Transcript Slide 1

Home Health Billing and
Common Denials
Presented by
EDS Provider Field Consultants
October 2009
Agenda
• Session Objectives
• Home Health Coverage
• Prior Authorization
• Billing Procedures
• Multiple Visit Billing
• Hospital Discharge
• Common Denials
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Objectives
At the end of this session, providers will understand:
• What types of services are covered by Home Health
• Billing procedures
• How to bill multiple visits
• How to bill for hospital discharge
• Common claim denials and how to resolve
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Home Health Coverage
• Home health services are available to the
Indiana Health Coverage Programs (IHCP)
members medically confined to the home
–When services are ordered in writing
from a physician and performed in
accordance with the written plan of
care
• Unlike Medicare, Medicaid members that
are confined to the home may:
–Work
–Attend school outside the home
–Leave the home with assistance of
another person or an assistive device,
such as a wheelchair or walker
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Prior Authorization
• Home Health Services require prior
authorization
• If the member is Traditional Medicaid
or ADVANTAGE Care Select, prior
authorization request is faxed to:
–ADVANTAGE Health Solutions
•
1-800-784-3981
• If the member is MDwise Care Select,
prior authorization request is faxed
to:
–MDwise Care Select
•
1-866-440-2449
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Billing Procedures
• Home health services must be
ordered in writing by a physician
and require prior authorization
(PA)
• Claims are billed on a UB-04 claim
form with revenue codes and
Healthcare Common Procedure
Coding System (HCPCS) codes
• Each day is billed as a separate
detail line item
• Level of services, such as a
registered nurse (RN) or licensed
practical nurse (LPN), provided on
the same date of service are billed
as separate line items
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Billing Procedures
• Billing units of home health visits for therapists, home health
aides (HHAs), licensed practical nurses (LPNs) and registered
nurses (RNs) should be rounded as follows:
–For therapy visits, if in the home one to seven minutes,
units cannot be rounded and are not billable. Services
consisting of eight to 15 minutes can be billed as one 15minute unit of service.
• For HHA, LPN, and RN visits, the claim should be billed as
follows:
- If in the home less than 29 minutes, the entire first hour
can be billed only when a service was provided
- Example: The nurse walks in and has to call 911 right away
for the patient
• If a member refuses service, the provider cannot bill any units
of service
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Billing Procedures
• Bill visits using code 99600
–LPNs use modifier TE
–RNs use modifier TD
–HHAs use no modifier
• When PA is granted for 99600
TD, the PA covers RN, LPN,
and HHA services
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Billing Procedures
• As of July 1, 2008, only one overhead is allowed per
provider, per member, per day
• An overhead rate is provided to cover administrative costs
and reimbursed in addition to a staffing reimbursement
component
• Only one overhead is billed per day even if there are one or
more encounters, which occurs when an RN, LPN, HHA, or
therapist:
–Enters the home
–Provides service to one or more members
–Leaves the home
• Overheads must be reported using occurrence codes 61
and occurrence date or occurrence spans in Fields 35a-36b
on the UB-04 claim form
• Occurrence codes are also reported in all electronic claim
formats
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Example of Billing Occurrence Code
• Provider goes to member’s home
and bills for procedure 99600 TD;
later that day provider goes back to
member’s home and bills 99600 TE
• This is considered two different
procedures and needs to be billed
on two separate detail lines
• Even though there were two visits,
providers must add the overhead to
only one of the detail lines
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Billing Procedures - MCO
• If a member is enrolled in risk-based
managed care (RBMC), providers must
contact the appropriate managed care
organization (MCO) to obtain prior
authorization and billing information:
–Anthem
•
1-866-406-2803
–MDwise
•
1-800-356-1204
–Managed Health Services
•
1-877-647-4848
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Multiple Visit Billing
• Billing for multiple visits for the
same PA to a member in one
day
–Should be billed on the same
claim form
–One detail with the total
number of units of service
provided
–If these services are billed on
separate claim forms or on
separate claim details, the
IHCP denies one or more of
the services with edit 5001 –
exact duplicate
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Hospital Discharge
Services that may be performed without PA:
• An IHCP member discharge from an inpatient
stay
• Therapy services ordered by a physician can
not continue beyond 30 units in 30 calendar
days without PA
• RN, LPN, or HHA-performed services that do
not exceed 120 units within 30 calendar days
from the inpatient discharge
–Physician must order services in writing prior
to the patient’s hospital discharge
–Patient must be homebound
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Hospital Discharge
• Services must be within the limits
specified in 405 IAC 5-16-3
• Providers are required to bill using
occurrence code 50 with the
corresponding date of discharge in
the occurrence code and occurrence
date fields 31-34, a-b on the UB-04
claim form
• If claims are submitted without
occurrence code 50 and there is an
existing PA, the units of the PA will
be decremented
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Common Denials
Edit 3001 – Dates of service not on PA database
• Cause – No prior authorization was obtained
• Resolution – PA needs to be obtained or, if this is a
hospital discharge, occurrence code 50 with date of
discharge should be billed
Edit 558 – Coinsurance and deductible amount missing
• Cause – Coinsurance and deductible were not submitted
on claim
• Resolution – Coordination of benefit screen would need
to be completed, or if paper UB-04 claim form then box
39 would need to be completed with value codes A1
Medicare deductible or A2 Medicare coinsurance
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Common Denials
Edit 593 – Medicare denied detail
• Cause – Claim crossed over from Medicare with a denied
Medicare detail
• Resolution – Medicare denied details are submitted to
Medicaid as a straight Medicaid claim with the Medicare
explanation of benefit
Edit 516 – Occurrence code date does not match claim detail
• Cause – Occurrence date does not match the claim detail
• Resolution – Each occurrence code date entered on the
header of the claim must match a service date or service
dates in the detail lines on the claim form
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Common Denials
Edit 4021 – Procedure code vs. program indicator
• Cause – Procedure code billed is not valid for the service
being billed
• Resolution – Procedure code billed is restricted to a specific
program; check the claim to make sure the appropriate
HCPCS are being billed for home health
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Resources
• IHCP Web site at
www.indianamedicaid.com
• FSSA Web site at www.in.gov/fssa
• IHCP Provider Manual (Web, CD-ROM, or
paper)
• Customer Assistance
–1-800-577-1278, or
–(317) 655-3240 in the Indianapolis
local area
• Written Correspondence
–P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations field consultant
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Questions
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Office of Medicaid Policy and Planning (OMPP)
402 W. Washington St, Room W374
Indianapolis, IN 46204
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950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
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October 2009