Transcript Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing

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 FamilyCentered Action Plan (F-CAP)
 Provide ongoing monitoring of health and safety of
the child, including home visits
PFC Services
Care Coordination (cont):

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
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
Coordinated care fee
Requires at least 22
hours of initial
assessment services
$1,000
One time fee
Monthly case
management
4 – 8 hours of case
management, per
child, per month
$229.17 per
unit
12 units per year
Bill prior to initial
F-CAP
T2022
May bill first unit
in same month
as G9001
1 unit per
month;
1 U = 4-8 hr.
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
Maximum of 60
hours every 90
days.
1 U = 1 hour
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
$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
Service Provider –
approved expressive
therapist
PFC Procedure Codes and Rates
Family Training:
Procedure
Code
Description
Rate
Limits
S5110
Home care training
$11.36 per unit (when
RN employed by
HA/HHA)
$8.94 per unit (when
provided by INP billing
independently)
Up to 12 units per
day
Up to 400 units
per year
Service Provider: RN
1 unit = 15 minute
PFC Procedure Codes and Rates
Respite Care:
Procedure Code
Description
H0045
Out-of-home respite
Provided in an approved
facility on a short-term basis.
Level of care 1. Skilled
nursing services A or B

Provider type:
Congregate
Living Health
Facility
Rate
Limits
Up to 30 days
per year,
combined with
in-home
respite.
$91.28 per
24 hrs.

Level of care 2 - Sub acute $358.97 per
24 hrs.

Level of care 3 – Acute
$490.60 per
24 hrs.
PFC Procedure Codes and Rates
Respite Care (cont):
Procedure Code
Description
Rate
Limits
T1005
In-home respite
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-ofhome respite
Provider type:
RN, LVN,
CHHA,
(HHA/HA);
RN, LVN ( INP)
Intermittent or regularly
scheduled temporary care
and supervision provided in
the home
PFC Procedure Codes and Rates
Family Counseling:
Procedure Code Description
X9508
Provider type:
LCSW, ACSW,
MFT, licensed
psychologist
Family Counseling
(Bereavement), one
hour
Rate
Limits
$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
*At least one visit must be provided, and the whole 22 units
billed, before the child’s death.
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 Coordination
 Additional SARs for requested PFC
services once F-CAP is completed
 Separate 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
UB-04 Field Descriptions (cont):
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 5065 (excluding box 56) should be entered on Line A.
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/Communication
Family-Centered Action Plan
 Services/Billing

 Federal
Assurances/
 Health & Welfare

Agency Responsibilities/Summary
[email protected]