Transcript Document
3rd • Party Primer 3rd party basics to answer the questions… – – – – – – – – – – Should I be a 3rd party provider? How do I evaluate 3rd Party Plans? Who are the insurers in Nebraska? How do I enroll? What exam procedures do insurers require? What services & materials do they pay for? What documentation is required? What is coding & how do I do it? How do I file a claim? Where can I go for help? 1 Resource For This Presentation NOA 3rd Party Web Page found at HTTP:// NEBRASKA.AOA.ORG/ PREBUILT/ NOA/ INDEX.HTM http://nebraska.aoa.org/prebuilt/NOA/index.htm 2 NOA rd 3 Party Web Page http://nebraska.aoa.org/prebuilt/NOA/index.htm 3 NOA 3rd Party Educational Videos http://nebraska.aoa.org/prebuilt/NOA/index_Page353.htm4 5 NOA 3rd Party Educational Videos http://nebraska.aoa.org/prebuilt/NOA/index_Page353.htm6 Video 1 Should I Become a 3rd Party Provider? The advantages, and disadvantages of becoming a 3rd Party Provider. · YouTube Presentation, with audio commentary, but inactive website links · PowerPoint Show presentation, with live website links & no audio; Use mouse to change slides. 7 s Should You Become a Provider? Don’t have to be provider; rather can… • Give Patient “super-bill” or a printed claim form • Patient pays your fee to you • Patient sends claim to Insurer • Insurer pays patient their allowable – Exception: Medicare If you see a Medicare patient, you must file the claim for the patient. 8 Should You Become a Provider? Advantages of being a provider On provider list (strong patient resource) Fewer $ collection problems Patient happy Doesn’t have to file own claim Less $ out-of pocket Fees seem more reasonable than out-of-plan provider’s fees 9 Types of rd 3 Party Payers Routine • • • • • (pre-paid) Care Cover Exam and materials Limits on frequency Limits on materials Does not pay for medical services (fields, gonioscopy, retinal photos) Generally file over Internet or may use own claim forms 10 Types of rd 3 Party Payers Medical (health insurance coverage of eye Dx) • Medical diagnosis only (not refractive codes) • Pays for other medical services (fields, photos) • Rarely pays for materials • File electronically using HIPAA approved format (5010 electronic claim format soon required), or • File on paper CMS-1500 forms • Only okay if less than 10 FTE employees • 5010 format coming up 11 Should You Become a MEDICARE Provider? 12 Should You Become a MEDICARE ADVANTAGE Provider? Medicare Advantage comes in a variety of types • HMO: Patients see only HMO panel doctors; panel networks small; providers accept HMO’s fees • PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees • PFFS (Private Fee For Service)…next slide 13 Video 2 How To Become a 3rd Party Provider What you need to do to become a 3rd Party Provider, including enrollment contact information for various 3rd parties found in Nebraska. · YouTube Presentation, with audio commentary, but inactive website links · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides. 14 s Enrolling as a Provider Multiple page application forms with considerable documentation: copies of • NPI (National Provider Identifier) • Optometry Diploma • State License •Turn-around • DEA Registration (need it) • Proof of Malpractice Insurance • Photo ID …plus more in some cases time: weeks to months 15 Contacts to Become a Provider Routine Care (July 2011) – Avesis http://www.avesis.com/provider_benefits.html – EyeMed (Eyecare Plan of America) http://portal.eyemedvisioncare.com/wps/portal/emweb/providers/become_a_provider – Optum (Spectera) https://www.optumhealthvision.com/providers/OH_Vision_Provider.jsp – Vision Service Plan (VSP) https://www.vsp.com/cms/provider/provider-home.html 16 Contacts to Become a Provider Medical Coverage Medicare – Medicare Part B http://www.wpsmedicare.com/j5macpartb/departments/enrollment/ – Rail Road Medicare Part B 877/288-7600 • http://www.palmettogba.com/palmetto/Providers.nsf/docsCat/Providers~Railroad%20Medicare~Resources~Provider%20 Enrollment?open – Medicare Durable Medical Equipment • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Brochure [PDF,87KB] https://www.noridianmedicare.com/dme/enroll/ 17 Contacts to Become a Provider Standard Medicaid • Via Nebraska Dept. of Health & Human Services • Both Routine & Medical • Patients age 65+ &/or in nursing home http://www.hhs.state.ne.us/med/providerenrollment.htm 18 Contacts to Become a Provider Medicaid Managed Care Organizations (MCOs) – State divided into two parts, each having two MCOs MCOs for Eastern 10 counties: – UnitedHealthCare Community Plan (United HealthCare) – Coventry Nebraska (Coventry) MCOs for Other 83 Counties: (starting July 1, 2012) – Coventry Cares (Coventry) – Arbor Health (AmeriHealth Nebraska via BCBS) 19 Filing Claims, Part 1 CMS-1500 & Electronic Equivalent; Diagnosis Coding Explanation of the CMS-1500 claim form and its electronic equivalent. Also, an explanation of Diagnosis Coding – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides. 20 s CMS-1500 21 TOP OF CMS-1500 Insurance Type 22 BOTTOM CMS-1500 Diagnosis Data 23 BOTTOM CMS-1500 Service & Materials Supplied 24 Medicare Provider Manual Billing Instructions Including what data in which box 25 Medicaid Provider Manual Billing Instructions What data in which box • Payments section: • • http://www.sos.ne.gov/rules-andregs/regsearch/Rules/Health_and_Human_Services_System/Title471/Chapter-03.pdf Form CMS-1500 Instructions – http://www.hhs.state.ne.us/reg/appx/471-000-65.pdf 26 Filing Claims, Part 2 92000 Exam Codes The basics of Services and Procedures coding. Also, coding the 92000 ophthalmology examination codes, including an unofficial 92000 coding score sheet created by Dr. Quack. – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides. 27 s BOTTOM CMS-1500 Service & Materials Supplied 28 Reference Current Procedural Terminology, or CPT Updated annually, so needs to be replaced annually. Covers •Examination coding, •Ancillary testing coding •Some dispensing and CL coding. 29 Medical Examination Coding Ophthalmology Codes 92000 Comprehensive New Estab 92002 (int) 92004 (cmp) 92012 (int) 92014 (cmp) 30 Chief Complaint A brief explanation of why the patient is in the office. The Chief Complaint drives the encounter To bill a medical insurer, the chief complaint must demonstrate Medical Necessity 31 32 33 34 blepharitis 1 1 cartaract 1 2 glaucoma 1 4 7 35 92000 Score Sheet http://nebraska.aoa.org/prebuilt/noa/92000-CPT-Documentation-Score-Sheet-2011.pdf 36 Filing Claims, Part 3 99000 E&M Exam Codes Coding the 99000 Evaluation and Management examination codes, including an unofficial 99000 coding score sheet created by Dr. Quack. – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides. 37 s Reference Current Procedural Terminology, or CPT Updated annually, so needs to be replaced annually. Covers •Examination coding, •Ancillary testing coding •Some dispensing and CL coding. 38 Evaluation and Management Coding 99000 Evaluation and Management Codes • There are three Key Components – History – Examination – Decision Making 39 Chief Complaint A brief explanation of why the patient is in the office. The Chief Complaint drives the encounter To bill a medical insurer, the chief complaint must demonstrate Medical Necessity 40 E&M Score Sheet Dr. Quack’s Evaluation and Management score sheet is… Based on the 1997 E&M Guidelines for single organ systems https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf Unofficial, but should be helpful in determining the level of E&M exam code 41 OU hazy mod. constant night driving headlights halos Cataract or Glaucoma Dry AMD 42 43 1 blepharitis 1 1 cataract 1 1 2 1 4 7 glaucoma susp. <1 44 58 min 45 Filing Claims, Part 4 Should I use the 92000 or 99000 Codes Discusses general advantages and limitations of the 92000 ophthalmology exam codes versus the 99000 E&M exam codes. – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides 46 s 99000 vs. 92000 • In general, the 99000 codes are more concrete, requiring less subjective judgment • But these concrete requirements may necessitate tests or procedures not required by comparable 92000 comprehensive codes. (dilation) 47 99000 vs. 92000 The 92000 codes for a comprehensive exam require a “diagnostic and treatment program” while the 99000 codes do not. • When following a patient chronic conditions that require… • no billable diagnostic testing and • no treatment, • …it is difficult to code comprehensive 92000 codes. 48 99000 vs. 92000 • Never examine and bill simply to maximize reimbursement rates… • To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges. 49 99000 vs. 92000 • • Maximum Medicare reimbursement for a 92000 comprehensive exam is higher in some cases than an equivalent 99000 exam. Any such advantage is dependent on your U&C 92000 and 99000 fees. – Many OD’s 92000 exam fees are not near that Medicare maximum, and to them there seems no $$ advantage in using the 92000 fees. 50 Filing Claims, Part 5 CPT Modifiers Explains the use of CPT Modifiers commonly used in an optometric practice. – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides 51 s BOTTOM CMS-1500 Service & Materials Supplied 52 http://www.wpsmedicare.com/j5macpartb/resources/modifiers/ 53 Modifier 24 • Unrelated Evaluation & Management Service by the Same Physician During a Postoperative Period. http://www.wpsmedicare.com/j5macpartb/resources/modifiers/ Example: GLC follow-up exam and fields during cataract post-op period. • Cataracts 90 days • Punctal plugs 10 days • Foreign body 0 days • http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes&next=Accept 54 Modifier TC Technical Component • • Example: technician performing 92083-TC while patient’s own OD is not on the premises OD and OMD codes that qualify Cannot charge Medicare if no doctors are on the premises Sensorimotor Exam 92060TC Orthoptic/Pleoptic 92065TC Visual Fields 92081,2,3TC Scanning Laser 92135TC Fundus Photos 92250TC Color Vision 92283TC Dark Adaptation 92284TC External Photography 92285TC 55 Modifier 50 Bilateral Procedure • http://www.wpsmedicare.com/j5macpartb/resources/modifiers/ To determine whether a procedure is bilateral, go to https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx • • • • • • • • Start Search -> Accept -> Click ‘Payment Policy Indicators’ Click ‘Single HCPCS code’ Enter Code you are inquiring about Select ‘All modifiers’ Submit -> Scroll Look at “Bilt Surg” column • • • • 0 1 2 3 means means means means bill each eye separately – bilateral does not apply paid 100%, 50%, 25% for 1st, 2nd, 3rd unit, respectively bill once for both eyes bill each eye separately https://www.highmarkmedicareservices.com/partb/reimbursement/mfsdbhelp.html 56 Modifier GY http://www.wpsmedicare.com/j5macpartb/resources/modifiers/ • • • Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit). It is filed at the request of the patient or to instigate subsequent payment by another insurer. Example: refraction 92015GY. 57 Surgeon’s name Surgeons NPI Date assumed care; date relinquished care 366.12 V43.1 01012009 68984 RT 55 2 Date of surgery 58 Filing Claims, Part 6 Medicare Supplier Codes Discusses coding Medicare Durable Medical Equipment as used for post-op glasses and contact lenses. – · YouTube Presentation, with audio commentary, but inactive website links – · PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides 59 s Who Manages Medicare DME DME Suppliers managed by the National Supplier Clearinghouse (NSC), currently administered by PalmettoGBA. DME Claims handled by our DME carrier, Noridian Administrative Services. 60 Our Medicare Supplier Administrative Contractor… https://www.noridianmedicare.com/dme/coverage/lcd.htm 61 Local Coverage Determination Policy Article HCPCS Codes Covered https://www.noridianmedicare.com/dme/coverage/lcd.htm 62 Local Coverage Determination 63 https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses.htm Policy Article https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses.htm 64 Cost to Become a Medicare Supplier To enroll as a supplier: ~$500 every three years Cost of Surety Bond (if needed…) 65 DME Requirements Accreditation (not needed by ODs) Requires none-degree holding suppliers to obtain accreditation from official accrediting body (initial cost $2500; + ~$1000 per year) Surety Bonds Requires some suppliers to obtain a $50,000 surety bond (costs $500-$1500 per year) 66 Other 3rd Party Resources NOA, Medicare, Medicaid, and other resources to help you understand 3rd party requirements and file 3rd party claims. YouTube Presentation, with audio commentary, but inactive website links PowerPoint slide presentation, with live website links & no audio; Use mouse to change slides 67 s Coding References • CPT (Current Procedure Terminology) – Service Codes • 92000 Ophthalmology • 99000 Evaluation & Mgmt – Surgical Procedure Codes • 65205 Removal of FB • 67820 Epilation of Lashes 68 Coding References • ICD-9-CM • International Classification of Diseases – Refractive Diagnosis Codes – Disease Diagnosis Codes – Injury Diagnosis Codes 69 CMS: Medicare Learning Network You can download it from: http://www.cms.hhs.gov/MLNProducts/downloads/physicianguide.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MLN_Suite_of_Products_and_Resources_for_Instructors.pdf 70 NE Medicare B References Medicare B – Local Coverage Determinations (LCDs) – http://www.wpsmedicare.com/j5macpartb/policy/active/local/ • Standardizes what Medicare considers “Reasonable and Necessary” • Lists very specific coding requirements for those services & procedures that have a history or potential of abuse 71 NE Medicare B References WPS Medicare Communiqué Quarterly Newsletter • Changes in CMS policy • Updates in coding requirements • Updates on documentation needed • FAQs • Changes in contact information • Changing in billing requirements All Provider are legally responsible for reading and abiding by this document. 72 https://corp-ws.wpsic.com/apps/commercial/unauth/medicareListservUserWelcomeLoadAction.do http://www.wpsmedicare.com/j5macpartb/index.shtml 73 NE Medicaid References Medicaid Provider Manual – Vision Care http://dhhs.ne.gov/medicaid/Pages/med_phvis.aspx Visual Care Services Payment Rules Fee Schedule Billing Instructions Bulletins http://www.sos.state.ne.us/rules-andregs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-24.pdf http://www.sos.ne.gov/rules-andregs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-03.pdf http://dhhs.ne.gov/medicaid/Documents/471-000-524.pdf http://dhhs.ne.gov/medicaid/Documents/471-000-65.pdf (bottom of page) http://dhhs.ne.gov/medicaid/Pages/med_phvis.aspx 74 NOA References NOA 3rd Party Newsletters Changes in Carrier Policy LMRP Updates & Reminders Unique Coding in Nebraska Changes on the Horizon HIPAA Updates Q & A Page 75 NOA References Monthly Newsletter Mass Email: 76 77 78 79 NOA References 80 81 NOA 3rd Party Consultation • Contact Methods – Email [email protected] – Fax 402 464-1214 (contact Ed first) • Cover page: Contains PHI-for Dr. Schneider’s eyes only • 24 hour turn-around time 82 Evaluating 3rd Party Plans Webinar Unlike the previous YouTube presentations, this a Webinar on evaluation of a 3rd party plan before becoming a provider for that plan. It runs about 20 minutes, the first 90 seconds of which suffered technical problems that were quickly rectified. 83 s Webinar Evaluating 3rd Party Plans 84 Evaluating 3rd Party Plans 85 Evaluating 3rd Party Plans 86 Summary of Videos 7 Should I Become a 3rd Party Provider? – The advantages and disadvantages of becoming a 3rd Party Provider. 14 How To Become a 3rd Party Provider – What you need to do to become a 3rd Party Provider, including enrollment contact information for various 3rd parties found in Nebraska. 20 CMS-1500 & Electronic Equivalent;Diagnosis Coding – Explanation of the CMS-1500 claim form and its electronic equivalent. – Also, an explanation of Diagnosis Coding 87 Summary of Videos 27 92000 Exam Codes – The basics of Services and Procedures coding. Also, coding the 92000 ophthalmology examination codes, including an unofficial 92000 coding score sheet created by Dr. Quack. 37 99000 E&M Exam Codes – Coding the 99000 Evaluation and Management examination codes, including an unofficial 99000 coding score sheet created by Dr. Quack 46 Should I use the 92000 or 99000 Codes – Discusses general advantages and limitations of the 92000 ophthalmology exam codes versus the 99000 E&M exam codes. 88 Summary of Videos 51 CPT Modifiers – Explains the use of CPT Modifiers commonly used in an optometric practice. 59 Medicare Supplier Codes – Discusses coding Medicare Durable Medical Equipment as used for post-op glasses and contact lenses. 67 Other 3rd Party Resources – NOA, Medicare, Medicaid, and other resources to help you understand 3rd party requirements and file 3rd party claims. 83 Evaluating 3rd Party Plans Webinar – a Webinar on evaluation of a 3rd party plan before becoming a provider for that plan. 89 http://nebraska.aoa.org/prebuilt/NOA/index_Page353.htm 90 Resource For This Presentation NOA 3rd Party Web Page found at HTTP:// NEBRASKA.AOA.ORG/ PREBUILT/ NOA/ INDEX.HTM http://nebraska.aoa.org/prebuilt/NOA/index.htm 91 Questions? 92 NOA 3rd Party Consultation • Multiple Contact Methods – Email [email protected] – Fax 402 464-1214 (call cell first) • Cover page: Contains PHI-for Dr. Schneider’s eyes only • 24 hour turn-around time 93