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Medicaid Provider Training Seminar Fall 2002

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Medicaid Provider Training Seminar Fall 2002 Powered By Docstoc
					         DEPARTMENT OF
PUBLIC HEALTH AND HUMAN SERVICES
       HEALTH RESOURCES DIVISION



         Medicaid OPPS Hospital
              Billing Guide
                Fall 2006
              OPPS

Outpatient Prospective Payment System
                         General
 Montana Medicaid uses Medicare’s Outpatient
  Prospective Payment System for reimbursing PPS,
  border and out-of-state hospitals since August 2003
• Medicaid uses a Montana specific conversion factor ($47.75) for
  PPS hospitals and updates quarterly along with Medicare
• Medicaid deviates from Medicare in some cases (i.e. therapies,
  obstetric observation, inpatient only)
• Payment for PPS hospitals is the lower of OPPS payment (fees and
  APCs) or your total claim charges
   • Charge cap does not apply to line level
• Appropriate and accurate coding is the key to proper
  reimbursement
       OPPS/APC for PPS Facilities
 Some services paid by fee schedule
   • Therapies (speech, physical, occupational)
   • Laboratory
   • Diagnostic
 If there is no APC, Medicare fee or Medicaid fee (RBRVS), some services
  pay hospital specific outpatient cost to charge ratio
   • Drugs and Biologicals
   • Devices
 Ambulatory Payment Classification
   • Payment based on CPT/HCPCS codes
   • Status Indicator tells the method of payment
   • Each service is eligible for potential payment
         Emergency room
         Treatment Room
         Provider-based clinic
         Cancer care
  Paint a Picture With your Claim
 Code every service every time for proper payment
 Where did your patient come into your facility?
   • ER, clinic, direct admit?
 What happened to the patient?
   • Surgery?
   • Clinic visit?
   • Treatment room?
 What resources did you use?
   • Supplies?
   • Pharmaceuticals?
   • Blood products?
 Your claim should tell the story of what happened to your patient.
               APC Status Indicators
   C – Inpatient only services            Q – Lab fee schedule (60% for
                                            non-sole community, 62% for
   E – Non-covered item or use
                                            sole community)
    another code
                                           S – Significant procedure paid by
   G – Drugs & biologicals paid by
                                            APC that the multiple procedure
    report (hospital specific
                                            discount DOES NOT apply to
    outpatient cost to charge ratio)
                                           T – Significant procedure paid by
   H – Devices paid by report
                                            APC that the multiple procedure
   K – Drugs and biologicals paid          discount DOES apply to
    by APC
                                           V – Medical visits in the clinic,
   M – Paid by a Medicaid specific         critical care or emergency
    fee or not a covered service (fee       department (includes codes for
    schedule will show as not               direct admits)
    allowed)
                                           X – Ancillary services paid by
   N – Service is bundled into an          their own APC
    APC – pays zero
                                           Y – Medicaid fee for therapies
                                            (90% of RBRVS office fee)
Observation
                 Observation Services
 Medicare/Medicaid Rules
•   OBS services must be reasonable and necessary
•   There must be a physician order prior to initiation
•   Physician order must be by a physician with privileges
•   Physician must be actively directing patient care
•   During OBS, patients must be actively assessed
•   Observation is not a substitute for inpatient
•   Observation is not for continuous monitoring
•   Observation is not for patients waiting for NH placement
•   Observation is not to be used for convenience or as routine prior to
    IP status
               Qualifying Observation
   Four qualifying conditions for payment
•   Chest Pain - Qualifying Diagnosis: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 786.05,
    786.50, 786.51, 786.51, 786.59
•   Asthma - Qualifying Diagnosis: 493.01, 493.02, 493.11, 493.12, 493.21, 493.22, 493.91, 493.92
•   Congestive Heart Failure - Qualifying Diagnosis: 391.8, 398.91, 402.01, 402.11, 402.91, 404.01,
    404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.33, 428.30,
    428.31, 428.31, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9
•   Obstetric Complications (pre-delivery complications) - 640.00, 640.03, 640.80, 640.83, 640.90,
    640.93, 644.00, 644.03, 644.10, 644.13, 630.00, 631.00, 641.03, 641.13, 641.23, 641.30, 641.33,
    641.83, 641.93, 642.03, 642.13, 642.23, 642.33, 642.43, 642.50, 642.53, 642.60, 642.63 642.70,
    642.73, 642.93, 643.00, 643.03, 643.10, 643.13, 643.20, 643.23, 643.80, 643.83, 643.90, 643.93,
    644.20, 645.13, 645.23, 646.03, 646.10, 646.13, 646.20, 646.23, 646.33, 646.43, 646.53, 646.60,
    646.63, 646.70, 646.73, 646.80, 646.83, 646.93, 647.03, 647.13, 647.23, 647.33, 647.43, 647.53,
    647.63, 647.83, 647.93, 648.03, 648.13, 648.23, 648.33, 648.43, 648.53, 648.63, 648.73, 648.83,
    648.93, 651.03, 651.13, 651.23, 651.33, 651.43, 651.53, 651.63, 651.83, 651.93, 652.03, 652.13,
    652.23, 652.33, 652.43, 652.53, 652.63, 652.73, 652.83, 652.93, 653.03, 653.13, 653.23, 653.33,
    653.43, 653.53, 653.63, 653.73, 653.83, 653.93, 654.03, 654.13, 654.23, 654.33, 654.43, 654.53,
    654.63, 654.73, 654.83, 654.93, 655.03, 655.13, 655.23, 655.33, 655.43, 655.53, 655.63, 655.73,
    655.83, 655.93, 656.03, 656.13, 656.23, 656.33, 656.43, 656.53, 656.63, 656.73, 656.83, 656.93,
    657.03, 658.03, 658.13, 658.23, 658.33, 658.43, 658.83, 658.93, 659.03, 659.13, 659.23, 659.33,
    659.43, 659.53, 659.63, 659.73, 659.83, 659.93, 660.03, 660.13, 660.23, 660.33, 660.43, 660.53,
    660.63, 660.73, 660.83, 660.93, 661.03, 661.13, 661.23, 661.33, 661.43, 661.93, 662.03, 662.13,
    662.23, 662.33, 663.03, 663.13, 663.23, 663.33, 663.43, 663.53, 663.63, 663.83, 663.93, 665.03,
    665.83, 665.93, 668.03, 668.13, 668.23, 668.83, 668.93, 669.03, 669.13, 669.23, 669.43, 669.83,
    669.93, 671.03, 671.13, 671.23, 671.33, 671.53, 671.83, 671.93, 673.03, 673.13, 673.23, 673.33,
    673.83, 674.03, 675.03, 675.13, 675.23, 675.83, 675.93, 676.03, 676.13, 676.23, 676.33, 676.43,
    676.53, 676.63, 676.83, 676.93, 792.3, 796.5, V28.0, V28.1, V28.2, V61.6
                Observation Services
 The qualifying diagnosis must be in either:
   • Admitting diagnosis (FL 76); or
   • Principal diagnosis (FL 67)
 Beginning January 1, 2006 the OCE will determine if a
  claim qualifies for observation
   • Code your claim to tell us if this was a direct or outpatient admission
   • Bill ALL observation regardless if you think it qualifies or not
 Beginning January 1, 2006 the following codes will be
  discontinued:
   • G0244, G0263, G0264
   • 99217-99220
   • Bill ALL observation regardless if you think it qualifies or not
 Beginning January 1, 2006 you do not have to bill G
  codes for Obstetric observation – it is up to you
Outpatient Admissions to Observation
 All observation services must be on a 13X bill type
    • Use G0378 to report the observation of patients admitted through an
      outpatient setting such as Emergency room, Critical care clinic,
      Provider-based clinic
        • Bill the first date of service (the date admitted to an observation
           bed) on this line
        • Bill your units of observation on this line (for obstetrics bill 1
           unit)
        • Bill charges observation charges on this line (for obstetrics bill $1)
    • Bill your ER, CC or Provider based visit on a separate line
        • Bill all other services as normal
    • If Obstetric observation, you must have a line with 99234-99236
        • Bill the first date of service (the date admitted to an observation
           bed) on this line
        • Bill total units of observation on this line
        • Bill observation charges on this line
        Direct Admissions to Observation
 All observation services must be on a 13X bill type
    • Use both G0378 and G0379 to report the observation of patients
      admitted directly
        • Bill the first date of service (the date admitted to an observation
          bed) on both lines
        • Bill total units of observation on the line with G0378 (for
          obstetrics bill 1 unit)
        • Bill observation charges on the line with G0378 (for obstetrics bill
          $1)
        • Only 1 unit of service and $1 in charges are reported on G0379
        • Bill all other services as normal
    • If Obstetric observation, you must have a line with 99234-99236
        • Bill the first date of service (the date admitted to an observation
          bed) on this line
        • Bill total units of observation on this line
        • Bill charges observation charges on this line
Provider-Based
           Provider Based Issues
• Medicaid follows Medicare rules for provider-based
  services with some exceptions
   • Medicaid must deem your facility and clinics provider-based prior
     to billing as such and will not back date your approval
   • Medicaid does not allow self-declaration of provider-based status
• Recipients must be notified that they will be assessed two
  cost shares for Medicaid or two co-payment and deductible
  charges for cross-over claims
   • Notices must be clearly posted in all clinics and facilities
   • Recipients must be individually notified in writing prior to
     providing service
            Provider-Based Billing
• Claims are billed for all of your provider-based facilities
  and clinics similar to how you would bill a claim in the
  Emergency Department
• There is a UB and a 1500 for each billable visit
   • 1500 claim must have place of service “22” outpatient
   • UB claim uses revenue code 510 for the facility side of the office
     visit
   • All other services are billed on the UB including procedures that
     the doctor or midlevel performed (10021 to 69990)
   • Procedures are also billed on the UB
   • If you cannot bill a 1500 (such as for a global) you cannot bill a
     UB and visa-versa
• Do not use modifier TC for your clinic visit lines on UB
   • Use TC only when appropriate
       Provider Based Billing Issues
 Obstetrics
   •    Billing for complete service, antepartum, delivery and postpartum
        • Bill as usual which means a global bill with POS 21 on the 1500
          side and delivery paid as a DRG on the UB side
   • Billing for incomplete services, antepartum or postpartum
        • Bill appropriate code for number of visits on 1500 and UB.
        • Codes such as 59425 are not turned on for facility side so bill a
          matching E&M on the UB side
 VFC
   • Where there is an E&M
        • Bill E&M and administration code on the 1500 with POS 22, bill
          E&M and injectibles on UB
   • Where there is an not an E&M
        • Bill administration code with modifier SL and the VFC code on
          the 1500 with POS 22, bill administration code on the UB, SL
          does not apply on the UB side
Modifiers
 HOSPITAL OPPS MODIFIERS
 Medicaid uses Medicare Outpatient Claim Edits
   •    www.cms.hhs.gov/NationalCorrectCodInitEd
 These edits apply to both CAH and PPS hospitals
 Medicaid does not allow reporting separate codes for
  related services when there is 1 code that includes all
  related services
 Medicaid does not allow breaking out bilateral procedures
  when 1 code is appropriate
 The paper UB-92 can accommodate 1 modifier
   •    The 837 can accommodate 4 modifiers
   •    Always report the payment modifier 1st as Medicaid processes the
       claim using only the first modifier
                    Modifier 25
 25-significant, separately identifiable E&M
  service by the same physician on the same day
   • Only used with E&M codes 92002-92014, 99201-
     99499, G0101, G0175 to indicate that the patient’s
     condition required a separately identifiable E&M
     service the same day a procedure was performed
   • Examples:
      • 99212-25 Office/outpatient visit, est.
      • 77412 Radiation treatment, 3 or more treatment areas
Modifier 25-Multiple Visits Same Day
     Under limited circumstances, medical visits on the same day as a procedure
      will result in additional payments. Using modifier 25 with an E/M code
      indicates that a medical visit was unrelated to any procedure performed that
      day with a status indicator of “T” or “S”. Modifier 25 is used only when the
      patient’s condition required a significant, separately identifiable E&M
      service the same day a procedure was performed. If the procedure was
      related to the medical visit you may not use modifier 25.
     •     Multiple E/M codes on the same day on the same claim may receive
           additional payment if they are for different revenue centers.
     •     Multiple E/M codes on the same day with the same revenue center will
           not receive additional payment. Please remember that Medicaid does
           not use condition codes. Adding condition code GO to these claims will
           not result in additional payment. If you have two distinct medical visits
           on the same day (such as two ER visits, one for a broken arm in the
           morning and one for chest pain in the afternoon) the claim must be
           separated onto 2 claims and sent to DPHHS, Hospital Claims
           Resolution, P O Box 202951, Helena, MT 59620-2951 for review and
           separate payment.
                     Modifier 50
 50 – Bilateral Procedure
   • Used to report bilateral procedures performed at the same
     operative session
   • The 2nd (or bilateral) procedure is identified by 50 added to the
     CPT code on a single line. Units are “1”.
   • DO NOT use if the code description indicates “bilateral” such as
     27395
   • Use when body parts have both right and left and you are doing
     separate services on each side. Do not use RT or LT with 50
   • Examples:
       • 28285-50 repair of hammertoe, or
       • 64721-50 carpal tunnel surgery
                Modifier 52
 52 – reduced or discontinued service
  • used to report a service that was partially reduced
    or discontinued and did not require anesthesia
  • A physician may discontinue or reduce a
    procedure for any number of reasons. The
    decision to do so is at the physician’s discretion
 Modifier 52 is used most often to identify
  reduced or interrupted radiological and
  imaging procedures
                      Modifier 59
 59 – Distinct Procedural Service
• Used to report two procedures that are not normally reported together
  but could be performed under certain circumstances
   • Different session or patient encounter
   • Different procedure or surgery
   • Different site or organ system
   • Separate incision
   • Separate injury that is not normally encountered or performed by
      the same physician on the same day
• Examples:
   • 93017 cardiac stress test
   • 93005-59 EKG
         Modifier 59-Drug Infusion
 Drug Infusion
•   Use of Modifier 59 on chemotherapy and non-chemotherapy drug infusion
    indicates a distinct encounter (59 is used for a different session or patient
    encounter, a different procedure or surgery, a different site or organ system) on
    the same date of service. For chemotherapy administration or non-
    chemotherapy infusion the following criteria must be met to use this modifier:
•   The drug administration occurs during a distinct encounter on the same date of
    service as a previous drug administration.
•   The same HCPCS code has already been billed for services provided at a
    separate and distinct encounter earlier on the same day.
•   Modifier 59 is not to be used when a patient receives infusion therapy at more
    than one vascular site of the same type (intravenous or intra-arterial) in the
    same encounter. Do not use Modifier 59 when an infusion is stopped and then
    started again in the same encounter.
•   In cases where infusions of the same type are provided through two vascular
    access sites of the same type in one encounter, bill 2 units of the appropriate
    first hour code for the initial infusion hours without Modifier 59.
               Infusions and Injections
       Billing for infusions and injections.
    •       Bill first hour infusion codes C8950, C8954 and 96422 after 15 minutes of infusion. If you provide different
            types of infusion that may be separately billed (e.g. intra-arterial and intravenous chemotherapy) in the same
            encounter you may bill a first hour for each different type of infusion.
    •       Infusions lasting less than 15 minutes should be billed as intravenous pushes.
    •       Subsequent infusion hours.
    •       Bill additional hours of infusion codes C8951, C8955 and 96423 only after more than 30 minutes have
            passed from the end of the previously billed hour. In other words, to bill an additional hour of infusion after
            the first hour, more than 90 minutes of infusion services must be provided. Bill 1 unit for each additional
            hour of infusion.
       Concurrent Infusions.
    •       Concurrent infusions through the same vascular access site are not separately billable. Include any charges
            associated with the concurrent infusion in your charges for the infusion service you bill.
       Intravenous or intra-arterial push.
    •       Bill push codes C8952, C8953 and 96420 for services that are less than 15 minutes or when a healthcare
            professional administering the injection is continuously present to observe the patient.
       Services that are not separately billable.
    •       Preparation of chemotherapy agent
    •       Use of local anesthesia
    •       IV start
    •       Standard tubing, syringes and supplies
    •       Access to indwelling IV, subcutaneous catheter or port
    •       Flush at conclusion of infusion
    Unbundling or Component Codes
   Medicaid does not allow reporting of separate codes for related services when
    1 code includes all the related services
     •   Unbundling Example:
          • Do not report:
              • 58150 Abdominal Hysterectomy w/wo removal of tubes, w/wo removal
                 of ovaries, and
              • 58700 Salpingectomy, and
              • 58940 Oophorectomy
          • Do report:
              • 58150 Total abdominal hysterectomy w/wo removal of tubes, w/wo
                 removal of ovaries
     •   Component Example:
          • Do not report together:
              • 94664 Demonstrate, evaluate patient utilization aerosol gen, nebulizer or
                 inhaler and
              • 94640 Pressurized or nonpressurized inhalation treatment for diagnostic
                 purpose w/aerosol generator, nebulizer, or inhaler
          • Report only one or the other
Common Claim Edits
                    Common Claim Edits
•   102 – Duplicate claim                        •   215 – Claim should pay by APC or
    Reason code – B13 Remark code – M86              OPPS but system could not group.
•   112 – A readmission has been detected            These hit for 4 reasons:
    Reason code -133                                  • Invalid bill type (usually you see
•   119 – Claim is for a potentially                     851 which should be 131)
    unbundled service                                 • Bad date- the span date doesn’t
    Reason code – B13 Remark code – M2                   match the line dates
                                                      • There is no APC to group to
•   120 – Date of service is more than 365               (department boo-boo)
    days from date received
                                                      • Revenue code 636 is used wrong-
    Reason code – 29                                     this rev code can only be used for
•   280- (physician claim) - diagnosis code or           RX or vaccination codes, not for
    procedure code is not on emergent list               the injections
    Reason code – 40 Remark code – N59                • 335 – Procedure code requires
                                                         review (unlisted code)
       Additional Common Claim Edits
•    342 – Diagnosis code requires a     •  371 – DRG = 468 (this DRG pays % of
     review (these are almost always V      charges so is always reviewed for
     codes)                                 correct coding) this means that there
    Reason code - 125                       was a procedure on the claim that was
    Remark code - N10                       not related to the main diagnosis and
                                            procedures
•    343 – Diagnosis code may not be a
     covered service                     • 483 – Units billed exceed allowed units
    Reason code - 47                       Reason code - 119
•    345 – Sterilization review            Remark code - M53
    Reason code - 17                     • 460 – Claim requires a prior
                                            authorization
    Remark code - N3
                                           Reason code - 62
•    347 – Hysterectomy review
                                            Remark code - M62
•    370 – Abortion review
    Reason code - 17
    Remark code - N3
                       More Claim Edits
•   472 – This exception will post when       •   920 – Diagnosis code and procedure don’t
    the PASSPORT provider number is               match- this means that a claim hit before or
    missing or invalid                            after the new quarterly grouper was
                                                  installed and a diagnosis code on the claim
    Reason code - 15                              now needs a fifth digit or is invalid or the
    Remark code - M68                             provider used an invalid diagnosis code
•   487 – This edit will fail when the            Reason code - 11
    client is a Team Care client and the      •   928 – Inpatient only services performed in
    Team Care provider did not submit             an outpatient setting-needs review to
    the claim or did not refer the client         determine if appropriate
    and the service requires PASSPORT
    approval                                      Reason code - 58
    Reason code - 15                              Remark code - M77
    Remark code - M68                         •   929 – E&M code on the same date as a
                                                  surgical or significant procedure without
•   905 – Line dates of services are              modifier 25 or 27 present on the E&M code
    inconsistent with the header level            (must be on the E&M code – not on the code
    dates of service or the line level date       with a SI of T or S) Reason code - 97
    of service is blank (usually see on
    bundled claims)                               Remark code – 144
    Reason code - 16                          •   930 – one procedure is a component of
                                                  another
    Reason code - MA122
                                                  Reason code – 59
                                                  Remark code - 005
Sterilization and Hysterectomy
   Sterilization and Hysterectomy
 Informed Consent to Sterilization (MA-38) or Medicaid
  Hysterectomy Acknowledgement (MA-39) must be attached to the
  claim without exception
 The forms must be legible, complete and accurate.
    • Revisions are not accepted for any reason
 The physician must sign and date the form the same day the
  recipient is informed that the procedure would render them
  permanently incapable of reproducing
    • The recipient must be informed orally and in writing
    • The form must be signed prior to the procedure
    • Make sure birth date and date of signature are accurate
                        MA-38 Form

 Informed Consent to Sterilization (MA-38)
    • It is the provider’s responsibility to obtain a correctly completed from
      the primary or attending physician
    • Elective sterilizations are still subject to the 30 day waiting period
 For retroactively eligible clients, the physician must certify in
  writing that the surgery was performed for medical reasons and
  must document:
    • Client was informed prior to the hysterectomy that the operation
      would render then permanently incapable of reproducing, or
    • Reason for the sterilization was a life-threatening emergency or the
      client was already sterile and the reason for the prior sterility
                           MA-39 Form
 Medicaid Hysterectomy Acknowledgement (MA-39)
    • Complete only one section of this form. Section A, B or C
    • If no prior sterility or life-threatening emergency exists, client and
      physician must sign and date Section A prior to the procedure
    • Oral and written consent prior to the procedure still applies for
      Section A
    • The client does not need to sign the form when sections B or C are
      used
 For retroactively eligible clients, the physician must certify in
  writing that the surgery was performed for medical reasons and
  must document:
    • Client was informed prior to the hysterectomy that the operation
      would render then permanently incapable of reproducing, or
    • Reason for the hysterectomy was a life-threatening emergency or the
      client was already sterile and the reason for the prior sterility
                    Resources

•   www.medicaid.org
•   www.cms.hhs.gov/NationalCorrectCodInitEd
•   www.cms.hhs.gov/HospitalOutpatientPPS/AU/list
•   www.cms.hhs.gov/Manuals/IOM/list/
•   www.medicare.bcbsmt.com/provider_part_a.asp
•   Med-Manual §3112.8 Outpatient Observation Services
•   Medlearn Matters
                   Contacts
• ACS, Inc. Provider Relations; (800) 624-3958 in-
  state/out of state; (406) 442-1837 Helena
• Rena Steyaert, Claims Resolution Specialist; (406) 444-
  7002; rsteyaert@mt.gov
• Debra Stipcich, Transplant and PPS Hospital Program
  Officer; (406) 444-4834; dstipcich@mt.gov
• Mary Patrick, Case Manager, Hospital Program; (406)
  444-0061; mpatrick@mt.gov
• Darci Wiebe, ACS Provider Relations Manager; (800)
  624-3958; darci.wiebe@acs-inc.com

				
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