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Legislative Updates: Uniform Coding and Billing

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Title: Legislative Updates: Uniform Coding and Billing


1
Legislative Updates Uniform Coding and Billing
  • Joint Meeting-MaHIMA/MAPAM
  • November 19, 2009
  • Prepared by
    Luisa DiIeso, MS, RHIA, CCS

2
Agenda
  • Legislative Overview and Requirements Chapter
    305
  • Division of Insurance Committee Oversight and
    Workgroup Activities
  • Coding Issues/Variations Category Overview
  • New Issues and Examples of Non-Compliance
  • Provider Practice Considerations

3
Chapter 305 Legislative Overview and Requirements
  • Uniform Coding and Billing Requirements
  • HIPAA Code Set Compliance Standards
  • Current Code Sets and Official Guidelines
  • ICD-9-CM Conventions AHA Coding Clinic
  • CPT-4 CPT Conventions, CPT Assistant, CPT
    Changes-Insiders View, AHA Coding Clinic for
    HCPCS
  • Level II HCPCS CMS Transmittals, AHA Coding
    Clinic for HCPCS

4
Chapter 305 Legislative Overview and Requirements
  • Standardized Claim Formats for Processing
  • National Uniform Claim Committee (NUCC)
  • National Uniform Billing Committee (NUBC)
  • Legislative Oversight
  • Office of Consumer Affairs and Business
    Regulation Division of Insurance (DOI)

5
Chapter 305 Legislative Overview and Requirements
  • Legislative Time Frames
  • 2011 Percentage of Compliance
  • 2012 100 Compliance
  • Compliance Metrics for Reporting
  • Line Level Denials Relating to Chapter 305
  • Total Lines Appealed
  • Total Appeals Disputed by Provider

6
Chapter 305 Legislative Overview and Requirements
  • Compliance Metrics
  • Total Line Denials Overturned on Appeal
  • Retrospective DRG Audits
  • Total DRG Claims
  • Total DRG Claims Re-Assigned on Audit
  • Total DRG Provider Appeals
  • Total Re-Assignments Overturned on Appeal

7
Division of Insurance Workgroup Composition and
Activities
  • Massachusetts Division of Insurance
  • Key Payer Representation
  • Mass. Medical Society
  • MaHIMA
  • Compliance Standards
  • Compliance Metrics for Reporting
  • Reporting Procedures Noncompliance
  • Audit Policies and Procedures

8
Technical Outpatient Issues
  • Modifier Updates
  • Hospital
  • Physician
  • -50
  • -52
  • -76
  • -59
  • V Codes
  • Specific Issues by Key Payers
  • Tufts
  • Blue Cross
  • PT/OT
  • Screening Colonoscopy
  • Follow-up Exams

9
Technical Issues
  • Unlisted CPT Codes
  • Provider Source Documentation
  • Temporary Level III CPT Codes Payer Policy
  • Retrospective CPT Audits
  • Recognition of Official Guidelines (ex CPT
    Assistant)
  • CCI Appeals Variations and Examples

10
Technical Issues
  • Medical Necessity
  • Systems Issue Updates and Progress
  • Key Policy Variations and Highlights by Payer
  • Status of Previous Policy Variations and
    Non-Compliance by Payer

11
Retrospective DRG Audits Patterns and Trends
  • Retrospective DRG Audits
  • PDX Guidelines
  • Stent Insertions
  • CV Diagnoses/ Catheterization-Potential Data
    Quality Issues
  • Single CC DRGs
  • Blue Cross
  • HPHP
  • Fallon
  • Tufts
  • MCR/RAC
  • MMIC
  • Other

12
New Issues and Examples of Non-Compliance
  • Retrospective DRG Audits
  • Proposed Medical Necessity Policy Lab and
    Pathology Services
  • Failure to Recognize New ICD-9-CM Diagnoses Codes
    Effective 10/01/09 (Example 274.00)

13
Provider Practice Considerations
  • Data Quality and Reporting (Documenting Payer
    Variations and Effect on Data Quality)
  • Provider Examples-MHA Workgroup
  • Clarifying and Quantifying Retrospective Appeals
    Process (MHA/Template Attachment)
  • Official Guidelines Coordinating and
    Streamlining Efforts for Feedback
    (Internal/Workgroup)

14
Attachments
  • Payer-Provider Coding Grid
  • MHA Coding Workgroup Templates/ Examples of Data
    Collection
  • Contact/Examples Anuj Goel,
    Esq. VP Legislation and Regulatory Affairs
  • E-Mail agoel_at_mha.link
  • Fax 781-262-6134
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