DEPARTMENT OF

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• DEPARTMENT OF
• PUBLIC HEALTH AND HUMAN SERVICES
• HEALTH RESOURCES DIVISION
• Medicaid PPS Hospital
• Billing Guide
• April 1, 2006

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OPPS

• Outpatient Prospective Payment System

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General

• Montana Medicaid uses Medicares Outpatient
  Prospective Payment System for reimbursing PPS
  hospitals since August 2003
• Medicaid uses a Montana specific conversion
  factor (47.75) for PPS hospitals and updates
  quarterly along with Medicare
• Medicaid deviates from Medicare in some cases
  (i.e. therapies, obstetric observation, inpatient
  only)
• Payment for PPS hospitals is the lower of OPPS
  payment (fees and APCs) or your total claim
  charges
• Charge cap does not apply to line level
• Appropriate and accurate coding is the key to
  proper reimbursement

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OPPS/APC for PPS Facilities

• Some services paid by fee schedule
• Therapies (speech, physical, occupational)
• Laboratory
• Diagnostic
• If there is no APC, Medicare fee or Medicaid fee
  (RBRVS), some services pay hospital specific
  outpatient cost to charge ratio
• Drugs and Biologicals
• Devices
• Ambulatory Payment Classification
• Payment based on CPT/HCPCS codes
• Status Indicator tells the method of payment
• Each service is eligible for potential payment
• Emergency room
• Treatment Room
• Provider-based clinic
• Cancer care

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Paint a Picture With your Claim

• Code every service every time for proper payment
• Where did your patient come into your facility?
• ER, clinic, direct admit?
• What happened to the patient?
• Surgery?
• Clinic visit?
• Treatment room?
• What resources did you use?
• Supplies?
• Pharmaceuticals?
• Blood products?
• Your claim should tell the story of what happened
  to your patient.

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APC Status Indicators

• C Inpatient only services
• G Drugs biologicals paid by report (hospital
  specific outpatient cost to charge ratio)
• H Devices paid by report
• K Drugs and biologicals paid by APC
• M Paid by a Medicaid specific fee or not a
  covered service (fee schedule will show as not
  allowed)
• N Service is bundled into an APC (If all your
  codes are N on your claim, your claim will pay at
  zero)
• Q Lab fee schedule (60 for non-sole community,
  62 for sole community)

• S Significant procedure paid by APC that the
  multiple procedure discount DOES NOT apply to
• T Significant procedure paid by APC that the
  multiple procedure discount DOES apply to
• V Medical visits in the clinic, critical care
  or emergency department (includes codes for
  direct admits)
• X Ancillary services paid by their own APC
• Y Medicaid fee for therapies (90 of RBRVS
  office fee)

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Modifiers

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HOSPITAL OUTPATIENT MODIFIERS

• Medicaid uses Medicare Outpatient Claim Edits
• www.cms.hhs.gov/providers/hopps/cciedits/
• These edits apply to both CAH and PPS hospitals
• Medicaid does not allow reporting separate codes
  for related services when there is 1 code that
  includes all related services
• Medicaid does not allow breaking out bilateral
  procedures when 1 code is appropriate
• The paper UB-92 can accommodate 1 modifier
• The 837 can accommodate 4 modifiers
• Always report the payment modifier 1st as
  Medicaid processes the claim using only the first
  modifier

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Level I Outpatient Modifiers

• Level I Modifiers
• 25 significant separate EM service
• 27 multiple EM same day
• 50 bilateral procedure
• 52 reduced services
• 58 staged or related service
• 59 distinct procedure
• 73 procedure terminated prior to anesthesia
• 74 - procedure terminated after anesthesia
• 76 repeat procedure by same physician
• 77 repeat procedure by another physician
• 91 repeat clinical diagnostic lab test

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Level II Outpatient Modifiers

• Level II Modifiers
• LT left side
• RT right side
• LC left circumflex coronary artery
• LD left anterior descending coronary artery
• RC right coronary artery
• GN service under speech language pathology plan
  of care
• GO - service under occupational therapy plan of
  care
• GP - service under physical therapy plan of care

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Common Outpatient Modifiers

• 25-significant, separately identifiable EM
  service by the same physician on the same day
• Only used with EM codes 92002-92014,
  99201-99499, G0101, G0175 G0264 to indicate
  that the patients condition required a
  separately identifiable EM service the same day
  a procedure was performed
• Examples
• 99212-25 Office/outpatient visit, est.
• 77412 Radiation treatment, 3 or more treatment
  areas

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Common Outpatient Modifiers

• 50 Bilateral Procedure
• Used to report bilateral procedures performed at
  the same operative session
• The 2nd (or bilateral) procedure is identified by
  50 added to the CPT code on a single line. Units
  are 1.
• DO NOT use if the code description indicates
  bilateral such as 27395
• Use when body parts have both right and left and
  you are doing separate services on each side. Do
  not use RT or LT with 50
• Examples
• 28285-50 repair of hammertoe, or
• 64721-50 carpal tunnel surgery

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Common Outpatient Modifiers

• 59 Distinct Procedural Service
• Used to report two procedures that are not
  normally reported together but could be performed
  under certain circumstances
• Different session or patient encounter
• Different procedure or surgery
• Different site or organ system
• Separate incision
• Separate injury that is not normally encountered
  or performed by the same physician on the same
  day
• Examples
• 93017 cardiac stress test
• 93005-59 EKG

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Common Outpatient Modifiers

• 91- Repeat Clinical Diagnostic Lab
• Use when the same lab test is repeated on the
  same day to obtain subsequent test results
• Do not use when tests are re-run to confirm
  initial results,
• when there were testing problems with specimens
  or equipment or
• for any other reason when a one-time result is
  all that is required
• Attach modifier to the second lab test
• Enter the number of times the subsequent lab test
  was done in the unit column
• Examples
• 82550 Creatinine Kinase (bill 1 unit)
• 82550-91 CPK (bill however many additional tests
  were performed

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Observation

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Observation Services

• Four qualifying conditions for payment
• Chest Pain
• Asthma
• Congestive Heart Failure
• Obstetric Complications (pre-delivery
  complications)
• Starting April 1, 2005, the qualifying diagnosis
  must be in either
• Admitting diagnosis (FL 76) or
• Principal diagnosis (FL 67)

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Observation Services

• Medicare/Medicaid Rules
• OBS services must be reasonable and necessary
• There must be a physician order prior to
  initiation
• Physician order must be by a physician with
  privileges at your hospital
• Physician must be actively directing patient care
• During OBS, patients must be actively assessed
• Observation is not a substitute for inpatient
• Observation is not for continuous monitoring
• Observation is not for patients waiting for NH
  placement
• Observation is not to be used for convenience or
  as routine prior to IP status

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Observation Services

• Beginning January 1, 2006 the OCE will determine
  if a claim qualifies for observation
• Code your claim to tell us if this was a direct
  or outpatient admission
• Bill ALL observation regardless if you think it
  qualifies or not
• Beginning January 1, 2006 the following codes
  will be discontinued
• G0244, G0263, G0264
• 99217-99220
• Bill ALL observation regardless if you think it
  qualifies or not
• Beginning January 1, 2006 you do not have to bill
  G codes for Obstetric observation it is up to
  you

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Outpatient Admissions to Observation

• All observation services must be on a 13X bill
  type
• Use G0378 to report the observation of patients
  admitted through an outpatient setting such as
  Emergency room, Critical care clinic,
  Provider-based clinic
• Bill the first date of service (the date admitted
  to an observation bed) on this line
• Bill your units of observation on this line (for
  obstetrics bill 1 unit)
• Bill charges observation charges on this line
  (for obstetrics bill 1)
• Bill your ER, CC or Provider based visit on a
  separate line
• Bill all other services as normal
• If Obstetric observation, you must have a line
  with 99234-99236
• Bill the first date of service (the date admitted
  to an observation bed) on this line
• Bill total units of observation on this line
• Bill observation charges on this line

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Direct Admissions to Observation

• All observation services must be on a 13X bill
  type
• Use both G0378 and G0379 to report the
  observation of patients admitted directly
• Bill the first date of service (the date admitted
  to an observation bed) on both lines
• Bill total units of observation on the line with
  G0378 (for obstetrics bill 1 unit)
• Bill observation charges on the line with G0378
  (for obstetrics bill 1)
• Only 1 unit of service and 1 in charges are
  reported on G0379
• Bill all other services as normal
• If Obstetric observation, you must have a line
  with 99234-99236
• Bill the first date of service (the date admitted
  to an observation bed) on this line
• Bill total units of observation on this line
• Bill observation charges on this line

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Provider-Based

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Provider-Based Services

• You may not self-attest for Medicaid
• Medicaid requires notification and verification
  from Medicare prior to billing
• Medicaid requires re-enrollment of all your
  providers with new tax ID numbers (the hospital
  may not have to re-enroll if they are the primary
  tax ID number)
• Billing is allowed from the date of Medicaid
  receipt of verification not from date of
  Medicare approval
• Provider-based rules are the same for Medicaid as
  they are for Medicare with few exceptions
• Including notifying the patient prior to service
  that there are 2 cost shares (4 for the 1500 and
  5 for the UB) for each visit

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Provider Based Billings

• Claims are billed for all of your provider-based
  facilities and clinics similar to how you would
  bill a claim in the Emergency Department
• There is both a UB and a 1500 for each billable
  visit
• 1500 claim must have place of service 22
  outpatient
• UB claim uses revenue code 510 for the facility
  side of the office visit-this is the only clinic
  visit revenue code allowed for provider-based
  facilities
• Procedures that the doctor or midlevel performed
  (10021 to 69990) are also billed on the UB
• All other services are billed on the UB

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Provider-Based Billing Exceptions

• Obstetrics
• Billing for complete service, antepartum,
  delivery and postpartum
• Bill as usual which means a global bill with POS
  21 on the 1500 side and delivery paid as a DRG on
  the UB side
• Billing for incomplete services, antepartum or
  postpartum     
• Bill appropriate code for number of visits on
  1500 and UB.
• Codes such as 59425 are not turned on for
  facility side so bill a matching EM on the UB
  side
• VFC
• Where there is an EM
• Bill EM and administration code on the 1500 with
  POS 22, bill EM and injectibles on UB
• Where there is an not an EM
• Bill administration code with modifier SL and the
  VFC code on the 1500 with POS 22, bill
  administration code on the UB, SL does not apply
  on the UB side
• If you cannot bill a 1500, you cannot bill a UB
  and visa-versa

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Provider-Based Billing Issues

• Inpatient Bundling
• Lab and diagnostic services provided 72 hours
  prior to inpatient stays must be bundled
• Outpatient visits 24 hours prior to inpatient
  stays must be bundled
• This includes provider-based services the UB
  portion of the provider-based visit must be
  bundled into the inpatient claim
• Audit
• Medicaid has started an audit of provider-based
  billing
• Issues identified so far
• Billing 1500 with place of service 11
• Billing lab, supplies and J-codes on 1500
• Not bundling visit into inpatient claim when 24
  hours previous
• Providers have not notified Medicaid of
  provider-based status

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Sterilization and Hysterectomy

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Sterilization and Hysterectomy

• Informed Consent to Sterilization (MA-38) or
  Medicaid Hysterectomy Acknowledgement (MA-39)
  must be attached to the claim without exception
• The forms must be legible, complete and accurate.
• Revisions are not accepted for any reason
• The physician must sign and date the form the
  same day the recipient is informed that the
  procedure would render them permanently incapable
  of reproducing
• The recipient must be informed orally and in
  writing
• The form bust be signed prior to the procedure
• Make sure birth date and date of signature are
  accurate

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MA-38 Form

• Informed Consent to Sterilization (MA-38)
• It is the providers responsibility to obtain a
  correctly completed form from the primary or
  attending physician
• Elective sterilizations are still subject to the
  30 day waiting period
• For retroactively eligible clients, the physician
  must certify in writing that the surgery was
  performed for medical reasons and must document
• Client was informed prior to the hysterectomy
  that the operation would render them permanently
  incapable of reproducing, or
• Reason for the sterilization was a
  life-threatening emergency or the client was
  already sterile and the reason for the prior
  sterility

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MA-39 Form

• Medicaid Hysterectomy Acknowledgement (MA-39)
• Complete only one section of this form. Section
  A, B or C
• If no prior sterility or life-threatening
  emergency exists, client and physician must sign
  and date Section A prior to the procedure
• Oral and written consent prior to the procedure
  still applies for Section A
• The client does not need to sign the form when
  sections B or C are used
• For retroactively eligible clients, the physician
  must certify in writing that the surgery was
  performed for medical reasons and must document
• Client was informed prior to the hysterectomy
  that the operation would render them permanently
  incapable of reproducing, or
• Reason for the hysterectomy was a
  life-threatening emergency or the client was
  already sterile and the reason for the prior
  sterility

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Common Claim Edits

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Common Claim Edits

• 215 Claim should pay by APC or OPPS but system
  could not group. These hit for 4 reasons
• Invalid bill type (usually you see 851 which
  should be 131)
• Bad date- the span date doesnt match the line
  dates
• There is no APC to group to (department boo-boo)
• Revenue code 636 is used wrong-this rev code can
  only be used for RX or vaccination codes, not for
  the injections
• 335 Procedure code requires review (unlisted
  code)

• 102 Duplicate claim
• Reason code B13 Remark code M86
• 112 A readmission has been detected
• Reason code -133
• 119 Claim is for a potentially unbundled
  service
• Reason code B13 Remark code M2
• 120 Date of service is more than 365 days from
  date received
• Reason code 29
• 280- (physician claim) - diagnosis code or
  procedure code is not on emergent list
• Reason code 40 Remark code N59

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Additional Common Claim Edits

• 342 Diagnosis code requires a review (these are
  almost always V codes)
• Reason code 125 Remark code N10
• 343 Diagnosis code may not be a covered service
• Reason code - 47
• 345 Sterilization review
• Reason code 17 Remark code N3
• 347 Hysterectomy review
• 370 Abortion review
• Reason code 17 Remark code N3

• 371 DRG 468 (this DRG pays of charges so is
  always reviewed for correct coding) this means
  that there was a procedure on the claim that was
  not related to the main diagnosis and procedures
• 483 Units billed exceed allowed units
• Reason code 119 Remark code M53
• 460 Claim requires a prior authorization
• Reason code 62 Remark code M62

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More Claim Edits

• 472 This exception will post when the PASSPORT
  provider number is missing or invalid
• Reason code 15 Remark code M68
• 487 This edit will fail when the client is a
  Team Care client and the Team Care provider did
  not submit the claim or did not refer the client
  and the service requires PASSPORT approval
• Reason code 15 Remark code M68
• 905 Line dates of services are inconsistent
  with the header level dates of service or the
  line level date of service is blank (usually see
  on bundled claims)
• Reason code 16 Reason code MA122

• 920 Diagnosis code and procedure dont match-
  this means that a claim hit before or after the
  new quarterly grouper was installed and a
  diagnosis code on the claim now needs a fifth
  digit or is invalid or the provider used an
  invalid diagnosis code
• Reason code - 11
• 928 Inpatient only services performed in an
  outpatient setting-needs review to determine if
  appropriate
• Reason code 58 Remark code M77
• 929 EM code on the same date as a surgical or
  significant procedure without modifier 25 or 27
  present on the EM code (must be on the EM code
  not on the code with a SI of T or S)
• Reason code 97 Remark code 144

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Contacts

• ACS, Inc. Provider Relations [phone]
  in-state [phone] out of state
• Brett Williams, Hospital and Clinic Bureau Chief
• Deborah Lane, Hospital and Clinic Analyst
• Rena Steyaert, Claims Resolution Specialist
  [phone] rsteyaert_at_mt.gov
• Debra Stipcich, Transplant and PPS Hospital
  Program Officer [phone] dstipcich_at_mt.gov
• Mary Patrick, Hospital and Transplant Case
  Manager [phone] mpatrick_at_mt.gov
• Bob Wallace, Rural Health Program Officer (CAH,
  FQHC, RHC) [phone] bwallace_at_mt.gov
• John Hein, ASC/IHS Program Officer (also ESRD and
  Freestanding Dialysis) [phone]
  jhein_at_mt.gov
• Thom Warsinski, Cost Settlement Program Officer
  [phone] twarsinski_at_mt.gov