Medicare Part A Updates

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Medicare Part A Updates

• Medicare Part A Provider Outreach and Education

April 2006 pp.ihs.2.1.medicare.part.a.updates-pres
entation
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IMPORTANT

• The information contained in this presentation
  was current as of March 2006.

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Agenda

• 2005 updates
• Ambulance.
• Orthotics.
• Prosthetics.
• Surgical dressings.
• Outpatient visits.
• Social admissions.
• 2006 updates
• Influenza, pneumococcal and hepatitis B.
• Rehabilitation.

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Ambulance Policy

• Effective Jan. 1, 2005.
• CMS Change Request (CR) 3521, dated Jan. 10,
  2005.

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Billing Requirements

• Applicable bill types
• 13X - Hospital outpatient.
• 85X - Critical Access Hospital (CAH).
• 12X - CAH.
• Revenue code 0540.

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HCPCS Codes

• Report one code per revenue code line.
• Each code reflects category of services provided.

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HCPCS Codes (Cont.)

• Applicable service HCPCS codes
• A0426 A0431
• A0427 A0432
• A0428 A0433
• A0429 A0434
• A0430
• Applicable mileage HCPCS codes
• A0425 A0436
• A0435

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Ambulance References

• TrailBlazer Web site
• www.trailblazerhealth.com/parta/Ambulance/Ambulanc
  e.asp?

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Ambulance Services
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• Orthotics/Prosthetics and Surgical Dressings

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Billing Procedures

• CMS CR 3674, dated Feb. 4, 2005.
• Effective July 1, 2005.
• Revenue code 0274.
• Applicable HCPCS code.
• Reimbursement based on Durable Medical Equipment
  Prosthetic, Orthotics and Supplies (DMEPOS) Fee
  Schedule.

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Billing Procedures (Cont.)

• CMS CR 3674, dated Feb. 4, 2005.
• Effective July 1, 2005.
• Revenue code 0623.
• Applicable HCPCS code.
• Reimbursement based on DMEPOS Fee Schedule.

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References

• Orthotic/Prosthetic/Surgical Dressings Handout
• www.trailblazerhealth.com/
• parta/downloads/orthoprosthetic.pdf
• Fee Schedule information
• www.cms.hhs.gov/
• DMEPOSFeeSched/01_overview.asp

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Outpatient Visits

• Drug administration only.
• CMS CR 3674, dated Feb. 4, 2005.
• Effective July 1, 2005.
• No All-Inclusive Rate (AIR) can be filed for an
  injection-only visit.
• Must be filed with the next qualifying visit with
  a physician.

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Social Admissions

• CMS CR 3452, dated Oct. 29, 2004.
• No 111 or 121 bill should be filed.
• The Ancillary Part B claim, Type of Bill (TOB)
  12X will be denied when
• TOB 13X (outpatient) or 72X (ESRD) is received
  from a separate facility with the same dates and
  an inpatient stay.

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Influenza, PPV and Hepatitis B Vaccines

• Effective Jan. 1, 2006, Pneumococcal Pneumonia
  Vaccine (PPV), influenza and hepatitis B vaccines
  may be billed to Medicare Part A for
  IHS/Tribal/CAHs.

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Influenza, PPV and Hepatitis B (Cont.)

• Billing requirements
• Condition code A6.
• Diagnosis.
• V0481 Influenza virus vaccine.
• V0382 PPV.
• V053 Hepatitis B vaccine.
• Revenue code(s).
• 0636 Vaccine.
• 0771 Administration.

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Influenza, PPV and Hepatitis B (Cont.)

• HCPCS codes
• Influenza vaccine.
• 90655 Flu vaccine no preserv 6-35 m.
• 90656 Flu vaccine no preserv 3 gt.
• 90657 Flu vaccine, 6-35 mo, im.
• 90658 Flu vaccine, 3 yrs, im.
• Influenza administration.
• G0008 Administration of influenza virus
  vaccine.

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Influenza, PPV and Hepatitis B (Cont.)

• HCPCS codes
• PPV vaccine.
• 90732 Pneumococcal vaccine.
• PPV administration.
• G0009 Administration of PPV virus vaccine.

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Influenza, PPV and Hepatitis B (Cont.)

• HCPCS codes
• Hepatitis B vaccine.
• 90740 Hep b vacc, ill pat 3 dose im.
• 90743 Hep b vacc, adol, 2 dose, im.
• 90744 Hep b vacc ped/adol 3 dose im.
• 90746 Hep b vaccine, adult, im.
• 90747 Hep b vacc, ill pat, 4 dose im.
• Hepatitis B administration.
• G0010 Administration of Hep B vaccine.

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Influenza, PPV and Hepatitis B (Cont.)

• Reimbursement
• Influenza/PPV.
• Paid at 100 percent of the Medicare-allowed
  amount.
• Part B deductible and coinsurance do not apply.
• Hepatitis B.
• Paid at reasonable cost.
• Part B deductible and coinsurance do apply.

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Rehabilitation

• Effective Jan. 1, 2006, physical therapy,
  occupational therapy and speech-language
  pathology are billed separately from the AIR or
  facility-specific rate for CAH providers.

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Rehabilitation (Cont.)

• Physical Therapy (OT) billing
• Occurrence code(s).
• 11 Onset of symptoms and illness.
• 29 The date a plan was established or last
  reviewed for physical therapy.
• 35 - Date treatment began for PT.
• Value code 50.
• Report the number of visits from onset.
• Revenue code 0420.
• HCPCS required.

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Rehabilitation (Cont.)

• Occupational Therapy (OT) billing
• Occurrence code(s).
• 11 Onset of symptoms and illness.
• 17 The date a plan was established or last
  reviewed for occupational therapy.
• 44 - Date treatment began for OT.
• Value code 51.
• Report the number of visits from onset.
• Revenue code 0430.
• HCPCS required.

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Rehabilitation (Cont.)

• Speech-language pathology billing
• Occurrence code(s).
• 11 Onset of symptoms and illness.
• 30 The date a plan was established or last
  reviewed for outpatient speech pathology.
• 45 - Date treatment began for speech therapy.
• Value code 52.
• Report the number of visits from onset.
• Revenue code 0440.
• HCPCS required.

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Rehabilitation (Cont.)

• Audiology billing
• No specific occurrence code or value code.
• HCPCS required.

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Inpatient Versus Observation

• CMS CR 3444, Transmittal 299, dated Sept. 10,
  2004.
• Effective April 1, 2004, condition code 44,
  inpatient admission changed to outpatient.
• For use on outpatient claims only, when the
  physician ordered inpatient services, but upon
  internal review performed before the claim was
  initially submitted, the hospital determined the
  services did not meet its inpatient criteria.
• Must be determined before discharge.

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Inpatient Same Day Readmission

• CMS CR 3389, Transmittal 266, dated July 30,
  2004.
• Effective Jan. 1, 2005, for patients that are
  discharged and readmitted the same day by the
  same Medicare provider.
• Same diagnosis
• Both claims are combined.
• Different diagnosis
• Two separate claims.
• Condition code B4.

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NPI

• National Provider Identifier (NPI)
• Replaces health care provider identifiers.
• Must be used beginning May 23, 2007.
• Note Small health plans have until May 23, 2008.
  

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NPI (Cont.)

• For additional information or to complete an
  application, visit
• https//nppes.cms.hhs.gov
• For questions and assistance in completing the
  NPI application, contact Fox Systems (the NPI
  Enumerator) at [phone].

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NPPES Web Site
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CMS Web Site

• IHS/Tribal/CAH providers may obtain further
  information through the CMS Web site at
• www.cms.hhs.gov/NationalProvIdentStand/

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CMS Web Site (Cont.)
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How to Apply
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NPI Timeline

• CMS has set the following dates for transitioning
  to the NPI in the fee-for-service Medicare
  program
• Jan. 3, 2006 - Oct. 1, 2006
• CMS systems will accept existing legacy Medicare
  numbers or an NPI as long as it is accompanied by
  an existing legacy number.
• Oct. 2, 2006 - May 22, 2007
• CMS systems will accept existing legacy Medicare
  numbers and/or NPI.
• May 23, 2007
• CMS systems will only accept an NPI.

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TrailBlazer HealthWeb Site
Log onto Web site www.trailblazerhealth.com Sel
ect Part A - IHS
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TrailBlazer Health Web Site (Cont.)
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Top 10 RTPs

• Top Return to Provider (RTP) errors
• Reason code 32400.
• HCPCS required for line item.
• Resolution in GPNet
• Claim page 3.
• Verify reported HCPCS.

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Top 10 RTPs (Cont.)

• Reason code 32404.
• HCPCS code reported is invalid.
• Resolution in GPNet
• Claim page 3.
• Verify reported HCPCS.

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Top 10 RTPs (Cont.)

• 3. Reason code 11801.
• Admission source (FL18) missing.
• Resolution in GPNet
• Claim page 1.
• Verify admission source.

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Top 10 RTPs (Cont.)

• 4. Reason code 32200.
• Principal diagnosis codes V0481 and/or V0382 are
  present with condition code A6.
• Resolution in GPNet
• Claim page 1.
• Verify A6 in condition code field.

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Top 10 RTPs (Cont.)

• 5. Reason code 12101.
• Patient discharge (FL 22) is missing.
• Resolution in GPNet
• Claim page 1.
• Verify patient discharge status field.

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Top 10 RTPs (Cont.)

• 6. Reason code 32019.
• Provider is not eligible to submit claims for
  payment after provider termination date.
• Resolution
• Verify the provider number used.

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Top 10 RTPs (Cont.)

• 7. Reason code 30715.
• Name and/or Health Insurance Claim Number (HICN)
  are invalid.
• Resolution
• Claim pages 1 and 5.
• Verify the beneficiary name used.

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Top 10 RTPs (Cont.)

• 8. Reason code 31357.
• Condition code 21 is present for denial but there
  are no non-covered charges.
• Resolution
• Claim page 2.
• Verify the non-covered charges.

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Top 10 RTPs (Cont.)

• 9. Reason code 19203.
• The attending physicians name and UPIN must be
  present.
• Resolution
• Claim page 3.
• Verify the physicians UPIN.

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Top 10 RTPs (Cont.)

• 10. Reason code 15321.
• The final entry, adjacent to revenue code 0001,
  must be the sum of all previous entries.
• Resolution
• Claim page 2.
• Verify the charges reported.

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IHS Listserv

• Join the IHS listserv.
• Keep updated on all new policy and billing
  information.
• Application forms are available at the
  TrailBlazer booth.

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Medicare Part A Updates

• Thank you for attending