Hospital Based Practitioners Workshop 2014

Hospital Based Practitioners –
Inpatient Services Workshop
Presented by
The Department of Social Services
& HP Enterprise Services
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Training Topics
• Reimbursement for Practitioner Services Rendered in a
Facility Setting
• Professional Web Claim Submission
• Medicare Billing – Web Claim Submission
• Other Insurance (OI) – Web Claim Submission
• Professional Claim Submission (837 Transaction)
• Professional Claim Submission (Paper)
• Provider Fee Schedule
• National Correct Coding Initiative (NCCI)
• Remittance Advice and ASC X12N 835
• Hospital Modernization Web Page
• Questions
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Reimbursement for Practitioner Services
Rendered in a Facility Setting
• Effective January 1, 2015, professional services delivered by a
hospital based practitioner during the inpatient stay will be
reimbursed outside of the APR DRG classification system.
• For dates of service January 1, 2015 and forward, hospitals
should no longer bill RCCs 96X, 97X, and 98X on their
inpatient hospital claims.
• The Department shall not pay for evaluations, diagnostic
interviews, and therapy services performed in hospital inpatient
or outpatient settings by behavioral health clinicians.
• All professional services will be reimbursed based on the
physician fee schedule.
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Types of Professional Claim Submission
• Professional claims for services rendered to Connecticut Medical
Assistance Program (CMAP) clients may be submitted via:
–Internet Web claim submission on the secure Web
portal www.ctdssmap.com
–Software vendor utilizing the HIPAA ASC X12N
transaction for a Professional Health Care Claim known
as an 837P
–Paper (CMS-1500 Claim Form version 02/12)
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Professional Web Claim Submission
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Professional Web Claim Submission
• Enter up to 12 Diagnosis codes on a professional claim, click
the add more button to enter more than 9.
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Professional Web Claim Submission
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Professional Web Claim Submission
• Professional claim submission instructions are located on the
Web site, www.ctdssmap.com, by selecting “Information”, then
“Publications”, and scrolling to the Provider Manual section.
From the Chapter 8 drop down box, choose the appropriate
provider specialty.
• Admission date – Enter the date of admission for inpatient
professional services.
• Procedure Code - Enter the appropriate procedure code for the
service performed.
–Refer to the Fee Schedule for procedure code(s) covered in
the Connecticut Medical Assistance Program.
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Professional Web Claim Submission
• Modifier - Enter the corresponding modifier based on rendering
provider or services being performed, examples below:
–26 - Professional Component
 Modifier
26 is allowed only on select procedure codes.
Please consult the physician fee schedules.
–51 - Multiple Surgery
–80, 81, 82 - Assistant Surgeon
–SA - Nurse Practitioner
–SB - Nurse Midwife
• Facility Type Code (FTC), also known as place of service code
(POS) – Enter 21 for inpatient hospital.
• Rendering Physician – Enter the NPI of the physician providing
the services.
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Medicare Billing – Web Claim Submission
• Secondary Web Claim Billing – Medicare Payment.
• To indicate a Medicare payment, the Medicare Crossover field
on the Professional Claim panel must indicate Yes.
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Medicare Billing – Web Claim Submission
• Each claim detail must contain the following:
–Medicare Paid Date
–Medicare Calculated Allowed Amount
–Medicare Paid Amount
–Medicare Deductible Amount
–Medicare Coinsurance Amount
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Medicare Billing – Web Claim Submission
• Secondary Claim Billing – Medicare Denial.
• To indicate a Medicare denial, the Medicare Crossover field on
the Professional Claim panel must indicate No.
• The TPL panel must contain the following:
–Select Other in the drop down list within the Client Carriers
field.
–Enter MPB for Medicare Part B in the Carrier Code field.
–Zero should remain in the Paid Amount field.
–Enter the Medicare denial date.
–All other TPL panel fields are optional.
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Medicare Billing – Web Claim Submission
• Secondary Claim Billing – Medicare Denial
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Other Insurance (OI) – Web Claim
Submission
• Medicaid is the Payer of last resort. The three digit Carrier Code
of the Other Insurance (OI) is required to be submitted on the
claim when OI is primary.
The three digit code can be found on the client eligibility
verification screen under TPL (Third Party Liability)
Information
It can also be found on the claim submission screen under
the TPL panel in the “Client Carriers” field.
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Other Insurance (OI) – Web Claim
Submission
• TPL payment of $100.00 from carrier code 060 with a paid
date of 07/01/2014.
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Medicare Billing – Web Claim Submission
• Medicare and Other Insurance billing instructions are located on
the Web site, www.ctdssmap.com, by selecting “Information”,
then “Publications”, and scrolling to the Provider Manual
section. From the Chapter 11 drop down box, choose
“Professional Other Insurance/Medicare Billing Guide”.
• Provider Manual Chapter 11 also includes Medicare/Other
Insurance billing instructions for CMS-1500 paper claim
submissions and ASC X12N Health Care 837P format.
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Professional Claim Submission (837
Transaction)
• Electronic claims are submitted using the ASC X12N Health
Care Claim 837 Professional format. Implementation guides
are available on the Washington Publishing Company Web site
at www.wpc-edi.com. Please see highlighted fields below:
−Rendering Provider (LOOP 2310B NM101—Enter “82”)
−“Person” (LOOP 2310B NM102—Enter “1”)
−Rendering Provider Last Name (LOOP 2310B NM103—Enter
the Last Name)
−Rendering Provider First Name (LOOP 2310B NM104—Enter
the First Name)
−NPI Qualifier (LOOP 2310B NM108—Enter “XX”)
−Rendering NPI (LOOP 2310B NM109—Enter NPI number)
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Professional Claim Submission (837
Transaction)
−Billing Provider (LOOP 2010AA NM101—Enter “85”)
−“Person” (LOOP 2010B NM102—Enter “1” for Non-Person)
−Billing Provider Name (LOOP 2010AA NM103—Enter the
Group Name)
−NPI Qualifier (LOOP 2010AA NM108—Enter “XX”)
−Billing Provider NPI (LOOP 2010AA NM109—Enter NPI
number)
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Professional Claim Submission (Paper)
• Professional paper claims are submitted on a CMS-1500 claim
form and instructions are located on the Web site,
www.ctdssmap.com, by selecting “Information”, then
“Publications”, and scrolling to the Provider Manual section.
From the Chapter 8 drop down box, choose the appropriate
provider type. Please mail CMS 1500 claim forms to HP at:
PO Box 2941
Hartford, CT 06104
–HP mailing addresses can be found in Chapter 1 of the CMAP
Provider Manual.
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Fee Schedules
• The current physician fee schedules can be accessed and
downloaded from Connecticut Medical Assistance Web site,
www.ctdssmap.com. From the Home page, go to “Provider”,
then to “Provider Fee Schedule Download”, you must read and
accept the End User License Agreement prior to downloading
the fee schedule and click “I Accept” and then go to the
appropriate “Physician” fee schedule. To access the CSV file,
press the control key while clicking the CSV link, then select
“Open”.
• Services rendered by an APRN or physician assistant (PA) will
be reimbursed at 90% of the established physician fee; or 90%
of the obstetrical or pediatric fee when all of the applicable
criteria are met.
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Fee Schedules
• CMAP fee schedules are available for
download from the Web site.
• Select
Provider
Fee
Schedule
Download from the Provider dropdown menu.
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Fee Schedules
• Provider Fee Schedules are listed by
provider type and specialty.
• Click the corresponding link to download
the appropriate fee schedule. If it is a
CSV link, you will be required to hold
down the “ctrl” key.
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Fee Schedules
• Example of the Physician Surgical fee schedule:
Physician Surgical
Rate type = PED; pediatric services; or OBS; obstetrical services; indicates a
_____unique rate for services for qualified clients and claim data. You may
_____disregard any other rate type.
Procedure Code Proc description
Mod1
Rate Type Max Fee Effective Date End Date PA
37192 Redo endovas vena cava filtr
FTS
228.37
10/1/2014 12/31/2299
37192 Redo endovas vena cava filtr
SUR
1134.5
1/1/2012 12/31/2299
37193 Rem endovas vena cava filter
FTS
228.15
10/1/2014 12/31/2299
37193 Rem endovas vena cava filter
SUR
1082.36
1/1/2012 12/31/2299
37195 Thrombolytic therapy stroke
SUR
195.86
1/1/2008 12/31/2299
37197 Remove intrvas foreign body
FTS
186.68
10/1/2014 12/31/2299
37197 Remove intrvas foreign body
SUR
788.05
1/1/2013 12/31/2299
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Surgery
#
Fee Schedules (Footer Section)
• The footer is a great source of additional information:
• Rate Types
–SUR – Surgical Rate
–MPH – Melded Physician
–FTM – Facility Melded Physician
–FTS – Facility Surgical Rate
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Fee Schedules
• The Fee Schedule Instructions link
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To comply with federal legislation, the Department of Social
Services (DSS) has adopted the Centers for Medicare and Medicaid
Services (CMS) National Correct Coding Initiative (NCCI) standard
payment edits designed to promote correct coding and control
improper billing that could lead to inappropriate payments.
DSS has implemented the following NCCI edits:
•
Medically Unlikely Edits (MUE) or units-of-service edits have been
defined for each Healthcare Common Procedure Coding System
(HCPCS)/Current Procedural Terminology (CPT) code which
identifies the number of units of service beyond which the
reported number of units of service is unlikely to be correct (e.g.
claims for excision of more than one gallbladder).
•
DSS will mirror Medicare’s adoption of MUE edits and notify
providers via a remittance advice banner page message only.
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NCCI edits (cont.)
•
Procedure code to procedure code edits define pairs of
HCPCS/CPT codes that should not be reported together on the
same date of service for a variety of reasons and prevent
reimbursement for both procedures.
•
Medicaid NCCI procedure-to-procedure edits have a single
column 1/column 2 correct coding edit (CCE) file.
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• Three Explanation of Benefits (EOB) Codes inform providers if the
procedure submitted on the claim fails the procedure code to
procedure code edits.
• For some code pairs, modifiers may be used to bypass CCE which
will allow column 1 and column 2 codes to be paid when
performed on the same day for the same client.
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EOB codes:
• 5924
– “Claim Denied, CCI Greater and Lesser Procedure
are Not Covered on Same Date of Service”. This edit will
set if both the greater and the lesser procedure codes are
submitted on the same claim.
• 5925
– “CCI Column 1 Code or Mutually Exclusive Code
Was Billed on the Same Date as Previous Column 2 Code”.
This edit will set if the lesser procedure code has been paid
and a claim with the greater procedure code is submitted
for the same client for the same date of service.
• 5926
– “CCI Column 2 Code Was Billed on the Same Date
as Previous Column 1 or Mutually Exclusive Code”. This
edit will set if the greater code has been paid and a claim is
submitted with the lesser code for the same client for the
same date of service.
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• The list of modifiers allowed by Medicaid is identical to the list
of modifiers allowed by Medicare.
–
The Chapter 8 Physician Provider Manual has a detailed list of
modifiers that can be used. This information can be accessed from
our Web site www.ctdssmap.com. From the Home page, click on
“Information”, then “Publications”, scroll down the page to Provider
Manuals section, select “Physician” from the drop down menu for
Chapter 8 and click “View Chapter 8”.
–
Provider Bulletins addressing NCCI can be accessed from our Web
site www.ctdssmap.com.
From the Home page, click on
“Information”, then “Publications”, and then enter the appropriate
year and bulletin number under Bulletin Search.
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• Visit the CMS Web site
http://www.cms.gov/NationalCorrectCodInitED/ for:
−
Instructions on how to use NCCI
−
How to locate the NCCI Tables Manual
−
How to look up procedure code to procedure code edits
−
Use of bypass modifiers
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Remittance Advice and ASC X12N 835
• Hospital practitioner groups will have their own Remittance
Advice (RA) viewable on the secure Web site
www.ctdssmap.com under “Trade Files” by choosing
“Download” from the drop down menu. Select “Remit. Advice
(RA) - PDF” from the “Transaction Type” on the File Download
Search screen.
• To update their ASC X12N 835 Health Care Claim
Payment/Advice, which is an electronic RA, the hospital or the
trading partner would need to submit an amendment to their
trading partner agreement adding their new physician group(s)
AVRS ID.
–To update the trading partner would need to sign into the
secure Web site and select their enrollment profile.
–Keep clicking on “next” until the trading partner reaches the
page that displays the cover providers.
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Remittance Advice and ASC X12N 835
–Keep clicking on “next” until the trading partner reaches the
page that displays the cover providers.
–Enter the AVRS ID of the new practitioner group and they
date they wish to begin receiving 835 date and add an end
date of 12/31/2299.
–Hit “submit”, this will complete your transaction and the
trading partner will get an electronic remit for the new
practitioner group after the next claim cycle. No further action
will be needed by the trading partner.
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Hospital Modernization Web Page
• In preparation for changes in reimbursement methodology for
hospitals, the Department of Social Services (DSS) and HP
created a new Web page link titled “Hospital Modernization”.
The page is now available on the www.ctdssmap.com Web site.
• The changes in reimbursement will affect inpatient claims with
admission dates January 1, 2015 and forward and outpatient
claims as of January 1, 2016.
• The link has two options - “Inpatient Hospital” and “Outpatient
Hospital”.
• The Web page includes Quick links, DRG Provider Publications,
Hospital FAQ, Hospital Important Message, DRG Calculator,
Provider Manual updates, Provider Training and Contact
Information.
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Hospital Modernization Web Page
• The new Web page will be continuously updated throughout the
year. Please refer to this page periodically for any updates.
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Hospital Modernization Web Page
• The new Web page will be continuously updated throughout the
year. Please refer to this page periodically for any updates.
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Training Session Wrap Up
Where to go for more information www.ctdssmap.com
• Important Messages
 Hospital
interChange IM updated monthly
• Provider Bulletins
HP Provider Assistance Center (PAC): Monday through Friday,
8 a.m. to 5 p.m. (EST), excluding holidays:
• 1-800-842-8440
• 1-800-688-0503 (EDI Help Desk)
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Time for Questions
• Questions & Answers
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