partners for children (pfc) waiver services, procedure codes, rates and billing jill abramson, md...
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Partners for Children(PFC) Waiver Services,
Procedure Codes, Rates and Billing
Jill Abramson, MD MPH February14, 2013
PFC Provider Training
Overview Care Coordination/CCSNL/Communication Family-Centered Action Plan
Services/Billing Federal Assurances/ Health & Welfare Agency Responsibilities/Summary
What Happens Before Submitting Claim
Services identified on F-CAP Services authorized by CCSNL SAR received by agency Service(s) provided
PFC Services, Procedure Codes, Rates and Billing
Objectives:
Understand PFC services Understand the use of the procedure codes
and billing limits Know the rates for each service Understand claims processing procedure
PFC Services
Care Coordination:
Will provide child/family with Care Coordinator to: Assume a majority of the responsibility, otherwise
placed on parents, of coordinating all medically necessary care in the community
Work with the child/family to develop the Family-Centered Action Plan (F-CAP)
Provide ongoing monitoring of health and safety of the child, including home visits
PFC Services
Regularly communicate with the CCSNL, child,
family, treating physician and other providers
Accompany child/family to appointments as
necessary such as; physician, school or hospital
Service Provider: RN, MSW
Care Coordination (cont):
PFC Services
Expressive Therapies:
Will allow children to express their understanding and reaction to their illness by utilizing play, art, music and massage therapy to improve the capacity of the body and mind to heal.Service Provider: certified therapist
PFC Services
Family Training:
Allows an RN to instruct caregivers about end of life care, palliative care principles, care needs, medical treatment regimen, use of medical equipment and how to provide in-home medical care to meet the needs of the child.Service Provider: RN
PFC Services
Respite Care:
Provides relief for family members either in the home or in an approved facility. This benefit may be intermittent or regularly scheduled. Service Provider: RN, LVN, HHA
PFC Services
Family Counseling:
Provides child/family with emotional support and grief counseling. Includes visits before and after the death of the child.Service Provider: LCSW, Licensed Psychologist, MFT, ACSW
PFC Procedure Codes and Rates
Care Coordination Services:
Procedure Code Description Rate Limit(s)
G9001
Bill prior to initial F-CAP
Coordinated care fee
Requires at least 22 hours of initial assessment services
$1,000 One time fee
T2022
May bill first unit in same month as G9001
Monthly case management
4 – 8 hours of case management, per child, per month
$229.17 per unit
1 unit per month;
1 U = 4-8 hr.
12 units per year
PFC Procedure Codes and Rates
Care Coordination Services (cont):
Procedure Code
Description Rate Limit(s)
G9012 Supplemental hourly care coordination
Used after 8 hours of monthly case management has been exceeded
Service Provider –
RN, MSW
$45.43 per unit
1 U = 1 hour
Maximum of 60 hours every 90 days.
PFC Procedure Codes and Rates
Expressive Therapies:
Procedure Code
Description Rate Limit(s)
G0176 Activity Therapy
45 minutes per session
Includes art, music, play and massage therapy
Service Provider – approved expressive therapist
$35.00 per unit
1 unit =
1 session
Up to three units (sessions) per day
Up to 60 sessions every 90 days
Will change to 4 U per day soon
PFC Procedure Codes and Rates
Family Training:
Procedure Code
Description Rate Limits
S5110 Home care training
Service Provider: RN
$11.36 per unit (when RN employed by HA/HHA)
$8.94 per unit (when provided by INP billing independently)
1 unit = 15 minute
Up to 12 units per day
Up to 400 units
per year
PFC Procedure Codes and Rates
Respite Care:
Procedure Code Description Rate Limits
H0045
Provider type: Congregate Living Health Facility
Out-of-home respite
Provided in an approved facility on a short-term basis.
Level of care 1. Skilled nursing services A or B
Level of care 2 - Sub acute
Level of care 3 – Acute
$91.28 per 24 hrs.
$358.97 per 24 hrs.
$490.60 per 24 hrs.
Up to 30 days per year, combined with in-home respite.
PFC Procedure Codes and Rates
Respite Care (cont):
Procedure Code Description Rate Limits
T1005
Provider type:
RN, LVN, CHHA, (HHA/HA);
RN, LVN ( INP)
In-home respite
Intermittent or regularly scheduled temporary care and supervision provided in the home
Ranges from $4.72 - $10.14 (based on provider skill level), per 15 minute unit
Maximum of 96 units per day, 30 days per year in combination with out-of-home respite
PFC Procedure Codes and Rates
Family Counseling:
*At least one visit must be provided, and the whole 22 units billed, before the child’s death.
Procedure Code Description Rate Limits
X9508
Provider type:
LCSW, ACSW, MFT, licensed psychologist
Family Counseling (Bereavement), one hour
$50.87 per unit (total billable amount $1,119.14 (22 units x per unit rate))
1 Unit = 1 hour
22 units to be billed at one time
Limited to a one-time only payment
Billing PFC Services
PFC services are Fee for Service PFC services must be authorized for the correct
dates of service Service Authorization Request (SAR) = auth. Agency requests service on F-CAP, sends to
CCSNL for authorization County CCS will share completed authorization with
Agency Very different from traditional hospice per diem
Billing PFC Services
Billing:– SARs (authorization)
Initial SAR to begin Care CoordinationAdditional SARs for requested PFC
services once F-CAP is completedSeparate SARs for other non-PFC
services covered by the state plan – Check Medi-Cal eligibility prior to
providing services
Billing PFC Services - Claim Completion
UB-04 Field Descriptions:Box # Field Name Instructions
1 Unlabeled (used for facility information)
Enter the facility name. Enter the address, without a comma between the city and state, and a nine-digit ZIP code, without a hyphen. A telephone number is optional in this field.
Note: The nine-digit ZIP code entered in this box must match the biller’s ZIP code on file for claims to be reimbursed correctly.
4 Type of Bill Enter the appropriate three-character type of bill code. The type of bill code includes the two-digit facility type code and one-character claim frequency code. This is a required field when billing Medi-Cal.
8b Patient Name Enter the patient’s last name, first name and middle initial (if known). Avoid nicknames or aliases.
10 Birthdate Enter the patient’s date of birth in an eight-digit MMDDYYYY (Month, Day, Year) format (for example, June 12, 2007 = 06122007). If the recipient’s full date of birth is not available, enter the year preceded by 0101
Billing PFC Services- Claim Completion
UB-04 Field Descriptions (cont):Box # Field Name Instructions
11 Sex Use the capital letter “M” for male or “F” for female. Obtain the sex indicator from the Benefits Identification Card (BIC).
42 Revenue Code Revenue codes are not required; however, this field is used when recording “Total Charges.” Enter “001” on line 23, and enter the total amount on line 23, field 47.
43 Description This field will help you separate and identify the descriptions of each waiver service. The description must identify the particular service code indicated in the HCPCS/Rate/HIPPS Code field (Box 44). This field is optional.
44 HCPCS/RATES/HIPPS Code
Enter the applicable waiver HCPCS procedure code and modifier. Note that the descriptor for the code must match the procedure performed and that the modifier must be billed appropriately. All modifiers must be billed immediately following the HCPCS code in the HCPCS/Rate field (Box 44) with no spaces.
Billing PFC Services- Claim Completion
UB-04 Field Descriptions (cont):
Box # Field Name Instructions
45 Service Date Enter the date the service was rendered in six-digit, MMDDYY (Month, Day, Year) format, for example, June 12, 2007 = 061207.
46 Service Units Enter the actual number of times a single procedure or item was provided for the date of service. Medi-Cal only allows two-digits in this field.
47 Total Charges In full dollar amount, enter the usual and customary fee for the service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar amount and cents, even if the amount is even (for example, if billing for $100, enter 10000 not 100).
Enter the “Total Charge” for all services on line 23. Enter code 001 in the Revenue Code field (Box 42) to indicate that this is the total charge line (refer to field number 42).
Billing PFC Services- Claim Completion
Box # Field Name Instructions
50A-C Payer Name Enter “O/P MEDI-CAL” to indicate the type of claim and payer.
Use capital letters only.
When completing Boxes 50-65 (excluding Box 56) enter all
Information related to the payer on the same line in order of
Payment.
When billing other insurance, the other insurance is entered on
Line A of Box 50, with the amount paid by Other Coverage on
Line A of Box 54 (Prior Payments). All information related to
Medi-Cal billing is entered on Line B of these boxes. Be sure to
enter the corresponding prior payments on the correct line.
If Medi-Cal is the only payer billed, all information in Boxes 50-
65 (excluding box 56) should be entered on Line A.
UB-04 Field Descriptions (cont):
Billing PFC Services- Claim Completion
UB-04 Field Descriptions (cont):
Box # Field Name Instructions
56 NPI Enter the National Provider Identifier (NPI).
60A-C Insured’s Unique ID Enter the 14-character recipient ID number as it appears on the Benefits Identification Card (BIC) or paper Medi-Cal ID card.
63 Treatment Authorization Codes
All waiver services must be prior authorized with a CCS Service Authorization Request (SAR) which includes a unique 11-digit SAR number beginning with a prefix “91” or “97.” The SAR number must be entered in this box. It is not necessary to attach a copy of the SAR to the claim. Claims without a SAR number will be denied.
Claim Completion
Sample UB-04
CCS/Medi-Cal claim authorized with a SAR
60.CIN or 14-digit
ID #
63.PFC
SAR #
Billing PFC Services - Claim Completion and Submission
For help completing UB04 and submission instructions:
Contact Xerox Regional Representative.
Xerox Telephone Service Center: 1-800-541-5555
Billing Troubleshooting
Denied Claims:– Check AEVS, CIN, SAR, correct dates (eligibility,
date on SAR corresponds to service), # units– If no clear reason for denial, send to PPC
mailbox: Name, CCS#, CIN, service, date of service, CCN, RAD,
notes, provider NPI
Billing: Troubleshooting
Underpaid claims– Verify $ in provider manual vs. $ paid.– If incorrect, send to PPC mailbox:
Name, CCS#, CIN, service, date of service, CCN, units paid, $ paid,
$ expected
Billing: Troubleshooting
Claims neither paid nor denied >2 months after submission
Send to PPC mailbox:– Name, CCS#, CIN, service, date of service, CCN (if
available), whether client has OHC
Questions?
PFC Provider Training
Overview Care Coordination/CCSNL/CommunicationFamily-Centered Action PlanServices/Billing
Federal Assurances/ Health & Welfare Agency Responsibilities/Summary
