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CMS-1500 Billing
HP Provider Relations
October 2010
Agenda
– Objectives
– Prior Authorization
– CMS-1500
– Code Sets
– Claim Form Billing Guidelines Various Specialties
– Fee Schedule
– Crossover Claims
– Consent Form, Sterilization and
Partial Sterilization
– Mail Order Incontinence,
Ostomy, and Colostomy
Supplies
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CMS-1500 Billing
October 2010
– ANSI version 5010 and CCI
– Common Denials
– Helpful Tools
– Questions
Objectives
Following this session, providers will be able to:
– Identify their provider classification
– Bill claims correctly for various specialties
– Submit crossover claims successfully
– Understand the sterilization consent completion
– Know the program exclusions
– Have more information about prior authorization
– Identify the various provider code sets
– Find and understand how the fee schedule can assist providers
– Understand the requirements of ANSI Version 5010
– Know the common denial causes and resolutions
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CMS-1500 Billing
October 2010
Learn
1500 claims
Types of 1500 Claims
– 837I – Electronic transaction
•
Companion Guide available on IHCP Web
site: www.provider.indianamedicaid.com
– Web interChange
– Paper claim
– Replacement/Adjustment request
(for a previously paid claim)
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CMS-1500 Billing
October 2010
Web interChange – 1500 Electronic filing
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CMS-1500 Billing
October 2010
Paper Claim Form Locators – CMS-1500
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CMS-1500 Billing
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Paper Claim Form Locators
CMS-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 member IHCP
identification (RID) number. 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.
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.
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.
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9a
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.
9c
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October 2010
Paper Claim Form Locators
CMS-1500
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.
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.
EMPLOYMENT (CURRENT OR PREVIOUS) – Enter X in the appropriate box. Required,
if applicable.
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10a
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.
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Paper Claim Form Locators
CMS-1500
Fields
Description
11b
EMPLOYER’S NAME OR SCHOOL NAME – Enter the requested member
information. Required, if applicable.
INSURANCE PLAN NAME OR PROGRAM NAME – Enter the member’s
insurance plan name or program name. Required, if applicable.
IS THERE ANOTHER HEALTH BENEFIT PLAN? Enter X in the appropriate
box. If the response is Yes, complete fields 9a–9d. Required, if applicable.
11c
11d
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16
17
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.
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.
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.
Note: The term referring provider includes those physicians primarily responsible
for the authorization of treatment for lock-in or restricted card members.
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CMS-1500 Billing
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
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.
17a
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Note: The term referring provider includes those physicians primarily responsible for the
authorization of treatment for lock-in or restricted card members.
ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER
SOURCE – Not used.
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
17b
NPI – Enter the 10-digit numeric NPI of the referring provider, ordering provider, or other
source. Required when applicable and for Care Select PMPs.
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.
Note: Report the PMP qualifier and ID number in 17a.
21.1 to
21.4.
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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.
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
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.
24A to 24I
NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I
is used to report NDC information. Required as of August 1, 2007.
Top Half –
Shaded Area 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 qualifier
 F2 – International Unit
 GR – Gram
 ML – Milliliter
 UN – Unit
5. Enter the NDC Quantity (Administered Amount) in the format 9999.99
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CMS-1500 Billing
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
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.
24A to 24I
NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I
is used to report NDC information. Required as of August 1, 2007.
Top Half –
Shaded Area 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 qualifier
 F2 – International Unit
 GR – Gram
 ML – Milliliter
 UN – Unit
5. Enter the NDC Quantity (Administered Amount) in the format 9999.99
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CMS-1500 Billing
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
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.
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.
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Paper Claim Form Locators
CMS-1500
Fields
Description
24I
Top Half –
Shaded
Area
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-toone 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
Top Half –
Shaded
Area
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.
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Paper Claim Form Locators
CMS-1500
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 10digit 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.
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.
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October 2010
Paper Claim Form Locators
CMS-1500
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 Signature on File certification form will
have their claims processed when a signature is omitted from this field. The form is
available on the IHCP Web site, Provider Services page at
http://www.indianamedicaid.com/ihcp/ProviderServices/provider_enroll.asp. Required if
applicable.
DATE – Enter the date the claim was filed. Required.
BILLING PROVIDER INFO & PH # – Enter the billing provider office location name,
address, and the ZIP Code+4. Required.
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33a
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Note: If the 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.
BILLING PROVIDER NPI – Enter the billing provider NPI. Required.
October 2010
Paper Claim Form Locators
CMS-1500
Fields
Description
33b
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
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CMS-1500 Billing
October 2010
Explain
Billing guidelines
Billing Guidelines
Provider classifications
– 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
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Billing Guidelines
Anesthesia
– Use Current Procedural Terminology
(CPT®) codes 00100-01999 (refer to
IHCP Provider Manual chapter 8 for
more information)
– Claim is processed in minute
increments. Bill the actual time in
minutes and include it in field 24G
– One unit = 15 minutes
– Additional units are allowed based on a
patient’s age when billing for emergency
services (bill using procedure code
99140)
CPT is copyright 2009 American Medical Association. All rights reserved. CPT® is a registered trademark of
the American Medical Association.
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October 2010
Billing Guidelines
Anesthesia
– Providers bill postoperative pain
management using code 01996
– The IHCP does not separately
reimburse this code on the same day the
epidural is placed
•
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However, it is reimbursed for subsequent days
when an epidural is managed
CMS-1500 Billing
October 2010
Billing Guidelines
Chiropractic services
– Package A services are limited to 50
chiropractic services per member, per
calendar year
• The
IHCP reimburses for no more than five
office visits within the 50 visits
– 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
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CMS-1500 Billing
October 2010
Billing Guidelines
Chiropractic services
– The following are covered codes for office
visits:
•
99201, 99202, 99203, 99211, 99212, 99213
– The following are covered codes for
manipulative treatment:
•
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98940-98943
CMS-1500 Billing
October 2010
Billing Guidelines
Injections
– 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
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CMS-1500 Billing
October 2010
Billing Guidelines
Injections and NDC codes
– 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 of the CMS-1500 claim form
refer to bulletin BT200713 dated May 29, 2007
– The NDC is not used for provider reimbursement
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CMS-1500 Billing
October 2010
Billing Guidelines
Mental health RBMC
– Effective January 1, 2007, 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 organizations
(MCOs), effective January 1, 2007:
•
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
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CMS-1500 Billing
October 2010
Billing Guidelines
Mental health RBMC
Services that are the MCO’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
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CMS-1500 Billing
October 2010
Billing Guidelines
Medicaid Rehabilitation Option (MRO)
– 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
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CMS-1500 Billing
October 2010
Billing Guidelines
Mental health RBMC
– MCOs
•
Anthem
www.anthem.com
•
Managed Health Services (MHS)
www.managedhealthservices.com
•
MDwise
www.mdwise.org
– Behavioral Health Organizations (BHOs)
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•
Magellan (Anthem)
www.magellanhealth.com
•
Cenpatico (MHS)
www.cenpatico.com
•
MDwise
www.mdwise.org
CMS-1500 Billing
October 2010
Billing Guidelines
Surgical services
Cosurgeons:
– Cosurgeons must append modifier 62 to the surgical
services
– Modifier 62 cuts the reimbursement rate to 62.5 percent 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 percent 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
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CMS-1500 Billing
October 2010
Billing Guidelines
Surgical services
– 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:
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•
Services unrelated to the surgical procedure
•
Care not considered routine
•
Postoperative care for surgical complications
CMS-1500 Billing
October 2010
Billing Guidelines
Multiple surgery procedures
– 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 percent of the global fee for the most expensive procedure
•
50 percent of the global fee for the second most expensive procedure
•
25 percent 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
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CMS-1500 Billing
October 2010
Billing Guidelines
Therapy services requirements
– 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, or avocational purposes, or for the
remediation of learning disabilities or developmental activities
that be performed by nonmedical personnel
– Coverage is not provided for rehabilitative services for a
member long than two years from the initiation of the therapy
unless a significant change in medical condition.
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CMS-1500 Billing
October 2010
Billing Guidelines
Therapy services requirements
– The IHCP does not cover maintenance therapy
– When a member is enrolled 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 approved any type of therapy services for more than on
hour per day, per type of therapy
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CMS-1500 Billing
October 2010
Billing Guidelines
Therapy services – Physical Therapist Assistant (PTA) billing
• The PTA is precluded from performing and interpreting tests, conducting
initial or subsequent assessments, and developing treatment plans
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•
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 bachelors degree with
the code billed and the rendering supervisors NPI number
•
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 than can be billed by a
PTA
CMS-1500 Billing
October 2010
Billing Guidelines
Podiatric services – routine foot care
– 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:
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•
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
CMS-1500 Billing
October 2010
Billing Guidelines
Podiatric services – routine foot care
– ICD-9-CM diagnosis codes that
represent systemic conditions that justify
coverage for routine foot care:
•
Diabetes mellitus: ICD-9-CM codes 250.00250.91
•
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
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CMS-1500 Billing
October 2010
Billing Guidelines
Podiatric services – routine foot care
– 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
– A visit can be billed separately only on the initial visit
– For subsequent visits, reimbursement for the visit is
included in the procedure performed on that date and not
billed separately
•
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Exception: If a second, significant problem is addressed on a
subsequent visit, the visit code may be reported with the 25 modifier
CMS-1500 Billing
October 2010
Billing Guidelines
Evaluation and management codes
– 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
Procedure Codes
99201-99215
99241-99245
99271-99275
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CMS-1500 Billing
October 2010
99381-99397
99401-99429
Billing Guidelines
Evaluation and management codes
– Professional services rendered during the course of a
hospital confinement must be submitted on the paper CMS1500 claim form or using the electronic 837P transaction
– 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 provider – once every three years
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CMS-1500 Billing
October 2010
Crossover Claims
Processing electronic claims
– The Coordination of Benefits Contractor
(COBC) crosses over HIPAA-compliant
Medicare claims to the IHCP
•
The Centers for Medicare & Medicaid Services (CMS)
selected Group Health, Inc. (GHI) to be the COBC
– When Medicare denied services cross over to
the IHCP, IndianaAIM adjudicates these with a
denied status
– The IHCP created edits for these claims
43
•
The edits are 0592 and 0593 – Medicare denied details
•
Resubmit denied details separately from paid details and
include the MRN from Medicare
CMS-1500 Billing
October 2010
Crossover Claims
Processing paper claims
– Allow 60 days for claims to automatically
cross over to the IHCP
– Bill denied charges to the IHCP and
include the Medicare Remittance Notice
(MRN)
– Complete field 22 as follows:
•
Left side = Coinsurance, deductible, and
psychiatric reduction
•
Right side = Medicare payment
– If applicable include the commercial
payment amount in field 29 (not used for
traditional Medicare)
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CMS-1500 Billing
October 2010
Billing Guidelines
Obstetric services
– 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:
45
•
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
CMS-1500 Billing
October 2010
Billing Guidelines
Pregnancy-related claims
– For pregnancy-related claims, indicate
the last menstrual period (LMP) in
MM/DD/YY format in
field 14
•
The IHCP will deny claims for pregnancyrelated services if there is no LMP
– Indicate a pregnancy-related
diagnosis code as the primary
diagnosis when billing for pregnancyrelated services
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CMS-1500 Billing
October 2010
Billing Guidelines
Pregnancy diagnosis codes
– 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
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CMS-1500 Billing
October 2010
Consent Form
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CMS-1500 Billing
October 2010
Sterilization and Partial Sterilization
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
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CMS-1500 Billing
October 2010
Sterilization Procedure
Hysteroscopic 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
50
CMS-1500 Billing
October 2010
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 PA updates to the original CMO
– Example:
51
•
Member is assigned to MDwise on 4/3/08, when the PA is requested
•
On 4/15/10, the member transitions from MDwise to ADVANTAGE
•
On 4/23/10, the primary medical provider (PMP) requests a System Update to the PA
•
The PMP must request the System Update from MDwise
CMS-1500 Billing
October 2010
Prior Authorization
– Members can change between traditional Medicaid fee-for-service,
Hoosier Healthwise/RBMC, and 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:
52
•
Member transitions from Hoosier Healthwise/RBMC to a Care Select CMO on
September 15, 2010
•
The MCO approved PA for dates of service 9/6/10 through 10/30/10
•
The Care Select CMO must honor the approved PA for 30 days from September 15,
2010
CMS-1500 Billing
October 2010
Prior Authorization
Member changes within a program
– When members transition from one CMO to another CMO, or from
Traditional Medicaid to a CMO, the receiving organization must honor
the approved PA until the PA expires
53
CMS-1500 Billing
October 2010
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
– The PA number format is alphanumeric
•
Alphanumeric PA numbers will identify the CMO that processed the PA
•
The three Eligibility Verification System (EVS) applications will accommodate the
alphanumeric value
– Pharmacy PA requests continue to be processed by Affiliated
Computer Services (ACS)
Refer to BR2010XX for instructions on the completion of the standardized PA
request form
54
CMS-1500 Billing
October 2010
Prior Authorization Contact Information
– ADVANTAGE Health Solutions (fee-for-service)
•
P.O. Box 40789
Indianapolis, IN 46240
1-800-269-5720
1-800-689-2759 (Fax)
– ACS (Pharmacy)
•
55
1-866-879-0106
1-866-780-2198 (Fax)
CMS-1500 Billing
October 2010
Prior Authorization Contact Information
– MDwise – CMO
•
P.O. Box 44214
Indianapolis, IN 46244-0214
1-866-440-2449
1-877-822-7186 (Fax)
– ADVANTAGE Health Solutions – CMO
•
56
P.O. Box 80068
Indianapolis, IN 46280
1-800-784-3981
1-800-689-2759 (Fax)
CMS-1500 Billing
October 2010
Code Sets
The following provider types have specific code sets
that were set on these dates:
– Chiropractic – April 28, 2005
– Durable Medical Equipment – February 12, 2009
– Hearing Services – February 1, 2005
– HIV Care Coordination – October 1, 2004
– Home Medical Equipment – February 12, 2009
– Optician – February 1, 2005
– Optometrist – June 24, 2008
– Transportation – September 16, 2004
– Vision – October 1, 2004
All Code Sets can be referenced on the
www.provider.indianamedicaid.com Web site
57
CMS-1500 Billing
October 2010
Fee Schedule
– The IHCP Fee Schedule is available on
the IHCP Web site and provides the
following information:
58
•
Pricing for procedure codes
•
PA requirements for individual procedure codes
•
List of noncovered codes
CMS-1500 Billing
October 2010
HIPAA 5010
– The mandatory compliance date for ANSI version 5010 and
the National Council for Prescription Drug Programs (NCPDP)
version D.0 for all covered entities is January 1, 2012
– If submitting claims to the IHCP, you need to prepare for these
upgrades to prevent delay in payment
– The IHCP and HP will test transactions on a scheduled basis
– Specific transaction testing dates will be provided at a future
date
59
CMS-1500 Billing
October 2010
HIPAA 5010
– Transactions affected by this upgrade:
60
•
Institutional claims (837I)
•
Dental claims (837D)
•
Medical claims (837P)
•
Pharmacy claims (NCPDP)
•
Eligibility verifications (270/271)
•
Claim status inquiry (276/277)
•
Electronic remittance advices (835)
•
Prior authorizations (278)
•
Managed Care enrollment (834)
•
Capitation payments (820)
CMS-1500 Billing
October 2010
Testing Information
– All trading partners currently approved to submit 4010A1 and
NCPDP 5.1 versions will be required to be approved for 5010
and D.0 transaction compliance
•
All software products used to submit 4010 and NCPDP 5.1 versions must be
tested and approved for 5010 and D.0.
– Testing will begin January 2011 and include:
•
Clearinghouses, billing services, software vendors, individual providers, and
provider groups
– Providers that exchange data with the IHCP using an IHCPapproved software vendor will not need to test
– Each trading partner will be required to submit a
new Trading Partner Agreement
61
CMS-1500 Billing
October 2010
What You Need To Do
– If you bill IHCP directly
• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
– If you are using a billing service or clearinghouse
• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP
vD.0
• IHCP Companion Guides will be available during the fourth quarter of 2010
– Questions should be directed to [email protected]
OR
– Call the EDI Solutions Service Desk
•
1-877-877-5182 or (317) 488-5160
– Watch for additional information on the testing process, revised
IHCP Companion Guides, and the schedule for transaction testing
on this mandated initiative in bulletins, banner pages, and
newsletters at www.provider.indianamedicaid.com
62
CMS-1500 Billing
October 2010
National Correct Coding Initiative
What is it?
– In the 1990s, the Centers for Medicare & Medicaid Services (CMS)
developed the National Correct Coding Initiative (NCCI) to promote
national correct coding methodologies and to control improper
coding leading to inappropriate payment
– NCCI has been in place for many years and most providers are
familiar with the editing methodologies with Medicare
– Based on input from a variety of sources:
• American Medical Association (AMA) CPT Guidelines
• Coding guidelines developed by national societies
• Analysis of standard medical and surgical practices
• Review of current coding practices
63
CMS-1500 Billing
October 2010
National Correct Coding Initiative
– The recent healthcare legislation passed into law (H.R. 3962),
requires that Medicaid programs incorporate compatible
methodologies of the National Correct Coding Initiative (NCCI) into
their claims processing system
• Section 1761 – Mandatory State Use of National Correct Coding Initiative of this bill
mandates that NCCI methodologies must be effective for claim date of service on or
after October 1, 2010.
− Watch future bulletins, banners and newsletters for implementation date.
– The IHCP has embarked on a project that will bring NCCI into the
claims processing effective October 1, 2010
– Initial editing will encompass three basic coding concepts:
• NCCI Column I and Column II (also known as bundling)
• Mutually Exclusive (ME) edits
• Medical Unlikely Edits (MUE)
64
CMS-1500 Billing
October 2010
Deny
Common denials for CMS-1500
Edit 2502
Recipient covered by Medicare Part B
–
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 right side
66
CMS-1500 Billing
October 2010
Edit 558
Coinsurance and deductible amount missing
–
Cause
• Coinsurance and deductible amount is 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
67
 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
CMS-1500 Billing
October 2010
Edit 1049
Care Select member’s PMP is missing
–
Cause
• The member is enrolled in the Care Select Program
• Affects claims for Care Select and the Right Choices Program
–
Resolution
• Add the member’s PMP information to the claim
• CMS-1500
 PMP
Taxonomy Code: Box 17a
 Precede the taxonomy with Qualifier “ZZ”
 PMP
68
CMS-1500 Billing
NPI: Box 17b
October 2010
Edit 2505
Recipient covered by private insurance
–
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
69
CMS-1500 Billing
October 2010
Edit 1047
Certification code missing – Care Select member
–
Cause
• This is a Care Select member
 Must
–
have two-digit certification code from the primary medical provider
Resolution
• Add the two-digit certification code from the primary medical provider for that
quarter
• CMS-1500
 PMP
70
CMS-1500 Billing
Certification Code – Box 19
October 2010
Edit 2017
Recipient ineligible on date of service due to enrollment in a managed
care organization
–
Cause
• The member was not eligible for fee-for-service medical assistance on the date
of service because he or she was enrolled in the risk-based managed care
program
–
Resolution
• Verify eligibility on any EVS and bill the appropriate managed care organization
71
CMS-1500 Billing
October 2010
Edit 5001
Exact duplicate
–
Cause
• Claim being processed is an exact duplicate of a claim on the history file or
another claim being processed in the same cycle
–
Resolution
• Research prior claims billed for “paid” status
72
CMS-1500 Billing
October 2010
Edit 0593
Medicare denied detail
–
Cause
• Occur when Medicare denies a detail line
• Are not crossover claims
–
•
Do not include the paid detail lines on the new claim
•
Processed as third-party liability (TPL) claims
•
Include the Medicare Remittance Notice (MRN) with the claim
Resolution
• Denied detail lines must be billed on a separate claim form
73
CMS-1500 Billing
October 2010
Edit 4021
Procedure code vs. program indicator
–
Cause
• Procedure code billed is restricted to a specific program
–
Resolution
• Verify eligibility and submit claim with appropriate procedure code
• Verify the service rendered is covered by the members plan
74
CMS-1500 Billing
October 2010
Edit 0513
Member name and number disagree
–
Cause
• The member name and the member identification number (RID) on the claim
do not match the member database
–
75
Resolution
•
Verify member name and RID on any EVS
•
Resubmit claim with corrected name and/or RID
CMS-1500 Billing
October 2010
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or
paper)
– HCBS Waiver Provider Manual (Web)
– Customer Assistance
• Local
• All
(317) 655-3240
others 1-800-577-1278
– Written Correspondence
• HP
Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
– Provider field consultant
77
CMS-1500 Billing
October 2010
Q&A