Sunday, April 24, 2016

What are the forms need to submit with worker compensation claims

3.0 Complete Bills;


(a) To be complete a submission must consist of the following:

(1) The correct uniform billing form/format for the type of health care provider.

(2) The correct uniform billing codes for the applicable portion of the OMFS under which the services are being billed.

(3) The uniform billing form/format must be filled out according to the requirements specified for each format in Appendix A and/or the Companion Guide. Nothing in this paragraph precludes the claims administrator from populating missing information fields if the claims administrator has previously received the missing information.

(4) A complete bill includes required reports and supporting documentation specified in subdivision (b).

(b) All required reports and supporting documentation sufficient to support the level of service or code that has been billed must be submitted as follows:

(1) A Doctor?s First Report of Occupational Injury (DLSR 5021), must be submitted when the bill includes Evaluation and Management services and a Doctor?s First Report of Occupational Injury is required under Title 8, California Code of Regulations § 9785.

(2) A PR-2 report or its narrative equivalent must be submitted when the bill is for Evaluation and Management services and a PR-2 report is required under Title 8, California Code of Regulations § 9785.

(3) A PR-3, PR-4 or their narrative equivalent must be submitted when the bill is for Evaluation and Management services and the injured worker?s condition has been declared permanent and stationary with permanent disability or a need for future medical care. (Use of Modifier – 17.)

(4) A narrative report must be submitted when the bill is for Evaluation and Management services for a consultation.

(5) A report must be submitted when the provider uses the following Modifiers – 22, – 23 and – 25.

(6) A descriptive report of the procedure, drug, DME or other item must be submitted when the provider uses any code that is payable “By Report”.

(7) A descriptive report must be submitted when the Official Medical Fee Schedule indicates that a report is required.

(8) An operative report is required when the bill is for either professional or facility Surgery Services fees.

(9) An invoice or other proof of documented paid costs must be provided when required by the OMFS for reimbursement.

(10) Appropriate additional information reasonably requested by the claims administrator or its agent to support a billed code when the request was made prior to submission of the billing. (This does not prohibit the claims administrator from requesting additional appropriate information during further bill processing.)

(11) For paper bills, any written authorization for services that may have been received by the physician.

(c) For paper bills, if the required reports and supporting documentation are not submitted in the same mailing envelope as the bill, then a header or attachement cover sheet as defined in Section One – 7.3 for electronic attachments must be submitted.

Wednesday, April 20, 2016

How to resolve when denial received on two provider submitting on DOS ?

My inpatient claim is overlapping a home health episode with the same date(s) of service. How can I resolve this?
A: Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.
• Verify dates of service on your claim
• If dates of service are incorrect, correct your claim and resubmit.
• If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim.
• Edit exclusions:
• The inpatient claim admission date is the same as the home health agency transfer/discharge date
• The inpatient claim discharge date is the same as the home health agency admission date
• The inpatient claim dates are between the occurrence span code 74 ‘From’ date and the day following the occurrence span code ‘Through’ date


Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

ICD 10 CODE for Osteopenia - M85.811 - M85.871 Bone density and structure

The Centers for Medicare & Medicaid Services (CMS) will implement Change Request  (CR) 9252 on January 4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252.) This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination (NCD) 150.3. CR9252 and  accompanying spreadsheet inadvertently omitted the condition of osteopenia and the ICD- 10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of bone density and structure. The codes and conditions identified within this subcategory are considered covered indications for bone mass measurement under NCD 150.3 and providers should report these appropriately according to medical documentation. Additional guidance and education as to the updated complete list of covered indications will be forthcoming as CMS continues to review this issue and the systems updates required.

Background

Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters article MM5521.) The accompanying Benefit Policy Manual, Publication 100-02, chapter 15, section 80.5.6, Beneficiaries Who May Be Covered, includes: 2. An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.

Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3 indications.

Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.


** M85.811 Other specified disorders of bone density and structure, right shoulder
** M85.812 Other specified disorders of bone density and structure, left shoulder
** M85.821 Other specified disorders of bone density and structure, right upper arm
** M85.822 Other specified disorders of bone density and structure, left upper arm
** M85.831 Other specified disorders of bone density and structure, right forearm
** M85.832 Other specified disorders of bone density and structure, left forearm
** M85.841 Other specified disorders of bone density and structure, right hand
** M85.842 Other specified disorders of bone density and structure, left hand
** M85.851 Other specified disorders of bone density and structure, right thigh
** M85.852 Other specified disorders of bone density and structure, left thigh
** M85.861 Other specified disorders of bone density and structure, right lower leg
** M85.862 Other specified disorders of bone density and structure, left lower leg
** M85.871 Other specified disorders of bone density and structure, right ankle and
foot
** M85.872 Other specified disorders of bone density and structure, left ankle and foot
** M85.88 Other specified disorders of bone density and structure, other site
** M85.89 Other specified disorders of bone density and structure, multiple sites

Sunday, April 17, 2016

Provider Enrollment - Some basic question on ownership and disclosing information

What does disclosing entity mean?

Disclosing Entity means a Medicaid provider (other than an individual practitioner), or a fiscal agent.

What does Publicly Owned mean?
In the United States, a publicly owned corporation is one whose shares are traded on public stock exchanges. Generally, anyone may purchase shares in such a corporation.

What does Privately Owned mean?
A privately owned corporation does not offer or trade its shares to the public on public stock exchanges.

What if there are no owners who have a 5% or more controlling interest in a publicly owned company?
In the PEAP system you would indicate YES where it states: “If the provider entity is a publicly held corporation and no person owns 5% or more of the corporation, you must select "Yes," and you must provide information for board members, agent(s) and managing employee(s). (Local, county and state government entities must select "No.")

What does managing employee mean?
Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

What is the definition of an Agent?
Any person who has been delegated the authority to obligate or act on behalf of a provider.

What does ownership or controlling interest mean?

Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.

A person with an ownership or controlling interest means a person or corporation that—
a. Has an ownership interest totaling 5% or more in a disclosing entity;
b. Has an indirect ownership interest equal to 5% or more in a disclosing entity;
c. Has a combination of direct and indirect ownership interests equal to 5% or more in a disclosing entity;
d. Owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5% of the value of the property or assets of the disclosing entity;
e. Is an officer or director of a disclosing entity that is organized as a corporation or is a partner in a disclosing entity that is organized as a partnership.


What does indirect ownership interest mean?
Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

Can a CEO be listed as a board member? 

Yes, if he/she serves on the board.
I have a physician who is owner and board member and who has also designed a component that is used in surgical procedures. Should I disclose that information, as he receives royalties for that, and we bill Medicaid for that component?
Yes.


What if I have a board member who is also an owner? How should I enter this person’s information?
The board member must be listed as both.
How do I know what my taxonomy code is?
You can obtain your taxonomy code from the letter you received to begin your revalidation. This letter also provided your Case Number for entering the Provider Enrollment Application Portal (PEAP).

What is a subcontractor?

(1) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or (2) An individual, agency, or organization with which an intermediary or carrier has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicare agreement.

Sunday, April 10, 2016

Q: What steps can be taken to identify claims that overlap with another provider?



A: If you receive an overlap reason code, you can do one of the following:

• Verify your claims submitted through direct data entry (DDE) pdf file

• Option -1 (inquiry menu), then option -12 (claims summary), and key in the beneficiary’s health insurance claim (HIC) number, your provider number, and press enter

• Review the list of claims submitted to identify those with identical dates of service, and validate they were submitted accurately

• Verify eligibility for home health episodes and hospice election from the ELGA and/or ELGH screens

• Verify the beneficiary/eligibility tab submenu on the secure provider online tool (SPOT)

• Home health episode start and end date, and the servicing provider’s NPI

• Hospice election effective and termination date, revocation code and the servicing provider’s NPI

• Click here to learn more about the SPOT

• NPI registry lookup external link enables you to search for the provider’s information

• Verify additional eligibility information from the submenu on the interactive voice response (IVR)

Hospice effective and termination dates (if applicable), and the servicing provider’s ID

• Home health effective and termination dates (if applicable), and the servicing provider’s ID

• Skilled nursing facility (SNF) effective and termination dates (if applicable), and the servicing provider’s ID

Thursday, April 7, 2016

BILLING Guideline for CPT Code 59425, 59409, S5100 and T1023

Incomplete Antepartum Care 

Service CPT

Billing for Incomplete Antepartum Care

59425 When billing for four to six prenatal visits
59426 When billing for seven or more prenatal visits with or without an initial visit


Billing for Multiple Deliveries For additional babies: 59409, 59514, 59612, or 59620   Modifier - 51 and 59


Oral and Maxillofacial Surgery

Do not use CPT procedure code 41899, as this is an unspecified code and will cause delay in payment for services

Locum Tenens and Reciprocal Billing
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement.
Q6 - Service furnished by a locum tenens physician


S5100 Day Care Services, Adult
1 Unit = 15 minutes
U2 modifier is no longer required when billing this service code.
POS -  12 Home 99 Other (Community)

Billing Presumptive Eligibility (PE) Determinations

T1023 to bill for PE determination

Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit

90471 to 90474 - If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25

Friday, April 1, 2016

What is claim overlap ? Claim submitted for same DOS

Q: What is an overlap?

A: When an incorrect claim is processed and posted to the Common Working File (CWF), resulting in claim overlap rejection(s) of subsequent claim(s), submitted by the same or a different provider. When more than one provider is involved, the providers must work together to resolve the error. Some overlapping claim examples include:

• Same provider – dates of service overlap
• Charges should be combined on one claim
• Outpatient claim submitted before allowing time for inpatient claim(s) to finalize
• Claims should be submitted in service date sequence


• Different provider – dates of service overlap
• Did not report a leave of absence on the claim
• Services are subject to consolidated billing
• Incorrect patient status code was submitted

Q: Why is my claim overlapping another facility’s when my dates do not fall within their dates of service?
A: The facility with the claim for the earliest dates of service may have billed an incorrect patient discharge status code. Applying the correct patient status code will help assure that the facilities receive prompt and correct payment.

• If your patient status code is incorrect, it can indicate a patient is still in your facility when, in fact, they were discharged and admitted to another facility. It is recommended that you submit an adjustment to update the patient status on your claim.

• If the other facility has submitted an incorrect patient status code, it is recommended that you contact the other facility and ask them to update the patient status code on the claim.

• Example: The claim indicates that the patient is still in the facility (patient status 30), but the patient was transferred to a Medicare certified Skilled Nursing Facility (patient status 03).

Q: I have contacted the overlapping facility numerous times and have asked them to correct their claim, but the claim has not been corrected. What steps can be taken to get the other facility’s claim updated?

A: While providers/facilities are required and expected to work together to resolve the billing issue, providers may occasionally require assistance from the Medicare Administrator Contractor (MAC). In that case, First Coast will work with both providers/facilities for resolution.
For further assistance with these claims, write in to the First Coast claims department: In order for your request to be considered, supporting documentation must be included with your written request to:
Medicare Part A
P.O. Box 2711
Jacksonville, FL 32231-0021

Monday, March 28, 2016

Use of an 8-Digit Registry Number on Clinical Trial Claims

Effective January 1, 2014, the Centers for Medicare & Medicaid Services (CMS) will require inclusion of an 8-digit clinical trial number on claims associated with clinical trial participation. Clinical trial related claims submitted to Medicare for dates of services on or after January 1, 2014, will be returned to the provider if the 8-digit clinical trial number is not present.

The 8-digit clinical trial number, also called the National Clinical Trial (NCT) Number or Clinical Trials identifier (IDE number), can be found on the ClinicalTrials.gov website.
http://clinicaltrials.gov/

This 8-digit NCT number will be added to the list of other required data:
Institutional clinical trial claims are identified through the presence of all of the following elements:
Value Code D4 and corresponding 8-digit clinical trial number (when present on the claim);
ICD-9 diagnosis code V70.7;
Condition Code 30; and
HCPCS modifier Q1: outpatient claims only. (See MM5805 related to CR5805 for more information regarding modifier Q1.)

Practitioner/DME clinical trial claims are identified through the presence of all of the following elements:

ICD-9 diagnosis code V70.7;
HCPCS modifier Q1; and
8-digit clinical trial number (when present on the claim).
On institutional claims, the 8-digit numeric clinical trial number should be placed in the value amount of value code D4 on the paper claim UB-40 (Form Locators 39-41) or in Loop 2300, HI – Value Information segment, qualifier BE on the 837I.


On professional claims, the clinical trial registry number should be preceded by the two alpha characters of “CT” and placed in Field 19 of the paper Form CMS-1500 or it should be entered WITHOUT the “CT” prefix in the electronic 837P in Loop 2300 REF02(REF01=P4).Medical record documentation of clinical trial title, sponsor name and sponsor protocol number should be kept on file with each participating facility.

Thursday, March 17, 2016

CPT CODE S5140, T1019, S5100, H2011 with covered DX

Certified Family Home (CFH) 

HCPCS Description Place of Service

S5140  Certified Family Home – Daily One to two participants Foster Care – Adult; per diem 1 unit = 1 day
T1019 Personal Care Service per 15 minutes
S5100 Adult Foster Care
H2011 Crisis intervention per 15 minutes

12 Home
33 Custodial Care Facility
99 Other



HCPCS Modifier Description Diagnosis Place of Service


H2019 Therapeutic Behavioral Services 1 Unit = 15 minutes
H2019 HM Therapeutic Behavioral Services Limited to 96 units per calendar month. 1 Unit = 15 minutes
H2011 Community Crisis supports (1 unit = 15 minutes)

Based on dates of service, enter the ICD-9-CM code V60.4 or the ICD-10-CM code Z74.2 for the primary diagnosis.
For more information on which ICD version to use, refer to ICD-9 and ICD-10 Diagnosis Billing Requirements.


11 Office
12 Home
99 Other (Community)

Sunday, March 6, 2016

What are information required for provider enrollment and adding service location

enrollment/revalidation process.

*** For information related to the pay-to provider:

*** NPI

*** Tax ID on file with Molina which is provided on your case number letter —Federal Employer Identification Number (FEIN) (this may be the Social Security Number (SSN)

*** Name, title, and email address of the office contact person

*** Phone numbers—primary (required), secondary, emergency, mobile, and fax

*** A copy of the provider’s W-9 form

*** For information related to the owners and/or board members:

*** The name, FEIN or SSN, tenure dates, and address information for all owners and/or board members

*** Information regarding sanctions, exclusions, or convictions of owners and/or board members

*** Information regarding owners’ and/or board members’ participation in other organizations that bill Medicaid for services

*** The relationships among owners and/or board members Information regarding the provider, owners, and employees with respect to certain legal situations

Note: If there are no owners or board members holding at least 5% interest or control in the facility, agency or organization, the provider is required to attest to this statement via the portal or in writing if completing a paper application. The ownership information must still be completed on the managing employee of the facility, agency or organization.


*** For service locations:


*** The physical and mailing addresses of the provider’s service location(s)

*** The current Medicaid IDs assigned to the provider’s service location(s)

*** A list of any languages spoken by the provider and his or her staff, in addition to English

*** General information about each service location, such as accessibility, office hours, whether the service location is accepting new patients, and the age range and gender restriction for patients

*** The provider type/specialty pairs that represent the provider’s practice, as well as all licensing and certification documents for those provider type/specialty pairs

*** Information about participation in WV Medicaid programs, including specifics for the Physician Assured Access System program, if applicable.