies as dependence)
• Impact (personal, family, friends, health, social, financial, etc.)
• Methods and skills for cessation
• Resources available
• Willingness to attempt to quit – If the patient is willing to attempt to quit, agreement on plan of approach
• Implementation date
• Method of follow-up
• Documentation of exact time spent in face-to-face counseling with the patient

Colonial Penn & Bankers Life have partnered with Zelis to offer Electronic Payment (EFT) and Electronic Remittance & Advice (ERA) for Medicare Supplement products. As an enrolled healthcare provider, you can access processed claim information, receive electronic payments, and manage claims payments.

Zelis is a web-based program available for health care providers to access payment and claim information. Zelis provides the following advantages:

Allows authorized users immediate access to information about:

• Claim status
• Remittance details
  • Claim payment details
  • Claim rejection details
• Payments

Provides delivery of claim payments in the following ways:

• Claim Payment Cards
• Electronic Funds Transfer (EFT)

Provides electronic delivery of Explanation of Payments.

Zelis Customer Service: (877) 828-8770.
Zelis Hours: Monday-Friday 8 AM-7PM EST.

Highmark is replacing its existing provider portal, NaviNet, with Availity® Essentials later this year. Availity serves plans nationwide, including many Blue Cross Blue Shield Association licensees like us. Availity’s multi-payer platform will support the existing payer-provider transactions necessary to manage care for Highmark members, including eligibility and benefits, claim status, and claim submission, and serve as a gateway to our utilization management platform to perform authorization transactions.

When is the Transition Happening?

• August & September 2023 – Highmark will engage a pilot group of providers to ensure a seamless transition to the Availity portal.
• October 22, 2023 – Providers who currently use Availity for other payers will see Highmark as an option in the states in which they are contracted.
• February 5, 2024 – Availity will be available to all Highmark providers.
• March – June 2024 – Highmark will retire its use of NaviNet and HEALTHeNET (NY). *More information on the transition timeline will be made available.

  What Do Providers Need to Do for This Transition?

If your organization is already registered with Availity, you do not need to re-register. You may only need to review the Highmark-specific features once they are live. If your organization is not already registered with Availity, you should register for access starting January 10, 2024, or soon thereafter. For details, go to the Register and Get Started with Availity Essentials webpage.

Highmark continues to make enhancements to its new Provider Data Maintenance (PDM) tool. The PDM tool is an easy-to-use electronic application to update, validate, and attest to the accuracy of your Highmark provider directory information in one electronic application. PDM also indicates the last time your directory information was validated and the due date for the next validation deadline.

Beginning June 23, 2023, professional providers will be able to use PDM to view the following credentialing process information:

• Insights into where credentialing applications are in the process.
• Open and closed cases.

Additional enhancements are coming soon, including the ability for providers to use PDM to begin the initial credentialing process and to see credentialing requests previously submitted to Highmark.

Effective July 1,2023, UHC Community Plan is updating its reimbursement for Co-Surgeon and Assistant-at-Surgery to align with the current CMS guidelines.

• Co-Surgeon services reported with modifier 62 will be reimbursed at 62.5% (current rate is 63%.)
• Assistant-at-Surgery services reported with modifier AS will be reimbursed at 13.6% (current rate is 14%.)

Starting Jan.1, 2024, Optum Physical Health will manage the physician, occupational and speech therapy networks for UHC Medicare Advantage and UHC commercial plans of New York.

If you have a contract with Optum Physical Health, no action is required on your part.

If you do not have a contract with Optum Physical Health, and want to prevent a disruption in your participation status, please call (800) 873-4575, or visit:
https://www.myoptumhealthphysicalhealth.com/.