Provider Outreach and Education Advisory Group (POE-AG) Minutes: November 13, 2024

Published 11/25/2024

The Jurisdiction J and Jurisdiction M Part B POE Advisory Group (POE-AG) meeting was held on Wednesday, Nov. 13, 2024.

Palmetto GBA Members

  • Yoshiko White Dimes
  • Belinda Marin
  • Kathy Boehm
  • Keiona Henry
  • Shannon Chase 
  • Kimberly Jeter
  • Shelly Dailey
  • Jazz Harrision
  • Wendy Weary

Welcome

POE-AG members were welcomed by the facilitator.

Goals/Purpose

Our Goals

  • Establish and maintain strong relationships with Palmetto GBA staff and the provider community 
  • Meet with Palmetto GBA and the provider community on a quarterly basis 
  • Provide the communication tools to facilitate thorough and prompt transfer of information to and from each representative 
  • Coordinate the issues within the provider community to adequately reflect the concerns of the majority 

Palmetto GBA’s Intent

  • Promote an atmosphere that facilitates an exchange of ideas and information to service the best interests of Medicare providers and Palmetto GBA’s Medicare program administration 
  • Provide educational forums that address various global provider concerns 
  • Allow the provider community an opportunity to communicate with Palmetto GBA’s staff on any areas that may need additional education activities 
  • Assist in making the Medicare program more understandable for providers 
  • Enhance providers’ understanding of the role and responsibilities of Palmetto GBA as their A/B Medicare Administrative Contractor (MAC) 

Old Business

  • None 
  • We will be conducting our annual POE-AG membership review for the remainder of the year. Members who do not meet the POE-AG requirements of attending three consecutive meetings will be rotated off the roster.

Special Agenda Topics

  • Autumn Run
    • Palmetto GBA’s Provider Outreach and Education team will be traveling across Jurisdictions J and M this November to bring you current updates and education from Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS). Every Autumn Run event is free to attend, but registration is required.
    • We are currently on the road traveling to Alabama, Tennessee, Georgia, North Carolina or Virginia. Each Autumn Run. Each event is a half-day, clinician-led and in-person. We will cover various topics to include provider enrollment, medical review, appeals, additonal documentation requests (ADRs), Targeted Probe and Educate (TPE) and Comprehensive Error Rate Testing (CERT) process. The sessions will run from Tuesday, November 12, through Monday, November 18.
  • Ornaments of Education
    • Registration will open soon for Ornaments of Education, a virtual prior authorization conference conducted by Provider Outreach and Education. Providers should watch upcoming email updates to register for the event, which will be held mid-December of this year. There is no cost to our provider community. Sessions will address Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT), Outpatient Prior Authorization Department (OPD), CERT, and TPE.
  • 2025 Spring Tour
    • We have begun planning for our 2025 face-to-face Spring Tour. We look to our provider community to suggest topics that you feel would benefit a large group of providers. We use these sessions to achieve our mission of providing global education, which is intended to reach and benefit the maximum amount of providers. 
    • Member submitted HCPCS code G2211
      • POE advised we have offered several educational sessions on the code and will advise members if any additional guidance is published on the codes
      • Member expressed they have attended sessions and appreciated the education
    • These are half-day sessions, but right on the heels of Spring Tour is our virtual MAYfest, so if we don’t get to your topics then, there will be several more opportunities to squeeze them in

Calendar of Events (Educational Needs)/Palmetto GBA Announcements

Hot Topics

Upcoming change requests and MLNs
(Please be advised, this is not an educational session. We will discuss MLNs, then give members an opportunity to advise what additional education may be needed for provider community.)

  • 2025 Final Rule Fact Sheet — Calendar Year (CY) 2025 Medicare Physician Fee Schedule 
    • Last POE-AG, we shared a listing that included all the topics CMS were considering as a proposal under the 2025 final rule. Since then, CMS has recently published a fact sheet with updates as to where they are in the process of finalizing the proposed rule.
    • On November 1, 2024, CMS issued a rule finalizing changes for Medicare payments under the PFS and other Medicare Part B policies, effective on or after January 1, 2025
    • The CY 2025 Physician Fee Schedule (PFS) final rule is one of several final rules. Many of these services are still being finalized and not in the final form yet, but CMS has published information in the latest MLN dated Nov. 7, with updates describing where they are in that process. We can however share with you the published Fact Sheet. CMS has released a Fact Sheet for the 2025 Medicare PFS Final Rule. HHS Finalizes Physician Payment Rule Strengthening Person-Centered Care and Health Quality Measures.
    • We anticipate that CMS will provide future direction on how the changes are to be implemented. Please be sure to sign up for our listserv messages to receive information as it becomes available 
       
  • Global Surgery
    • Information published in the September 5 MLN
    • In a report (PDF), the Office of the Inspector General found that providers didn’t always comply with federal requirements when they bill for surgical services, including missing co-surgery and assistant-at-surgery modifiers. Review Global Surgery (PDF), and learn about: Coding, Billing and Payment.
    • As part of a collaborative effort, we will be holding a two-part Global Surgery Webinar Series
      • During this two-part webinar series, participants will learn about the global surgery concept, as well as the correct use of modifiers for visits and other procedures within the global surgical period. While participation in both sessions is not a requirement, providers are strongly encouraged to register and attend both sessions for the most comprehensive education regarding all aspects of the Medicare global surgery package.
      • Session 1: November 14, 2024, 10 a.m. ET — JJ/JM Part B Fundamentals of Global Surgery. This 90-minute session will discuss the basics of global surgery and explore the Evaluation and Management (E/M) CPT modifiers 24 and 25, while demonstrating scenarios to appropriately apply these modifiers. We'll guide you through billing scenarios and reimbursement methodologies for surgical situations and endoscopic procedures. Our goal is for you to gain a better understanding of global surgery and clarify billing situations within the global surgery period.
      • Session 2: November 22, 2024, 10 a.m. ET — JJ/JM Part B Global Surgery Modifiers. This 90-minute session will build on the global surgery basics provided in session 1 and will discuss the basics of CPT modifiers 54, 55, 57, 58, 78, 79, 50 and HCPCS modifiers LT/RT, while demonstrating scenarios to appropriately apply these modifiers. We'll guide you through billing scenarios and reimbursement methodologies for surgical situations related to these modifiers and the global surgery package.
      • This session was developed through the A/B MAC Provider Outreach & Education (POE) Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.
         
  • 2024/2025 Vaccine Updates
    • COVID-19
    • Influenza and Pneumococcal
      • CMS has released the 2024 Influenza and Pneumococcal Vaccines and Administration Reimbursement (Article Title)
      • It will include a listing of that includes the services that are paid at 100 percent of the established fee schedule amount. Coinsurance and the annual deductible do not apply. 
      • Payment allowances for influenza vaccines are effective August 1, 2024, unless stated otherwise
      • Please note: Influenza and pneumococcal vaccine payment allowances are subject to change on a quarterly basis*
      • Quarterly changes to influenza and pneumococcal vaccine payment allowances can be located on the CMS ASP Pricing Files website
      • Administration payment allowances are updated annually on January 1
      • Influenza, and Pneumococcal Administration Codes and Fees
      • Following are the 2024 influenza and pneumococcal administration fees for dates of service January 1 – December 31, 2024
      • Influenza Virus Vaccine National Fees Effective August 1, 2024 – July 31, 2025. The 2024/2025 flu season fees are listed below. Contractors are required to implement these fees no later than September 27, 2024. Palmetto GBA implemented the following fees on August 28, 2024, for dates of service August 1, 2024, and after. All claims processed and paid prior to August 28, 2024, will be automatically adjusted. No further action is required
      • Disclaimer: The list may not be all-inclusive. Please be sure you are providing vaccines appropriate for the current 2024/2025 flu season
    • Pneumococcal Vaccine National Fees 
      • The fees provided below are subject to change with each quarterly drug update. Current fees, are posted on the CMS website
      • 2024 Influenza and Pneumococcal Vaccines and Administration Reimbursement
  • More Part B IVR Changes
    • Beneficiary Eligibility to Be Removed from Interactive Voice Response System
      • In the coming months, Medicare providers will no longer be able to obtain beneficiary eligibility information via Palmetto GBA’s Interactive Voice Response (IVR) telephone system
      • The most efficient way of validating beneficiary eligibility is via Palmetto GBA’s internet portal, eServices. You can utilize the MBI Lookup Tool there to quickly and easily verify a beneficiary’s eligibility. If you are not already using our provider internet portal, we encourage you to register for eServices today.
      • Presently, callers cannot obtain this information from our customer service representatives. Moving forward, this information will become unavailable to callers to the IVR as well.
      • Following a review by the Office of Inspector General (OIG), CMS has determined to eliminate eligibility requests via the IVR. This action is being taken in the interests of protecting the security of both providers and beneficiaries by eliminating avenues for potential fraud and abuse.
      • Only a small percentage of eligibility requests are made via the IVR. Transition to the Palmetto GBA eServices portal for verifying beneficiary eligibility should be easily accomplished
      • Disable Beneficiary Eligibility Information from Medicare Administrative Contractor (MAC) Interactive Voice Response (IVR) Systems
      • Beneficiary Eligibility to Be Removed from Interactive Voice Response System
      • eServices: Eligibility Options Module 
      • We created a module as a quick step guide for providers needing a refresher on how to look up patient eligibility information
      • The current implementation date as published by CMS is March 31, 2025
         
  • Educational Opportunities
    • In addition to our Autumn Run, Ornaments of Education and Spring Tour 2025, we also have some additional offerings for you

What: Additional Documentation Requests: Responding to an ADR webinar
Date: Tuesday, November 19, 2024
Time: 11:30 a.m. ET

Palmetto GBA will host the Additional Documentation Requests: Responding to an ADR webinar on November 19, 2024, at 11:30 a.m. ET. This webinar session will provide a clear understanding of the ADR process and explain the appropriate process when responding to an ADR. The subject matter expert will describe examples of medical record documentation for submission in response to an ADR and clarify steps to take upon collection and preparation of medical record documentation prior to submission for review. This session will also deliver information regarding the TPE process, the CERT program.

What: Documenting Outpatient Therapy Services webinar
Date: Tuesday, November 19, 2024
Time: 2 p.m. ET

This live webinar session will provide a clear understanding of the differences between physical, occupational, and speech language therapy and also provide a clear understanding of therapy documentation guidelines for the federal Medicare program. The subject matter expert will explain the differences between maintenance and rehabilitative therapies, clarify general guidelines for physical and occupational therapy, as well as deliver information regarding documentation requirements for manual therapy, therapeutic exercise and activities, and neuromuscular re-education. Valuable references and resources will be offered, as well as a live question and answer period.

Name: Part B Surgical Debridement webinar
Date: Thursday, November 21, 2024
Time: 1 p.m. ET 

This webinar focus covers the billing and coverage guidelines for surgical debridement services. We will review documentation and medical necessity tips with a goal of preventing costly denials. 

  • If you miss the ADR or OTPT therapy webinar, no worries, they will be held again in December


What: Jurisdictions J and M Recovery Audit Contractor (RAC), Cotiviti webinar
Date: Wednesday, December 18, 2024
Time: 10 a.m. ET (60 minutes)
Presenter: Karen Reed, Cotiviti Program Director, RAC

Palmetto GBA is pleased to partner with Cotiviti, the CMS RAC, for a webinar on December 18, 2024, at 10 a.m. Palmetto GBA Part A, B, home health, and hospice providers, facilities and agencies will have the opportunity to hear directly from the RAC as they share insight into Cotiviti's roles, responsibilities, and general RAC activities as a CMS RAC. This session will be of interest to Part A and B facilities, providers, home health and hospice agency, compliance officers, auditors, coders, billers, account receivable staff, office managers and other Medicare billing staff.

  • Be on the look out for the December Quarterly Updates webinar. Registration for that session should be on the website by the end of the week
     
  • 2025 POE-AG — POE-AG members discussed POE-AG times slot for 2025. Members were polled to determine what time works best for group. POE-AG lead to collect responses via email.

eServices Enhancements/Updates

  • Fourth Quarter Website Updates and Enhancements
    • Claims Messages/EOB Narrative
      • eServices now displays claim line messages that give further claim details. If you are looking up the status of your claims, you will now see a field titled ‘line messages’. This field contains high level EOB narratives that have been added to the claim tab so providers can see the high level remarks codes that appear on their remittance advice.
      • Note: There is a high possibility that additional messages are also on your remittance advice. Please download a copy of your remittance advice from the Claim Status information page.
      • We recently had a focus group where providers gave feedback on this feature, stating they would like to see those additional messages on the same tab. The eCommerce team gathered the feedback, but informed providers there may be system limitations that prevent us from pulling those into eServices at this time. They plan to review this in the future to see what can be done. 
    • Account Activity Link
      • We introduced this enhancement during the last POE-AG as well. Since then, this feature has been implemented and is performing extremely well. This enhancement was designed to prevent 30-day lockouts for providers who don’t regularly use the eServices portal.
      • We have seen a drastic decrease in the number of tickets submitted to our eCommerce team seeking account resets 
      • As a recap, providers will no longer need to login
      • When you get the email, “...to prevent ACCOUNT SUSPENSION” just use the link in the email and your account will stay active
      • Providers will get a message after using the link that your action was successful. No need to do anything else.
      • The link will expire, so be sure to use it before the date in the email title

Agenda Items Submitted by Members

  • Off-Label Drug Approval
    • What is the process for getting off label drugs (both medical and pharmacy benefit) approved? 
      • From Chapter 15, Medicare Benefit Policy Manual, 50.4.2 — Unlabeled Use of Drug, the following applies: 50.4.2 — Unlabeled Use of Drug (Rev. 1, 10-01-03) B3-2049.3 An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label may be covered under Medicare if the A/B MAC (B) determines the use to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. In the case of drugs used in an anti-cancer chemotherapeutic regimen, unlabeled uses are covered for a medically accepted indication as defined in §50.5. These decisions are made by the MAC on a case-by-case basis.
      • Note: Medicare provides coverage for items and services that are reasonable and necessary to diagnose or treat an illness or injury or to improve the functioning of a malformed body member. Payment is excluded if the medical necessity for the service cannot be substantiated (the Act, and CMS, IOM, Publication 100-02, MBPM, Chapter 16, Sections 20 and 90).
         
  • Palmetto GBA Medical Directors
    • A member inquired about the structure of Palmetto in terms of the medical directors — who are they, do they each cover a specific area of the state or specialty?

Open Discussion Questions

None.

Next Meeting Date

TBD 2025.

Adjournment
 


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