hp provider relations october 2011 cms-1500 billing

HP Provider RelationsOctober 2011

CMS-1500 Billing

CMS-1500 Billing October 20112

Agenda

– Objectives

– Enhanced Code Auditing

– Clear Claim Connection

– Upcoming changes – International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10 CM)

– CMS-1500

– Claim Form Billing Guidelines - Various Specialties

– Consent Form, Sterilization, and Partial Sterilization

– Prior Authorization

– Code Sets

– Fee Schedule

– Common Denials

– Helpful Tools

– Questions


Objectives

Following this session, providers will be able to:

– Identify their provider classification

– Bill claims correctly for various specialties

– Understand the sterilization consent completion

– Have more information about prior authorization

– Identify the various provider code sets

– Find and understand how the fee schedule can assist providers

– Know the common denial causes and resolutions

LearnEnhanced Code Auditing


Enhanced Code Auditing

– The Indiana Health Coverage Programs (IHCP) is implementing enhanced code auditing into the claims processing to support the Office of Medicaid Policy and Planning’s (OMPP’s) effort to promote and enforce correct coding efforts for more appropriate and accurate program reimbursement

Why is the IHCP implementing the enhanced code auditing?



– Code auditing rules that have been implemented represent correct coding methodologies and other coding methods based upon general guidance from the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), specialty society guidance, industry standard coding, and prevailing clinical practice

What supporting information is used for the new code auditing rules?



What is it?

– Identifies claims containing two or more procedure codes used to report individual components of a service when a single, more comprehensive procedure code exists that more accurately represents the service performed• Individual unbundled procedures will be denied

Multiple component billing



– Effective for claims received on or after April 1, 2011

– Identifies when individual components of a bundled service are billed separately rather than using the comprehensive Current Procedural Terminology (CPT®) code

– Unbundled code line items will be denied:• Edit 4186

Service denied. This is a component of a more comprehensive service. This service is reimbursed under a distinct comprehensive code

Healthcare services should be reported with the procedure code that most comprehensively describes the services performed

Multiple component billing – Laboratory BT201102

CPT is copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.


Enhanced Code AuditingMultiple component billing – Example of lab panel rebundling

Line Number

Date of Service

To Date of Service

Procedure Code

Description Billed Amount

Component Rebundling EOB

01 4/1/2011 4/1/2011 82040 Albumin; serum, plasma or whole blood

$100 Detail is denied with EOB 4186

02 4/1/2011 4/1/2011 82247 Bilirubin; total $100 Detail is denied with EOB 4186

03 4/1/2011 4/1/2011 82248 Bilirubin; total direct $100 Detail is denied with EOB 4186

04 4/1/2011 4/1/2011 84075 Phosphatase, alkaline $100 Detail is denied with EOB 4186

05 4/1/2011 4/1/2011 84155 Protein, total, except by refractometry; serum, plasma or whole blood


06 4/1/2011 4/1/2011 84450 Transferase; aspartate amino (AST) (SGOT)


07 4/1/2011 4/1/2011 84460 Transferase; alanine amino (ALT) (SGPT)




Effective for date of service (DOS) on or after July 15, 2011, the IHCP began applying code auditing of the following:

–CMS-1500 claims that are billed with multiple units of the same laboratory code on the same date of service

Edit 4189 - Multiple units of the same laboratory service are not payable for the same date of service, same member, and same or different provider without medical necessity

Changes to code auditing methodologies – BT201135



– CPT add-on codes reported without reporting a corresponding primary procedure/service• Edit 4190 – Add-on codes are performed in addition to the primary service or

procedure and must never be reported as a stand-alone code

– Reporting multiple units of a primary service when add-on codes should be used• Edit 4191 – A primary service or procedure code is limited to one unit per date of

service




Effective for DOS on or after August 1, 2011, the system began applying code auditing of the following:

– Non-anesthesia services submitted by an anesthesia provider specialty where the service billed is not normally performed by an anesthesia provider specialty

• Edit 4192 – Non-anesthesia services are not reimbursable for the anesthesiology provider specialty billed




– Non-anesthesia services submitted by an anesthesia provider specialty where there is a more appropriate anesthesia code that should be used for billing• Edit 4193 – Non-anesthesia services are not reimbursable for the anesthesiology

provider specialty billed.

• Claim lines containing non-anesthesia services submitted by an anesthesiology provider specialty will be denied. Providers may resubmit the denied details with the anesthesia code(s) as appropriate.

– These anesthesia-related code auditing rules apply only to providers enrolled with the anesthesia specialty• Multiple specialty providers will not be subjected to this type of code auditing




Effective for dates of service on or after August 31, 2011, the following code audits were implemented:

– Evaluation and management (E/M) codes billed on the same date of service as a procedure with a global period

• Edit 4194 – Identifies procedure codes billed by the same provider on the same date of service as a code with a global period

– E/M codes billed within the pre-operative period

• Edit 4196 – Identifies procedure codes billed by the same provider within a procedure's preoperative period

Note: E/M services performed in a postoperative period that are unrelated to a surgical procedure should only be reported using the proper modifier



Enhanced Code AuditingBilling reminders – Use of modifiers

– Modifiers may be appended to Healthcare Common Procedure Coding System (HCPCS)/CPT codes only when clinical circumstances justify them

– A modifier should not be appended to an HCPCS/CPT code solely to bypass Component Rebundling auditing• The use of modifiers affects the accuracy of claims billing and reimbursement, and

Component Rebundling auditing

–Same procedures, performed during the same session

• Roll all the units to a single line, unless otherwise specified in medical policy

AnnouncingClear Claim Connection


Clear Claim Connection

– Clear Claim Connection is a web-based solution that enables HP/OMPP to share the National Correct Coding Initiative (NCCI) claim auditing rules with providers

– The tool is for providers to perform claim analysis prior to submitting the claim for processing

– Providers have access to Clear Claim Connection through a link within the Claim Submission menu option on Web interChange• Web interChange users must have access to Claim Submission to use Clear Claim

Connection



Enter NPI or LPI


Click “Disallow” or “Review” to obtain clinical edit

clarification


Clear Claim Connection – Overview

– Select the Clear Claim Connection link under the Code Auditing menu

– Choose appropriate National Provider Identifier (NPI) if it is not currently populated

– Click Continue button and click Agree on the Terms and Agreement page to access the Clear Claim Connection

– Enter claim detail information to determine how the claim will process according to the auditing rules set up in ClaimsXten McKesson

– Click Review Claim Audit Results to view the results

– Click New Claim to input information for another claim

– Click Current Claim to change the information on the current scenario and continue with claim analysis

DiscussHP ICD-10 Compliance Project Status


Details

– Professional diagnosis codes will increase to 12 entries per transaction .

– Diagnoses fields will increase from 5 characters to 7.

– ICD-9 procedure fields will increase from 4 characters to 7 alphanumeric characters for ICD-10 .

– Diagnosis code pointer (professional claims) will expand from 4 positions to 8 (4, 2-character fields).

– The ICD version qualifier will be required on paper, Web, or EDI claim submissions to indicate the version of ICD codes being used.

– Claims submitted with both ICD-9 and ICD-10 listed will be rejected.

– Date of service (DOS) will aid in determining if ICD-9 or ICD-10 is used when billing your claims to the IHCP.


FAQs

– What is the current implementation time frame?

HP has completed the assessment for the Medicaid Management Information System (MMIS) and is on target for the October 1, 2013, implementation of the ICD-10 Compliance Project.

– Is there going to be a system freeze? If so, when?

Yes, there will be a system freeze. Currently, it is scheduled for September 2013.

– Will there be vendor testing? When?

Yes, there will be vendor testing that will include managed care entities (MCEs). Vendor testing is scheduled to begin January 1, 2013.

– Will providers/vendors be able to use the ICD-9 codes after the October 1, 2013, implementation?

No, you must use ICD-10 codes for DOS or DOD on or after the October 1, 2013, implementation date. There is no grace period.


ICD-10 IHCP Provider Readiness Survey

– The first IHCP Provider Readiness Survey is in development • A link to the survey will be posted on the Indiana Medicaid Web site Provider page

– The survey will be available from November 7 to November 14

– Upcoming Bulletins, Banner Pages, and Newsletters will include information about accessing the survey

– This survey should be completed by the individual that is instrumental in planning, implementing, and managing the transition to ICD-10 in the provider’s business

– Survey results will help us help you, by tracking your progress and capturing your issues

Learn1500 Claims


Types of 1500 Claims

– 837P – Electronic transaction• Companion Guide available on IHCP Web

site: provider.indianamedicaid.com

– Web interChange

– Paper claim

– Replacement/Adjustment request (for a previously paid claim)

http://provider.indianamedicaid.com/


Web interChange – 1500 Electronic filing


Paper Claim Form Locators – CMS-1500


Paper Claim Form LocatorsCMS-1500

Fields Description

1 INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid. Required.

1a INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1) – Enter the IHCP member identification number (RID). Must be 12 digits. Required.

2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Provide the member’s last name, first name, and middle initial obtained from the Automated Voice Response (AVR) system, electronic claim submission (ECS), Omni, or Web interChange verification. Required.

9 OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) – If other insurance is available, and the policyholder is other than the member shown in fields 1a and 2, enter the policyholder’s name. Required, if applicable.

9a OTHER INSURED’S POLICY OR GROUP NUMBER – If other insurance is available, and the policyholder is other than the member noted in fields 1a and 2, enter the policyholder’s policy and group number. Required, if applicable.

9c EMPLOYER’S NAME OR SCHOOL NAME – If other insurance is available, and the policyholder is other than the member shown in fields 1a and 2, enter the requested policyholder information. Required, if applicable.



Fields Description

9d INSURANCE PLAN NAME OR PROGRAM NAME – If other insurance is available, and the policyholder is other than the member shown in field 1a and 2, enter the policyholder’s insurance plan name or program name information. Required, if applicable.

10 IS PATIENT’S CONDITION RELATED TO – Enter X in the appropriate box in each of the three categories. This information is needed for follow-up third-party recovery actions. Required, if applicable.

10a EMPLOYMENT (CURRENT OR PREVIOUS) – Enter X in the appropriate box. Required, if applicable.

10b AUTO ACCIDENT – Enter X in the appropriate box. Required, if applicable.

PLACE (State) – Enter the two-character state code. Required, if applicable.

10c OTHER ACCIDENT – Enter X in the appropriate box. Required, if applicable.

11 INSURED’S POLICY GROUP OR FECA NUMBER – Enter the member’s policy and group number of the other insurance. Required, if applicable.

11a INSURED’S DATE OF BIRTH – Enter the member’s birth date in MMDDYY format. Required, if applicable.

SEX – Enter an X in the appropriate sex box. Required, if applicable.



Fields

Description

11b EMPLOYER’S NAME OR SCHOOL NAME – Enter the requested member information. Required, if applicable.

11c INSURANCE PLAN NAME OR PROGRAM NAME – Enter the member’s insurance plan name or program name. Required, if applicable.

11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Enter X in the appropriate box. If the response is Yes, complete fields 9a–9d. Required, if applicable.

14 DATE OF CURRENT ILLNESS (First symptom date) OR INJURY (Accident date) OR PREGNANCY (LMP date) – Enter the date of the last menstrual period (LMP) for pregnancy-related services in MMDDYY format. Required for payment for pregnancy-related services.

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION – If field 10a is Yes, enter the applicable FROM and TO dates in a MMDDYY format. Required, if applicable.

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE – Enter the name of the referring physician. Required, if applicable. For waiver-related services, enter the provider name of the case manager. Required for Care Select PMP for dates of service prior to January 1, 2011.

Note: The term referring provider includes those physicians primarily responsible for the authorization of treatment for lock-in or Right Choices Program members.



Fields Description

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – Enter the requested FROM and TO dates in MMDDYY format. Required, if applicable.

19 RESERVED FOR LOCAL USE – Enter the Care Select primary medical provider (PMP) two-digit alphanumeric certification code. Required for Care Select members when the physician rendering care is not the PMP or a physician in the PMP’s group or a clinic for dates of service prior to January 1, 2011.

Note: Report the PMP qualifier and ID number in 17a.21.1 to 21.4.

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – Complete fields 21.1, 21.2, 21.3, and/or 21.4 to field 24E by detail line. Enter the ICD-9-CM diagnosis codes in priority order. A total of four codes can be entered. At least one diagnosis code is required for all claims except those for waiver, transportation, and medical equipment and supply services. Required.

22 MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B crossover claims only. For crossover claims, the combined total of the Medicare coinsurance, deductible, and psych reduction must be reported on the left side of field 22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must be submitted in field 22 on the right side under the heading Original Ref No. Required, if applicable.



Fields Description24A to 24I

Top Half – Shaded Area

NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I is used to report NDC information. Required as of August 1, 2007.

To report this information, begin at field 24A as follows:

1.Enter the NDC qualifier of N4

2.Enter the NDC 11-digit numeric code

3.Enter the drug description

4.Enter the NDC Unit qualifierF2 – International UnitGR – GramML – MilliliterUN – Unit

5.Enter the NDC Quantity (Administered Amount) in the format 9999.99 24A

Bottom Half

DATE OF SERVICE – Provide the FROM and TO dates in MMDDYY format. Up to six FROM and TO dates are allowed per form. Required.



Fields Description24B PLACE OF SERVICE – Use the POS code for the facility where services were

rendered. Required.For a list of POS codes, go to the Place of Service Codes Overview page on the CMS Web site at cms.hhs.gov.

24C EMG – Emergency indicator. This field indicates services were for emergency care for service lines with a CPT or HCPCS code in field 24D. Enter Y or N. Required, if applicable.

24D PROCEDURES, SERVICES, OR SUPPLIES

CPT/HCPCS – Use the appropriate procedure code for the service rendered. Only one procedure code is provided on each claim form service line. Required.

MODIFIER – Use the appropriate modifier, if applicable. Up to four modifiers are allowed for each procedure code. Required, if applicable.

24E DIAGNOSIS CODE – Enter number 1–4 corresponding to the applicable diagnosis codes in field 21. A minimum of one, and a maximum of four, diagnosis code references can be entered on each line. Required.

http://www.cms.gov/PlaceofServiceCodes/

http://www.cms.gov/



Fields Description

24F $ CHARGES – Enter the total amount charged for the procedure performed, based on the number of units indicated in field 24G. The charged amount is the sum of the total units multiplied by the single unit charge. Each line is computed independently of other lines. This is a 10-digit field. Required.

24G DAYS OR UNITS – Provide the number of units being claimed for the procedure code. Six digits are allowed, and 9999.99 units is the maximum that can be submitted. The procedure code may be submitted in partial units, if applicable. Required.

24H EPSDT Family Plan – If the patient is pregnant, indicate with a P in this field on each applicable line. Required, if applicable.



Fields Description

24I


RENDERING ID QUALIFIER – Enter the qualifier indicating what the number reported in the shaded area of 24J represents – 1D for IHCP LPI rendering provider number or ZZ for rendering provider taxonomy code.

1D is the qualifier that applies to the IHCP provider number (LPI) for atypical nonhealthcare providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs.

ZZ is the qualifier that applies to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match.

Taxonomy – Enter the taxonomy code of the rendering provider. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.

24J


RENDERING PROVIDER ID – Enter the LPI if entering the 1D qualifier in 24I for the Rendering Provider ID. Required, if applicable for non-healthcare providers only.

LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s number must be entered here.



Fields Description

24J

Bottom Half

RENDERING PROVIDER NPI – Enter the NPI of the rendering provider. Required if applicable.

28 TOTAL CHARGE – Enter the total of all service line charges in column 24F. This is a 10-digit field, such as 99999999.99. Required.

29 AMOUNT PAID – Enter the payment received from any other source, excluding the Medicare paid amount. All applicable items are combined and the total entered in this field. This is a 10-digit field. Required, if applicable.

Other insurance – Enter the amount paid by the other insurer. If the other insurer was billed but paid zero, enter 0 in this field. Attach denials to the claim form when submitting the claim for adjudication.

30 BALANCE DUE – TOTAL CHARGE (field 28) – AMOUNT PAID (field 29) = BALANCE DUE (field 30). This is a 10-digit field, such as 99999999.99. Required.



Fields Description

31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS – An authorized person, someone designated by the agency or organization, must sign and date the claim. A signature stamp is acceptable; however, a typed name is not. Providers that have signed the Claims Certification Statement for Signature on File form will have their claims processed when a signature is omitted from this field. The form is available on the Forms page on indianamedicaid.com. Required if applicable.

DATE – Enter the date the claim was filed. Required.

33 BILLING PROVIDER INFO & PH # – Enter the billing provider office location name, address, and the ZIP Code+4. Required.

Note: If the U.S. Postal Service provides an expanded ZIP Code (ZIP Code + 4) for a geographic area, this expanded ZIP Code must be entered on the claim form.

33a BILLING PROVIDER NPI – Enter the billing provider NPI. Required.

http://www.indianamedicaid.com/



Fields Description33b BILLING PROVIDER QUALIFIER AND ID NUMBER – Healthcare providers may enter

a billing provider qualifier of ZZ and taxonomy code. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.

If the billing provider is an atypical provider, enter the qualifier 1D and the LPI. Required.

Note: Qualifiers are ZZ = Taxonomy and 1D = LPI

ExplainBilling Guidelines


Billing Guidelines

– Billing Provider – Provider classification assigned to a billing entity or solo practitioner at a service location

– Group Provider – The classification given to a corporation or other business structure that has rendering providers linked that are the performers of the services provided

– Rendering Provider – A provider that performs the services for a group or clinic and is linked to the group or clinic

– Dual – A billing provider performing services as a sole proprietor at an assigned service location and is also a rendering provider working for a group

Provider classifications


Billing Guidelines

– Use Current Procedural Terminology (CPT®) codes 00100-01999 (refer to IHCP Provider Manual chapter 8 for more information)

– One unit = 15 minutes

– Bill the actual time in minutes and include it in field 24G

– Additional units are allowed based on a patient’s age when billing for emergency services (bill using procedure code 99140)

Anesthesia

CPT is copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.


Billing Guidelines

– Providers bill postoperative pain management using code 01996

– The IHCP does not separately reimburse this code on the same day the epidural is placed• However, it is reimbursed for subsequent days

when an epidural is managed

Note: When two claims for the same billing NPI but with different rendering NPIs are denying for edit 4181, they need to be special batched. Contact your field consultant .

Anesthesia


Billing Guidelines

– IHCP limits chiropractic services to 50 per member, per calendar year • The IHCP reimburses for no more than five office visits out of the 50 total units

– Package B reimbursement is available for medically necessary pregnancy-related services. Refer to Chapter 8 of the IHCP manual for a listing of pregnancy diagnosis codes.

– Package C members are allowed five office visits and 14 therapeutic physical medicine treatments per member, per calendar year

Chiropractic services


Billing Guidelines

– The following are covered codes for office visits:• 99201, 99202, 99203, 99211, 99212, 99213

– The following are covered codes for manipulative treatment:• 98940-98943

Note: Services denied by Medicare must be billed as Medicaid primary claims and be submitted with the Medicare Remittance Notice (MRN)

Chiropractic services


Billing Guidelines

– The IHCP reimburses for physician office injectable drugs using Healthcare Common Procedure Coding System (HCPCS) J codes and CPT immunization codes

– Pricing includes the current average wholesale price plus a $2.90 administration fee

– The IHCP reviews pricing for a physician office administered drug each quarter

– To price appropriately, HCPCS code J3490 must be submitted with the appropriate NDC, name, strength, and quantity

Injections


Billing Guidelines

– The IHCP Provider Manual contains lists of J codes that require a National Drug Code (NDC)• Chapter 8, Section 4

– For paper CMS-1500 claims forms, report NDC information in the shaded area of field 24• Refer to bulletin BT200713 dated May 29, 2007

– The NDC is not used for provider reimbursement

Injections and NDC codes


Billing Guidelines

– Outpatient mental health services are carved-in to the risk-

based managed care (RBMC) delivery system

– Services provided to RBMC members by the following

specialty types are the responsibility of the managed care

entities (MCEs):• Freestanding Psychiatric Hospital• Outpatient Mental Health Clinic• Community Mental Health Center• Psychologist• Certified Psychologist• Health Service Provider in Psychology (HSPP)• Certified Clinical Social Worker• Psychiatric Nurse• Psychiatrist

Mental health RBMC


Billing Guidelines

Services that are the MCE’s responsibility:

– Office visits with a mental health diagnosis

– Services ordered by a provider enrolled in a mental health specialty, but provided by a nonmental health specialty (such as a laboratory and radiology)

– Mental health services provided in an acute care hospital

– Inpatient stays in an acute care hospital or freestanding psychiatric facility for treatment of substance abuse, chemical dependency or patients with a mental health diagnosis

Mental health RBMC


Billing Guidelines

– Effective July 1, 2010, MRO services no longer require the use of modifiers to note the midlevel scope of practice

– MRO services require the use of the HW modifier

– Providers should use the NPI of the supervising practitioner, which is the physician or health service provider in psychology (HSPP)

– Group setting should be billed using the U1 modifier

Note: When billing Group setting for addiction counseling, do not use a modifier

Refer to Bulletin BT201023 dated July 8, 2010

Medicaid Rehabilitation Option (MRO)


Billing Guidelines

– MCEs• Anthemanthem.com

• Managed Health Services (MHS)managedhealthservices.com

• MDwisemdwise.org

– Behavioral Health Organizations (BHOs)• Anthem

anthem.com

• Cenpatico (MHS)cenpatico.com

• MDwisemdwise.org

Mental health RBMC

http://www.anthem.com/

http://www.managedhealthservices.com/

http://www.mdwise.org/

http://www.anthem.com/

http://www.cenpatico.com/

http://www.mdwise.org/


Billing Guidelines

Cosurgeons:

– Cosurgeons must append modifier 62 to the surgical services

– Modifier 62 cuts the reimbursement rate to 62.5% of the rate on file

Bilateral Procedures:

– To indicate a bilateral procedure, providers bill with one unit in field 24G, using modifier 50

– Use of this modifier ensures that the procedure is priced at 150% of the billed charges or the rate on file

Note: If the CPT code specifies the procedure as bilateral, then the provider must not use modifier 50

Surgical services


Billing Guidelines

– Postoperative care for a surgical procedure includes 90 days following a major procedure surgical procedure and 10 days following a minor surgical procedure

– Separate reimbursement is available for care during the global postoperative period for:• Services unrelated to the surgical procedure

• Care not considered routine

• Postoperative care for surgical complications

– For surgery codes only, separate reimbursement is available for surgeries that have unusual complications using modifier 22– Additional documentation is required

Surgical services


Billing Guidelines

– When two or more covered surgeries are performed during the same operative session, multiple surgery reductions apply to the procedure based on the following adjustments:• 100% of the global fee for the most expensive procedure

• 50% of the global fee for the second most expensive procedure

• 25% of the global fee for the remaining procedures

– All surgeries performed on the same day, by the same rendering physician, must be billed on the same claim form; otherwise, the claim will be denied and the original claim may be adjusted

Multiple surgery procedures


Billing Guidelines

– A qualified therapist or qualified assistant under the direct supervision of the therapist, must provide the therapy

– Therapy must be provided at the level of complexity that is based on the condition of the member based on the evaluation

– Reimbursement is made only for medically reasonable and necessary therapy

– The IHCP does not cover therapy rendered for diversional, recreational, vocational, maintenance therapy or avocational purposes, or for the remediation of learning disabilities or developmental activities that performed by nonmedical personnel

– Coverage is not provided for rehabilitative services for a member longer than two years from the initiation of the therapy unless a significant change in medical condition

Therapy services requirements


Therapy services requirements

– When a member is receiving therapy, ongoing evaluations to assess progress or lack of progress are part of the program• The IHCP does not separately reimburse for ongoing evaluations

– One hour of billed therapy must include a minimum of 45 minutes of direct patient care with the balance of the hour spent in related patient services

– The IHCP does not approve any type of therapy services for more than one hour per day per type of therapy

Billing Guidelines


Billing Guidelines

• The PTA is precluded from performing and interpreting tests, conducting initial or subsequent assessments, and developing treatment plans

• Under direct supervision, a PTA is still required to consult with the supervising physical therapist daily to review treatment

• The consultation can be either face-to-face or by telephone

• Claims will be billed with modifier HM – Less than a bachelor’s degree – with the code billed and the rendering supervisor’s NPI

• Pricing for these services will be at 75% of the fee on file for the procedure billed

• Chapter 8, section 4 provides a listing of codes that can be billed by a PTA

Therapy services – Physical therapist assistant (PTA) billing


Billing Guidelines

– Routine foot care is only covered if a member has been seen by a medical doctor or doctor of osteopathy for treatment or evaluation of a systemic disease during the six-month period prior to rendering routine foot care

– A maximum of six routine foot care services is covered per rolling 12-month period when the member has one of the following:• Systemic disease of sufficient severity that a

treatment of the disease may pose a hazard when performed by a nonprofessional

• Systemic conditions that result in severe circulatory embarrassment or has had areas of desensitization in the legs or feet

Podiatry services – Routine foot care


Billing Guidelines

– ICD-9-CM diagnosis codes that represent systemic conditions that justify coverage for routine foot care:• Diabetes mellitus: ICD-9-CM codes 250.00-

250.91

• Arteriosclerotic vascular disease of lower extremities: ICD-9-CM codes 440.20-440.29

• Thromboangitis oblierans: ICD-9-CM code 443.1

• Post-phlebitis syndrome: ICD-9-CM code 459.1

• Peripheral neuropathies of the feet: ICD-9-CM codes 357.1-357.7

– Routine foot care is not a covered service for Package C members

Podiatry services – routine foot care


Billing Guidelines

– Reimbursement is limited to one office visit using procedure code 99211, 99212, and 99213 per member, per 12 months, without obtaining prior authorization

– New patient office visits, using procedure codes 99201, 99202, and 99203 are reimbursable at one per member, per provider, within the last three years as defined by the CPT guidelines

– On the initial visit, both the office visit and the procedure performed are reimbursable

– For subsequent visits, reimbursement for the visit is included in the procedure performed on that date and not billed separately• Exception: If a second, significant problem is addressed on a

subsequent visit, the visit code may be reported with the 25 modifier

Podiatry services – routine foot care


Billing Guidelines

– Reimbursement is available for office visits to a maximum of 30 per rolling 12-month period, per IHCP member, without prior authorization (PA), and subject to the restrictions in Section 2 of 405 IAC 5-9-1

– Per 405 IAC 5-9-2, office visits should be appropriate to the diagnosis and treatment given and properly coded

Evaluation and management codes

Procedure Codes

99201-99215 99381-99397

99241-99245 99401-99429

99271-99275


Billing Guidelines

– Professional services rendered during the course of a hospital stay must be submitted on Web interChange, using the electronic 837P transaction or on a paper CMS-1500 claim form

– The IHCP makes reimbursement in accordance with the appropriate professional fee schedule

– The inpatient diagnosis-related group (DRG) reimbursement methodology does not provide payment for physician fees, including the hospital-based physician fee

– New patient office visits are limited to one visit per member, per billing provider – once every three years

Evaluation and management codes


Billing Guidelines

– The IHCP covers the following 14 antepartum visits:• Three visits in trimester one

• Three visits in trimester two

• Eight visits in trimester three

– Providers use the following codes to bill for visits:• First visit – Evaluation and management (E/M) – 99201-99205

• Visits one through six – 59425

• Seventh and subsequent visits – 59426

– Providers use the following modifiers with procedure codes:• U1 for trimester one – Zero through 14 weeks

• U2 for trimester two – 14 weeks, one day through 28 weeks

• U3 for trimester three – 28 weeks, one day through delivery

Obstetric services


Billing Guidelines

– For pregnancy-related claims, indicate the last menstrual period (LMP) in MM/DD/YY format infield 14

• The IHCP will deny claims for pregnancy-related services if there is no LMP

– Indicate a pregnancy-related diagnosis code as the primary diagnosis when billing for pregnancy-related services

Pregnancy-related claims


Billing Guidelines

– Use normal low-risk pregnancy diagnosis codes:• V22.0

• V22.1

– Use high-risk pregnancy codes:• V60.0 through V62.9

For additional information, refer to the IHCP Provider Manual, Chapter 8, Section 4

Pregnancy diagnosis codes

DescribeSterilization and Partial Sterilization


Consent Form


Sterilization and Partial Sterilization

– A sterilization form is not necessary when a patient is rendered sterile as a result of an illness or injury• Providers must note partial sterilization with an

attachment to the claim indicating “Partial Sterilization” and no consent required

– Partial sterilization can also be submitted on the electronic 837P transaction when “Partial Sterilization” is indicated in the claim notes

Partial sterilization


Sterilization Procedure

– Can be performed in the office as an outpatient or in an ambulatory surgical center (ASC)

– Device billed separately on CMS-1500 form using sterilization HCPCS code A9900 – Miscellaneous supply, accessory, and/or service component of another HCPCS code

– Use primary diagnosis code of ICD-9-CM V25.2 – Sterilization

– Print “Sterilization Device Implant” on the claim form or accompanying invoice

– Submit cost invoice with claim

– Submit a valid, signed Sterilization Consent form

– Print Hysteroscopic Sterilization Procedure on the claim form or on the invoice

Refer to BR201006 for more information

Hysteroscopic Sterilization Procedure

ExplainPrior Authorization


Prior Authorization

– Providers must verify member eligibility to determine the care management organization (CMO) that will process the PA or Update request• CMO information via Web interChange is real time

• Send the PA request to the assigned CMO as of the date of the request

• Send System Update Request form to the original CMO

– Example:• Member is assigned to MDwise on 4/3/11, when the PA is requested

• On 4/15/11, the member transitions from MDwise to ADVANTAGE

• On 4/23/11, the primary medical provider (PMP) requests a System Update to the PA

• The PMP must request the System Update from MDwise


Prior Authorization

– Members can be reassigned from traditional Medicaid fee-for-service, to Hoosier Healthwise/RBMC, or Care Select

– When the member changes programs, the receiving organization must honor PAs approved by the prior organization for the first 30 days following the reassignment, or for the remainder of the PA dates of service, whichever comes first

– Example:• Member transitions from Hoosier Healthwise/RBMC to a Care Select CMO on

September 15, 2011

• The MCE approved PA for dates of service 9/6/11 through 10/30/11

• The Care Select CMO must honor the approved PA for 30 days from September 15, 2011


Prior Authorization

– When members transition from one CMO to another CMO, or from Traditional Medicaid to Care Select, the receiving organization must honor the approved PA until the PA expires

Member changes within a program


Prior Authorization

– Each CMO is responsible for processing medical service PA requests and updates for members assigned to their organization at the time of the request

– Traditional Medicaid fee-for-service PA requests are processed by ADVANTAGE Health Solutions

– Pharmacy PA requests continue to be processed by Affiliated Computer Services (ACS)


Prior Authorization Contact Information

– ADVANTAGE Health Solutions (fee-for-service)• P.O. Box 40789

Indianapolis, IN 462401-800-269-57201-800-689-2759 (Fax)

– ACS (Pharmacy)• 1-866-879-0106

1-866-780-2198 (Fax)


Prior Authorization Contact Information

– MDwise – Care Select• P.O. Box 44214

Indianapolis, IN 46244-02141-800-356-12041-877-822-7186 (Fax)

– ADVANTAGE Health Solutions – Care Select• P.O. Box 80068

Indianapolis, IN 462801-800-440-24491-800-689-2759 (Fax)

InformCode Sets


Code Sets

The following provider types have specific code sets:

– Chiropractic

– Durable Medical Equipment

– Hearing Services

– Home Medical Equipment

– Optician

– Optometrist

– Transportation

– Vision

All code sets can be referenced on the provider.indianamedicaid.com Web site

http://provider.indianamedicaid.com/

DescribeIHCP Fee Schedule


Fee Schedule

– The IHCP Fee Schedule is available on the IHCP Web site and provides the following information:• Coverage

• Pricing for procedure codes

• PA requirements for individual procedure codes

DenyCommon Denials for CMS-1500


Edit 2502

– Cause• Medical claims for Medicare Part B coverage for a member have Part B on the

eligibility screen but there is no Medicare MRN with the claim showing Medicare denial

– Resolution• Submit the Medicare payment on the right side of field 22 and the coinsurance,

deductible, or blood deductible on the left side

– Resolution

• Submit the coordination of benefits information

Recipient covered by Medicare Part B


Edit 558

– Cause• Coinsurance and deductible amount are missing, indicating this is not a

crossover claim

– Resolution• Add coinsurance and/or deductible amount and/or Medicare paid amount to

the CMS-1500

• CMS-1500

Add coinsurance and/or deductible amount on the left side of field 22

Add the Medicare Payment amount on the right side in field 22

Coinsurance and deductible amount missing


Edit 2505

– Cause• This member has private insurance, which must be billed prior to Medicaid

– Resolution• Add the other insurance payment to the claim

• CMS-1500

Add other insurance excluding Medicare payments to field 29

• If the primary insurance denies, the explanation of benefits (EOB) must be sent with the claim, either on paper with a paper claim, or as an attachment if claim is sent on Web interChange

Recipient covered by private insurance

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

http://www.indianamedicaid.com/

hp provider relations october 2011 cms-1500 billing

Documents

enhanced code auditing

comprehensive procedure

new code auditing rules

various provider code

comprehensive service

resolutions slide

bundled service

medicare medicaid services