Medica Provider Forums

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Medica Provider Forums

• May 2003
• Facility/Ancillary Coding Session

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Coding Consultants

• Kathy Baker, CPC
• Radiology, ER, Laboratory, Pathology,
  Physician
• Carolyn Larson, CPC
• DME, IV Therapy, Medicare Policy
• Noreen Nowak, CPC
• Ancillary, Public Health
• Pam Tienter, CPC
• Anesthesiology, Physician
• Ann Tomasetti, RHIT, CCS
• Hospital, Home Health, SNF

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Overview

• ASC crosswalk
• Revenue code update
• Home Health/Public Health Billing
• Background/changes
• UB form locators and codes
• Claim issues
• Resources
• QA

4
Overview

• DME related 2003 code changes
• Incontinence products
• Ostomy code changes
• E1399
• Other deleted MN local codes and recommended
  cross references
• Mental Health H codes and modifier update
• Recommended units for binaural hearing aids
• QA

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ASC Crosswalk

• Payment of outpatient surgical claims at Medica
  is typically based upon CMSs ASC (Ambulatory
  Surgical Center) payment system (with some
  modifications)
• CMS assigns surgical CPT codes to 1 of 9 payment
  groups, which are listed in a crosswalk by CPT
  code
• As a general rule, CMS groups surgical codes only
  (10000-69999)

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ASC Crosswalk

• When a claim containing codes outside this range
  is submitted along with certain revenue codes
  (primarily surgical) the claim may deny
• 200 - Diagnosis or CPT Code Missing or Invalid
  (older claims were denying 333)
• Medica is currently working to resolve this issue
• Updates will be published in Link as they become
  available

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Revenue Codes

• 4-digit revenue codes
• 210X - Alternative Therapy Services (effective
  4/1/02)
• 310X - Adult Care (New code series - effective
  4/1/03)
• A system enhancement that will enable Medica to
  accept 4-digit revenue codes is scheduled for
  6/28/03
• Actual reimbursement decisions, however, are
  based upon the members Certificate of Coverage
  and the provider contract

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Revenue Codes

• 068X Trauma Response
• Charges for a trauma team activation
• 0 - Not used
• 1 - Level 1
• 2 - Level 2
• 3 - Level 3
• 4 - Level 4
• 9 - Other Trauma Response

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Revenue Codes

• Refer to UB-92 manual for usage notes
• To be used by licensed or government designated
  trauma centers/hospitals
• It is to be used for patients for whom a trauma
  team activation occurred
• Trauma team activation Notification of key
  hospital personnel in response to triage
  information from pre-hospital caregivers in
  advance of the patients arrival.
• 068X is for reporting trauma activation costs
  only. It is not a replacement for the emergency
  room visit fee

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Home Health/Public HealthBackground

• Per MN Statute 62J all home health services are
  to be billed on a UB-92 claim form
• Medica home health providers were required to
  bill on the UB-92 effective with July 1,2002 DOS
• Medica public health providers were required to
  bill all home health services on the UB-92
  effective with January 1,2003 DOS

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Background

• Public Health
• All home health services (59 provider type) bill
  on UB-92
• All clinical services (83 provider type) continue
  to bill on CMS 1500

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UB-92

• Handouts
• Frequently Asked Questions
• FL 4 Type of Bill
• FL 42 Revenue Codes
• FL 44 HCPCS/Rates
• FL 63 Treatment Authorization Codes

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FL 4 Type of Bill

• The appropriate 3-digit code should be entered
• In most cases 331 should be entered
• 1st digit - Type of Facility Home Health
  Agency..3
• 2nd digit - Bill Classification
  Outpatient..3
• 3rd digit - Frequency Admit Through D/C
  Claim.1

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FL 42 Revenue Codes

• Medica typically reimburses these services on a
  per-visit basis
• 421 Physical Therapy/Visit
• 431 Occupational Therapy/Visit
• 441 Speech Pathology/Visit
• 561 Medical Social Services/Visit

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FL 42 Revenue Codes

• Reimbursement for these services is based upon
  the actual service provided as indicated by the
  HCPCS or CPT code submitted
• 41X Respiratory Services
• 55X Skilled Nursing (RN or LPN)
• 57X Aide/Home Health (includes services provided
  by a PCA)
• Refer to UB manual to determine the third digit
  (X)

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FL 42 Revenue Codes

• UB-92 manual does not provide codes for the
  following services
• Skilled Nursing Supervision of Personal Care
  Attendant
• Medica has decided to use 559 - Other Skilled
  Nursing
• Homemaker Services
• Medica has decided to use 589 - Other Home Health
  Visits

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FL 42 Revenue Codes

• The following revenue codes should not be
  submitted on a home health claim
• 270 (Medical Surgical Supplies)
• 274 (Prosthetic/Orthotic Devices)
• These charges need to be billed through the
  members DME provider and will be denied if
  included on a home health claim.

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FL 44 HCPCS/Rates

• Should have received reference guide/payment
  appendix from Contract Manager at time of
  contract renewal (handout)
• The applicable HCPCS/CPT code must be selected
  from this list and included in FL 44
• 333 denial - Diagnosis or CPT code missing or
  invalid
• Local codes
• Per HIPAA, effective 10/16/03 all local X codes
  will be eliminated

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FL 63 Treatment Authorization Code

• Used to indicate that a payer has authorized
  treatment
• Some home health services require prior
  authorization per Medica Medical Policy
• Refer to handout

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Claim Issues

• Public Health providers will need to split bill
• All services listed on the home health payment
  appendix should be billed on the UB-92 with the
  providers designated 59 provider number
• All other services should be billed on the
  CMS-1500 with the providers designated 83
  number
• Claims not submitted in this manner will deny
• 226 - Resubmit with correct provider number
• Notification of any changes will be published in
  Link/Connections

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Resources

• Medica.Com
• Provider Administrative Manual (Chapter 12, pg.
  12-17)
• Link - December 2002 Home Health Billing on
  UB-92 Form
• Reference Tools and Forms How to Complete
  UB-92
• UB-92 Manual
• MN Hospital and Healthcare Partnership (MHHP)
  651-641-1121 or toll free at 1-800-462-5393
• UB-92 Editor
• 1-877-INGENIX (464-3649), option 1 or
  www.ingenixonline.com

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QA
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2003 DME Related Code Changes

• Incontinence Products
• Units mirror DHS assigned values
• Ostomy Codes
• Unit max currently at 90 for each of the new
  codes
• E1399 Grid Update
• Deleted MN Local Codes and Recommended Crosswalks
  

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Mental Health H Codes and Modifiers

• HCPCS code range is H0001 - H2037
• All codes currently under review by UBH
• Medica accepts H0002 - behavioral health
  screening to determine eligibility for admission
  to treatment program - when submitted by
  licensed and contracted programs
• HCPCS modifier range is H9 - HZ
• All modifiers currently under review by UBH

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Units for Binaural Hearing Aids

• Medica is recommending submission of 2 units for
  the binaural defined HCPCS codes in the range of
  V5120 - V5261
• This follows the DHS guideline
• Accepted only for the Medica Government Products

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QA
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Coding Questions

• E-mail coding.questions_at_medica.com
• Fax [phone]
• Turn-around time goal is 5 working days
• If a response is not received within 5 days
  contact Paige Hinz (Coding Consultant Manager) at
  paige.hinz_at_medica.com or 952-992-2988
• Access Database
• All questions are logged, tracked, and data is
  trended

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Issues to Send to Coding Questions Mailbox

• Questions should be related to Medica claims
• 807 denials (bundling)
• 106 denials (units)
• 478 denials (diagnosis and procedure mis-match)
• 067 denials (incorrect procedure code)
• E1399 coding
• Questions on how to code a procedure
• New, deleted, changed codes
• Modifier usage
• Revenue codes/bill type

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Issues for Provider Service Center

• Reimbursement
• Coverage of services
• Claim denials for any other reason than
  previously noted
• 952-992-2232 or 1-800-458-5512

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HIPAA Reminder

• HIPAA privacy regulations went into effect on
  April 14,2003
• Medicas e-mail system is currently unprotected
  but we are in the process of obtaining encryption
• Patient identifiable information should not be
  included on communications
• If patient identifiable information is included
  in an e-mail, it will be removed before a reply
  is sent
• Communication can include patient account number
  and Medicas audit number

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Medica.Com Provider Resources

• Provider Alerts
• Reference Tools and Forms
• Coding Lists
• Coding Questions Fax Form
• Reference Materials
• Examples How to Complete UB-92, Disallow
  Denial and Adjustment Code List
• Link/Connections
• Future Updates

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Other Provider Resources

• Administrative Uniformity Committee
  http//www.mmaonline.net/auc
• CMS
• HCPCS Closed Item List
• 1500 Manual
• UB-92 Manual
• Legislative Resources
• TAGs (Technical Advisory Groups)