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IHCP Updates
HP Provider Relations
February 2012
Agenda
– Objectives
– Revenue Code 513
– New provider types
– Dental cap
– 5010 implementation statistics
– Electronic Health Records (EHR)
– International Classification of
Diseases, 10th Revision (ICD-10)
implementation
– Return to provider claims
– Claim denials
– Helpful tools
– Questions
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IHCP Updates
February 2012
Objectives
– Understand billing requirements for revenue code 513
– Learn about new provider types and specialties, including birthing
centers
– Know the current status of the ICD-10 implementation
– Be aware of the most recent changes to coverage and reimbursement
– Understand how to avoid returned claims
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IHCP Updates
February 2012
Learn
Billing Requirements for Revenue Code 513
Revenue Code 513 – Clinic/Psychiatric
See bulletin BT201157
– Applies to claims for dates of service on or after January 1, 2012 for
therapy services rendered in an outpatient facility and billed on the
UB-04 claim form.
– For outpatient claims with dates of service on or after January 1, 2012,
providers will no longer bill individual, group, or family therapy with
revenue code 510 – Clinic.
– Providers that continue to bill revenue code 510 for outpatient
individual, group, or family therapy will be subject to post-payment
review by the Indiana Health Coverage Programs (IHCP) Program
Integrity Department.
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IHCP Updates
February 2012
Revenue Code 513 – Clinic/Psychiatric
See bulletin BT201157
– For family and group therapy codes,
the IHCP will reimburse the lesser of
the billed amount or a statewide flat
fee of $20.40, per member, per
session.
– Individual therapy codes will be
reimbursed the lesser of the billed
amount or a statewide flat fee of
$40.80, per member, per session.
– The 5% reduction in effect for
provider type 01 will apply to these
rates at the time of processing.
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IHCP Updates
February 2012
Revenue Code 513 – Who does it affect?
See bulletin BT201157
– This change applies to claims for Traditional Medicaid and Care Select
members.
– For members enrolled in managed care, providers must contact the
member’s managed care entity (MCE) for guidelines on billing
outpatient therapy services, including instructions regarding billing
bridge appointments using revenue code 513.
– This change does not apply to claims for members who are dually
eligible for Medicare and Medicaid.
•
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Providers must continue to bill Medicare for dually eligible members following Medicare
claim submission policy, which may include revenue code 510.
IHCP Updates
February 2012
Explain
New Provider Types
Birthing Center/CORF/IDTF/IDTF mobile
See bulletin BT201158
– In 2012, the IHCP will expand its
list of eligible providers to allow
birthing centers, comprehensive
outpatient rehabilitation facilities
(CORFs), independent diagnostic
testing facilities (IDTFs), and
mobile independent diagnostic
testing facilities (IDTFs) to enroll
as IHCP providers.
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IHCP Updates
February 2012
New Provider Types and Specialties
See bulletin BT201158
– Birthing centers
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Type 08 – Clinic
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Specialty 088 – Birthing Center
– Comprehensive Outpatient Rehabilitation Facility (CORF)
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Type 04 – Rehabilitation facility
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Specialty 041 – Comprehensive Outpatient Rehab Facility
– Independent Diagnostic Testing Facility (IDTF)
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Type 28 – Laboratory
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Specialty 282 – Independent Diagnostic Testing Facility
– Independent Diagnostic Testing Facility – mobile (IDTF)
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•
Type 28 – Laboratory
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Specialty 283 – Independent Diagnostic Testing Facility Mobile
IHCP Updates
February 2012
Inform
Dental Cap
Dental Cap Removed
– Effective November 4, 2011, the U.S. District Court for the Northern
District of Indiana issued a preliminary injunction enjoining the agency
from enforcing 405 IAC 5-14-1(b).
– The monetary cap of $1,000 for dental services has been removed in
accordance with the Court’s order, subject to all other requirements,
pending further order of the Court.
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IHCP Updates
February 2012
Inform
5010 Implementation status
Status Update
• On
November 17, 2011, the Centers for Medicare & Medicaid
Services (CMS) announced that it will delay enforcement of the
required HIPAA new ASC X12 Version 5010 and the NCPDP
D.0
• Delay was set for electronic healthcare claims until March 31,
2012.
• This was not a delay of the January 1, 2012 compliance date.
It was a delay in enforcing penalties associated with providers'
noncompliance.
• The process to be considered for the grace period for 5010
noncompliance was to submit an email containing the request
to the [email protected] mailbox by December 27,
2011.
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IHCP Updates
February 2012
Describe
EHR Incentive Program
EHR Incentive Program
– The American Recovery and Reinvestment Act (ARRA) of 2009
provides for incentive payments for eligible professionals (EP), and
eligible hospitals (EH) who are meaningful users of certified electronic
health record (EHR) technology.
– EPs include the following:
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Doctor of medicine or osteopathy
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Dentist
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Certified nurse midwife
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Nurse practitioner (advanced practice nurse)
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Physician assistants (PAs) when practicing at a Federally Qualified Health Center
(FQHC) or rural health clinic (RHC) that is led by a PA
– EHs include:
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Acute care hospital
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Children’s hospital
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Critical access hospital (CAH)
IHCP Updates
February 2012
EHR Incentive Program
Meaningful use of EHR
– CMS has determined “meaningful use” focuses on establishing the
functionalities in certified EHR technology that allow for the following:
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Continuous quality improvement
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Ease of information exchange
– This includes:
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Electronically capturing health information in a structured format
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Using that information to track key clinical conditions and communicating that
information for care coordination purposes
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Implementing clinical decision support tools to facilitate disease and medication
management using EHRs to engage patients and families
•
Reporting clinical quality measures and public health information
IHCP Updates
February 2012
EHR Incentive Program
– EPs and EHs register for the incentive program through a two-step
process:
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1.
Providers must register using the CMS Registration and Attestation system and
select Indiana as their state
2.
Providers register their EHR system using the Provider Profile feature of Web
interChange
IHCP Updates
February 2012
EHR Incentive Program
Eligible Professional (EP)
– Per federal rule, EPs must register for EHR incentive payments no
later than calendar year (CY) 2016.
– EPs must meet patient volume criteria as follows:
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EPs, other than pediatricians, must have a minimum 30 percent patient volume
attributable to Medicaid funded services; for pediatricians, the patient volume minimum
requirement is 20 percent.
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Practice predominantly in an FQHC or RHC and have a minimum 30 percent patient
volume attributable to needy individuals.
– Hospital-based providers are not eligible for the EHR incentive
program.
•
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An EP is considered to be hospital-based when 90 percent of his or her services are
furnished in a hospital inpatient or emergency room setting.
IHCP Updates
February 2012
EHR Incentive Program
Eligible Professional (EP)
– EPs may not receive EHR incentive
payments from both Medicare and
Medicaid programs in the same year.
– If an EP qualifies for EHR incentive
payments from both Medicare and
Medicaid programs, the EP elects to
receive payments from only one
program.
– After the EP qualifies for the EHR
incentive payment under one program,
but before 2015, an EP can switch
between the Medicare and Medicaid
programs one time.
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IHCP Updates
February 2012
Update
ICD-10
ICD-10
Implementation October 1, 2013
– January 16, 2009, the Department of Health and Human Services
(HHS) released a final rule mandating Health Insurance Portability and
Accountability Act (HIPAA)-covered entities to implement ICD-10 for
medical coding by October 1, 2013.
– ICD-10 codes must be used on all HIPAA transactions including
Outpatient and Professional claims with dates of service (DOS) and
Inpatient claims with dates of discharge (DOD) on or after October 1,
2013.
– ICD-10 does not affect Current Procedural Terminology®1 (CPT)
coding.
– To accommodate ICD-10, the new transaction standard X12 version
5010 must be operational.
1
Source: Center for Medicare & Medicaid Services (CMS) at www.cms.gov/icd10
1
Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American
Medical Association
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IHCP Updates
February 2012
ICD-10
CMS Mandate
– Providers will not be able to continue to report ICD-9 codes for
services provided on or after October 1, 2013.
– The last regular annual update to both ICD-9 and ICD-10 code sets
was made on October 1, 2011.
– After October 1, 2012, there will be only limited code updates to both
ICD-9 and ICD-10 code sets to capture new technology and new
diseases.
– After October 1, 2013, there will be only limited code updates to ICD10 code sets to capture new technologies and new diseases.
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There will be no updates to ICD-9 on or after October 1, 2013, as the code set will no
longer be a HIPAA standard.
– On October 1, 2014, regular updates to the ICD-10 code sets will
begin.
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IHCP Updates
February 2012
ICD-10
FAQs
– What is the current implementation timeframe?
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HP has completed the assessment for the MMIS system 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?
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No. There are no plans at this time to freeze claims processing.
– Will there be vendor testing? When?
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Yes, there will be vendor testing that will include 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?
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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.
IHCP Updates
February 2012
ICD-10
Provider Readiness Surveys
– The second provider survey was released on February 7, 2012 and
closed on February 21, 2012.
– Survey results will help us help you, by tracking your progress and
capturing your issues.
– HP and the Family and Social Services Administration (FSSA) have
committed to surveying contracted vendors and IHCP providers every
90 days through August 2013.
– The purpose of continuously surveying contracted vendors and IHCP
providers is to understand where they are in preparation for the
change to ICD-10 and to track progress.
– Information about these surveys is available in the IHCP Newsletters
available on indianamedicaid.com.
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IHCP Updates
February 2012
ICD-10
Advice to IHCP providers
– Now is the time to begin the ICD-10 planning process, if you haven’t
already.
– If you have not been contacted by your software vendor and/or
clearinghouse about ICD-10 readiness, be proactive and contact
them.
– The IHCP has posted ICD-10 information pages at
indianamedicaid.com which includes:
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ICD-10 Information page with links to relevant websites.
•
ICD-10 FAQs page with ICD-10 questions and answers posed by providers, vendors,
and stakeholders.
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ICD-10 Decisions page with explanations of decisions that have been made and issues
for your consideration. Providers, vendors, and stakeholders are encouraged to weigh
in on these issues during the open (posted) discussion period.
IHCP Updates
February 2012
Explore
Returned Claims
Claims Returned to Providers
January 2012
– 2,879 claims were returned to providers by the HP mailroom because
of errors identified during the claim preparation process.
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32% - member number invalid
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14% - Medicare Replacement Claims
– These claims do not get scanned or keyed by HP data entry
– 3,686 claims were returned by HP data entry due to missing or invalid
information that is essential to processing the claim.
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53% - CMS-1500 claims with missing or invalid National Provider identifier (NPI),
taxonomy and ZIP Code.
IHCP Updates
February 2012
How do you avoid returned claims?
– Verify Member ID when registering members.
– Include Medicare replacement plan billing information.
• CMS-1500
claim forms
− Write “Medicare Replacement Plan” on the top of the claim and on the
replacement plan EOB.
− DO NOT complete field 22.
− Enter the replacement plan prior payment in field 29.
• UB-04
claim forms
− Write “Medicare Replacement Plan” on the top of the claim and on the
replacement plan explanation of benefits (EOB).
− DO NOT complete field 39 with coinsurance or deductible information.
− Enter the words “Replacement Plan” in field 50b.
− Enter the amount paid by the replacement plan in field 54b.
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IHCP Updates
February 2012
How do you avoid returned claims?
– Verify the NPI, taxonomy and ZIP Code are correct.
• CMS-1500
− Enter the ZIP Code + 4 in field 33 and verify the information entered
matches the service location found in Provider Profile on Web
interChange.
− Enter the NPI for the Billing or Group Provider enrolled with the IHCP in
field 33a.
− Enter the taxonomy code (if needed) in field 33b and verify the information
entered matches the provider profile on Web interChange.
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IHCP Updates
February 2012
Reduce
Paper Claims
Paper Claims Received in 2011
Dental
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Medical
Pharmacy
Institutional
Totals
Jan
8,917
109,430
435
12,623
131,405
Feb
7,440
95,811
671
10,891
114,813
March
7,451
99,735
592
11,949
119,727
April
9,071
108,676
244
12,606
130,597
May
9,218
101,377
201
12,449
123,245
June
8,229
101,132
231
13,513
123,105
July
6,716
85,256
145
11,136
103,253
August
8,693
95,863
96
12,284
116,936
Sept
7,172
83,473
59
11,280
101,984
Oct
6,727
79,540
94
11,543
97,904
Nov
7,250
76,151
98
10,537
94,036
Dec
8,622
85,658
68
12,499
106,847
IHCP Updates
February 2012
Help
Top Claim Denials
Top 5 Claim Denials
– EOB 558 - Coinsurance and deductible amount is missing indicating
that this is not a crossover claim.
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Coinsurance and deductible amounts must be included on all crossover claims.
– EOB 593 - At least one detail submitted contains Medicare COB data,
resulting in a review of all detail COB data.
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When submitting Medicare crossover claims, ensure that all Medicare coordination of
benefits (COB) information is on the claim for all details. This applies to CMS-1500
claims.
– EOB 5001 - This is a duplicate of another claim.
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Review claims to see if any billed services were previously paid. Verify previous claim
payments and denials using Web interChange to avoid erroneous rebilling of paid
claims.
IHCP Updates
February 2012
Top 5 Claim Denials
– EOB 4021 - Procedure code is not covered for the dates of service for
the program billed.
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Verify that the procedure code is covered for the dates of service via the Fee Schedule
at indianamedicaid.com.
– EOB 2510 - Member is eligible for Medicare B/D.
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Claim must be billed to Medicare before billing the IHCP.
IHCP Updates
February 2012
Find Help
Resources Available
Helpful Tools
– IHCP Web site at indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or
paper)
– IHCP Fee Schedule
– Customer Assistance
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1-800-577-1278, or (317) 655-3240 in the Indianapolis
local area
– Written Correspondence
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P.O. Box 7263
Indianapolis, IN 46207-7263
– Provider field consultant
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provider.indianamedicaid.com/contact-us/providerrelations-field-consultants.aspx
IHCP Updates
February 2012
Q&A