Health Check Seminar by 4v4x0P4

VIEWS: 7 PAGES: 66

									NC Department of Health and Human Services   north carolina
                                                 medicaid



             Health Check Seminar




                 September 2012
       Presented by: HP Enterprise Services

                                                              DMA
 north carolina
     medicaid

                     Health Check Resources
• DMA Website
   – www.ncdhhs.gov/dma

• Health Check Billing Guide

• EPSDT Policy Instructions (updated 1/11/2010)

• Request for Non-Covered Services Forms



                                                  DMA
    north carolina
        medicaid
                         For Providers




EPSDT and Health Check




                                 DMA
   north carolina
       medicaid
                    Fee Schedules




Fee Schedules




                            DMA
  north carolina
      medicaid

                           Who’s Who in Medicaid
• Centers for Medicare and Medicaid Services
   – CMS

• Department of Health and Human Services
   – DHHS

• Division of Medical Assistance
   – DMA




                                               DMA
 north carolina
     medicaid

                           Who’s Who in Medicaid
• Department of Social Services
  – DSS

• HP Enterprise Services
  – HPES

• Computer Sciences Corporation
  – CSC


                                           DMA
north carolina
    medicaid
   EARLY AND PERIODIC SCREENING,
DIAGNOSIS, AND TREATMENT (EPSDT)




            MEDICAID FOR CHILDREN
   Contact:      EPSDT Nurse Consultant
                 Division of Medical Assistance
                 Telephone #: 919-855-4260
                 FAX #: 919-715-7679

                                                  DMA
 north carolina
     medicaid
                                   EPSDT Websites

Basic Medicaid and N.C. Health Choice Billing Guide
http://www.ncdhhs.gov/dma/basicmed/

Health Check Billing Guide
http://www.ncdhhs.gov/dma/healthcheck/

EPSDT Provider Page
http://www.ncdhhs.gov/dma/provider/epsdthealt
 hcheck.htm


                                                   DMA
north carolina
    medicaid
                 EPSDT Provider Website




                                  DMA
north carolina
    medicaid
                 EPSDT Provider Website




                                  DMA
 north carolina
     medicaid

                              Provider Responsibility
• Verify Recipient Eligibility

• Carolina ACCESS

• Health Check Overview

• Maintain Medical Records

• Health Check Billing Requirements


                                                DMA
 north carolina
     medicaid

                   Eligibility Verification Methods
• NCECSWeb Tool
  – Free Service
  – Need Submitter ID & Password

• Automated Voice Response (AVR) System
  – 1-800-723-4337

• EDI Vendor


                                             DMA
north carolina
    medicaid
                                                             Verify Eligibility




                               Use any of these methods to search
                                                 Tips:
                                          Use MPN or NPI
                 If no date is keyed it will reflect eligibility for the date of search
                      Can not check future date until the first of that month
                                     Can search back 365 days

                                                                                DMA
north carolina
    medicaid                                     Eligibility Results


                              123456789k




                     08/01/2012                            08/31/2012




                              Jane Doe             123456789k           1/1/1960


                        08/01/2012- 08/31/2012




                 987654321A
                                                                        DMA
 north carolina
     medicaid

                          Carolina ACCESS (CA)
• Primary Care medical home for enrolled
  recipients

• Obtain referral from Primary Care Provider

• Referring NPI reported on claim

• More information: Basic Medicaid and N.C.
  Health Choice Billing Guide Section 6-
  Managed Care Programs

                                               DMA
 north carolina
     medicaid

                             CA Override Request
• Considered only for extenuating
  circumstances

  http://www.ncdhhs.gov/dma/ca/CAOverrideForm.pdf




                                                DMA
north carolina
    medicaid

                     Carolina ACCESS Denial Codes
  – EOB 270
     • Billing provider is not the recipient’s Carolina
       ACCESS PCP. Authorization is missing or
       unresolved

  – EOB 286
     • Incorrect authorization number on claim form.
       Verify number and re-file claim



                                                    DMA
  north carolina
      medicaid

                                 Provider Responsibility

 Verify Recipient Eligibility

 Carolina ACCESS

 Health Check Overview

 Maintain Medical Records

 Health Check Billing Requirements


                                                 DMA
 north carolina
     medicaid

                           Health Check/EPSDT Overview

• Important because…

     – Provides for early and regular medical, developmental,
       dental screenings and ongoing surveillance for all
       Medicaid recipients under the age of 21

     – Part of the federal Medicaid EPSDT requirement to
       provide medically necessary health care




                                                           DMA
 north carolina
     medicaid

                      Screening Assessments


• Health Check recommends regular medical screening
  assessments (well-child visits) for recipients

• Screening, diagnostic and treatment services are
  FREE of charge to the recipient




                                                     DMA
 north carolina
     medicaid
     Health Check/EPSDT Recommended
                   Periodicity Schedule
Within 1st month     9 or 15 months


2 months             12 months


4 months             18 months


6 months             For children ages 2
                     through 20, annual visits
                     are recommended
                                            DMA
 north carolina
     medicaid
                  Periodic Health Check Screening
• Require all age-appropriate components

   – Developmental Screening
   – Vision Screening
   – Hearing Screening
   – Dental Screening
   – Immunizations


                                            DMA
 north carolina
     medicaid

                  Interperiodic Health Check Screening

• Require all age-appropriate components EXCEPT
   – Developmental Screening
   – Hearing Screening
   – Vision Screening

• Screening may be performed outside of the
  periodicity schedule

• All electronic claims should list referral code
  indicator “E” when a referral is made for follow-up

                                                        DMA
 north carolina
     medicaid
Health Check Screening Assessment Components

• Comprehensive unclothed physical assessment

• Comprehensive health history

• Nutritional assessment

• Anticipatory guidance and health education

• Measurements, blood pressure and vital signs


                                                 DMA
    north carolina
        medicaid

Health Check Screening Assessment Components

•     Developmental surveillance
•     Immunizations
•     Vision screening
•     Hearing screening
•     Dental screening
•     Laboratory procedures


                                       DMA
 north carolina
     medicaid

                            Developmental Screening

• Includes physical and mental development

• Required component of a Periodic Screening at the
  following ages:
   – 6, 12, and 18 or 24 months old
   – 3, 4, and 5 years old

• Must use a standardized and validated screening tool

• CPT code 96110 with EP modifier

                                                   DMA
 north carolina
     medicaid
                       Developmental Screening



• Autism Screening CPT Code 99420 with EP
  modifier

• Screening at ages 18 and 24 months




                                            DMA
 north carolina
     medicaid
                                  Developmental Screening Cont.
• Health Risk Assessments and Behavioral/Mental
  Health Screening
   – CPT Code
            • 99420 EP modifier
• Smoking/Tobacco Use Cessation Counseling
   – CPT Codes
            • 99406 EP modifier
            • 99407 EP modifier
• Alcohol/Substance Abuse Structured Screening and
  Brief Intervention
   – CPT Codes
            • 99408 EP modifier
            • 99409 EP modifier

                                                          DMA
north carolina
    medicaid




                 Break Time…..

          See you back in 15 minutes!!




                                    DMA
 north carolina
     medicaid
                                       Immunizations


• Same provider

• Same date of service as Health Check screening

• Same location as Health Check screening

• EP modifier appended to the immunization
  administration CPT code
   – Recipients from birth through age 20


                                                   DMA
 north carolina
     medicaid

                                          Immunizations

• The North Carolina Immunization Program (NCIP)

• Vaccines for Children (VFC)

• Birth through 18 years of age - no charge

• Reimbursement for the administration of vaccines

• EP modifier required


                                                     DMA
   north carolina
       medicaid
Procedure Code      Description
90471               Immunization administration (includes percutaneous,
                    intradermal, subcutaneous, or intramuscular injections); one
                    vaccine (single or combination vaccine/toxoid)

90472+              Immunization administration (includes percutaneous,
(add-on-code)       intradermal, subcutaneous, or intramuscular injections); one
                    vaccine (single or combination vaccine/toxoid) each
                    additional vaccine (single or combination vaccine/toxoid)
                    List separately in addition to code for primary procedure

90473               Immunization administration by intranasal or oral route; one
                    vaccine (single or combination vaccine/toxoid)

90474+*             Immunization administration by intranasal or oral route;
(add-on-code)       each additional vaccine (single or combination
                    vaccine/toxoid)
                    List separately in addition to code for primary procedure

                                                                            DMA
 north carolina
     medicaid

                                      Vision Screening
• Required for Periodic Examinations beginning at age
  3 through 10 years

• Age 11- screening needed only once every three
  years

• CPT code 99172 or 99173 with EP modifier




                                                   DMA
 north carolina
     medicaid

                                      Hearing Screening
• Objective screenings using an otoacoustic auditory
  emission (OAE) tool or audiometer

• Performed annually for ages 4-10

• All other ages, selective screening based on
  assessment of risk

• CPT code 92551, 92552, or 92587 with EP modifier




                                                     DMA
 north carolina
     medicaid
What if the hearing or vision component cannot
                      be performed because….
• Uncooperative, blind, deaf, or autistic

• Document the date of service and reason why unable
  to perform screening

• Submit claim without component CPT code




                                                  DMA
 north carolina
     medicaid

                                         Dental Screening

• An oral screening is to be performed at every Health
  Check visit

• Referral to a dentist is recommended for every child
  before age 1 and required at age of 3

• Dental Varnishing allowed once every 60 calendar
  days
     – D1206 and D0145, no EP modifier


                                                     DMA
 north carolina
     medicaid

                              Frequently Asked Questions

• Is Dental Varnishing a requirement of the
  Health Check program?

• Answer: No

• Is Dental Varnishing separately reimbursable
  in addition to a Health Check visit?

• Answer: Yes

                                                 DMA
 north carolina
     medicaid
                                      Laboratory Procedures

• Laboratory procedures include:

     –     Hemoglobin or Hematocrit
     –     Newborn Metabolic/Sickle Cell Screening
     –     Tuberculin Test
     –     Lead testing

• Included in Health Check fee when billed on same
  date of service


                                                      DMA
  north carolina
      medicaid

                                 Provider Responsibility
 Verify Recipient Eligibility

 Carolina ACCESS

 Health Check Overview

 Maintain Medical Records

 Health Check Billing Requirements


                                                   DMA
  north carolina
      medicaid
                                         Claim Submission
• Electronic submission

• Software Vendor or Clearinghouse

• NC Electronic Claims Submission (NCECSWeb Tool)

• Paper submission
   – For claims meeting exception criteria only




                                                    DMA
north carolina
    medicaid
                 Health Check Billing Requirements


     What are the six billing requirements
     specific to the Health Check Program?




                                             DMA
    north carolina
        medicaid
                                        Requirement 1:
• Identify and record       • Medical diagnoses
  diagnosis code              – Listed after primary,
   – CMS-1500, block 21         and before
                                immunization
                                diagnoses
• Primary diagnosis first
   – Periodic- V20.2
                            • Immunization diagnosis
   – Interperiodic V70.3
                              code
                               – Required when one or
                                 more immunizations
                                 are provided as the
                                 only service

                                                        DMA
  north carolina
      medicaid
                                    Requirement 2:
• Identify and record       • Vision CPT codes 99172
  preventive medicine         or 99173 with EP modifier
  code and component
  codes

                            • Hearing CPT codes
• Developmental screening
                              92551, 92552, or 92587
  CPT codes 96110,
                              with EP modifier
  99420, 99406, 99407,
  99408, 99409 with EP
  modifier



                                                   DMA
  north carolina
      medicaid
                                   Requirement 3:

• EP is a required modifier for all Health Check
  claim details

   – Screening assessments

   – Vision, Hearing, and Developmental screening

   – Immunization administration

                                               DMA
 north carolina
     medicaid
                                       Requirement 4:

• Record Referrals:

    – List referral code indicator “E” for claims
      submitted via NCECSWeb Tool

    – List referral code indicator “F” when a referral is
      made for Family Planning services




                                                      DMA
 north carolina
     medicaid
                                    Requirement 5:
• Next Screening Date

   – Systematically entered according to the
     predetermined periodicity schedule

   – Provider-entered Next Screening Date

   – Systematically entered Next Screening Date



                                                  DMA
 north carolina
     medicaid
                                Requirement 6:

• Identify and Record Immunization
  Administration CPT Code(s) and the EP
  Modifier

• Refer to immunization guidelines




                                          DMA
 north carolina
     medicaid
                        Preventive Medicine CPT Codes
                  Age       New Patient   Established   Append EP
                                            Patient      Modifier

 Under age 1 year             99381         99391          Yes


 1 through 4 years            99382         99392          Yes

5 through 11 years            99383         99393          Yes


12 through 17 years           99384         99394          Yes


18 through 20 years           99385         99395          Yes



                                                                 DMA
    north carolina
        medicaid

                              Frequently Asked Question


• Can I get paid for a sick visit and a well visit on the
  same date of service?

•     Answer: No

• If they are sick, treat the visit as a sick visit and
  reschedule the well check




                                                            DMA
 north carolina
     medicaid
                                     Billing Information


• Report CA Overrides on the NCECSWeb Tool using:
   – “Referring Physician Provider Number”
      (Carolina ACCESS Physician Number)

• Electronic Funds Transfer (EFT)

• Checkwrite schedule
     • Cut-off date and time
     • http://www.ncdhhs.gov/dma/provider/calendar.htm


                                                    DMA
  north carolina
      medicaid
                                Billing Tips-All Providers
 Two Health Check screening assessments on different
  dates of service cannot be billed together

 Can be billed when performed during a periodic or
  interperiodic Health Check assessment for ages 11-20
  – CPT codes: 99406, 99407, 99408, 99409,

 Can be billed when performed during a periodic or
  interperiodic Health Check assessment for ages birth
  through 20
  – CPT code: 99420

 Immunizations and therapeutic injections may be billed on
  same claim/date of service


                                                         DMA
 north carolina
     medicaid
                  Billing Tips - Private Sector Provider

• Health Check screening and office visit with different
  dates of service must be billed separately

• Health Check screening assessment and office visit
  cannot be paid initially on the same date of service

• For denied claim to be reconsidered
   – Submit an adjustment with medical documentation and
     EOB attached

• AVR and claim status



                                                      DMA
  north carolina
      medicaid

                   Billing Tips - Local Health Department


• Two Health Check screenings on different dates of
  service cannot be billed on the same claim form

• An immunization administration fee may be billed if
  the immunization is provided in addition to a Health
  Check screening visit.




                                                         DMA
  north carolina
      medicaid

                   Health Check Coordinators (HCCs)

• Assist parents and providers in assuring that
  Medicaid-eligible children have ACCESS to Health
  Check services

• Provide education and outreach services in 100 NC
  counties and the Qualla Boundary




                                                      DMA
 north carolina
     medicaid

                      Health Check Common EOBs

 EOB 10                        EOB 1769
 – Diagnosis or service         – No additional payment
   invalid for recipient age      made for vision, hearing
                                  and/or developmental
                                  screening services
 EOB 1036
 – Thank you for reporting      EOB 1770
   vaccines                     – Invalid
                                  procedure/modifier/
                                  diagnosis




                                                        DMA
 north carolina
     medicaid
                              Health Check References

• Billing reference sheet       • Claim examples


• Immunization billing          • Local Health
  reference sheet                 Department HSIS
                                  screens
• Resource list
                                •   N.C. Periodicity
                                    Schedule and Coding
                                    Matrix
http://www.ncdhhs.gov/dma/healthcheck/coding_matrix.pdf

                                                          DMA
north carolina
    medicaid
                                 Frequently Used Forms




                 Medicaid Resolution Inquiry
                                                 DMA
  north carolina
      medicaid
                                          Medicaid Overrides
• Resolution Inquiry Form
   – Use only when requesting
            •      Time Limit Override
            •      Third Party Override
            •      Medicare Override
            •      HMOs
• Attached with Explanation of Benefits (EOB) and
  paper claim

• Mail to: HP Enterprise Services
           PO Box 300009
           Raleigh, NC 27622
                                                       DMA
 north carolina
     medicaid

                                         Primary Insurance
• Private Insurance pays, submit electronic claim to
  Medicaid

• Non-payment indicated? Submit claim on paper
   – Attach Medicaid Resolution Inquiry Form, claim, and
     primary EOB

• Check “Third Party Override” box
   – Applied to the Deductible, Non-Covered Service, Policy
     Terminated
   – Exceeds maximum benefits for the year


                                                           DMA
  north carolina
      medicaid
                   DMA-2057/Electronic Transmissions
 Update recipient’s commercial insurance
  information

 Transmit electronically via secured internet
  connection
  – New & preferred method

 Ability to send claim upon receipt of the
  confirmation e-mail from vendor

 HMS website http://ncprovider.hms.com

                                                 DMA
 north carolina
     medicaid

                                Contact Information

• Automated Voice Response (AVR) System
  1-800-723-4337

• Billing questions HP Enterprise Services
  1-800-688-6696 or 919-851-8888, Option 3

• Provider enrollment CSC EVC Call Center
  1-866-844-1113 or email NCMedicaid@csc.com


                                               DMA
  north carolina
      medicaid

                                             Review
• A child comes in for a sports physical, outside of
  their periodicity schedule. Is this a periodic or
  interperiodic screening?

• Answer: Interperiodic

• What diagnosis code is required?

• Answer: V70.3


                                                  DMA
  north carolina
      medicaid
                                         Review

• True or False: An EP modifier is required when
  billing a health check visit code

• Answer: TRUE




                                             DMA
  north carolina
      medicaid

                                 Provider Responsibility
• Verify Recipient Eligibility

• Carolina ACCESS

• Health Check Overview

• Maintain Medical Records

• Health Check Billing Requirements



                                                   DMA
  north carolina
      medicaid

                                                Review
• True or False: Although Medicaid ID cards are
  issued annually, eligibility information can still
  change on a monthly basis

• Answer: TRUE




                                                       DMA
   Thank You


ANY QUESTIONS?

								
To top