Saturday, May 28, 2016

WHY POS is important in claim submission ?

Reporting place of service (POS) codes

Physicians are required to report the place of service (POS) on all health insurance claims they submit to Medicare Part B contractors. The POS code is used to identify where the procedure is furnished. Physicians are paid for services according to the Medicare physician fee schedule (MPFS). This schedule is based on a payment system that includes three major categories, which drive the reimbursement for physician services:

• Practice expense (reflects overhead costs involved in providing service(s))
• Physician work
• Malpractice insurance

To account for the increased practice expense physicians incur by performing services in their offices, Medicare reimburses physicians a higher amount for services performed in their offices (POS code 11) than in an outpatient hospital (POS 22-23) or an ambulatory surgical center (ASC) (POS 24). Therefore, it is important to know the POS also plays a factor in the reimbursement.

Note: Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding POS codes.

Important facts when filing a claim to Medicare

• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim

• The name, address and zip code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent
• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS
• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)
• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)



Helpful hints for POS codes for professional claims

• Implement internal control systems to prevent incorrect billing of POS codes
• Keep informed on Medicare coverage and billing requirements
• For example, billing physician's office (POS 11) for a minor surgical procedure that is actually performed in a hospital outpatient department (POS 22) and collecting a higher payment is inappropriate billing and may be viewed as program abuse

Wednesday, May 25, 2016

Timely filing limit for BBHHF providers

Timely Filing for BBHHF Providers;
Timely Filing Policy under Charity Care To meet timely filing requirements for the BBHHF Charity Care program, claims must be received within 180 days from the date of service. Claims that are 180 days old must have been billed and received within the 180 day filing limit.

The original electronic claim must have had the following valid information:
• Valid Provider Number
• Valid Member Number
• Valid Date of Service
• Valid Bill Type

Claims that are over 180 days must be submitted on paper with a copy of the original remittance advice showing where the claim was initially received PRIOR TO the 180 day limit. Claims with dates of service over 360 days are NOT eligible for reimbursement. This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over 180 days, the replacement claim must be submitted on paper with a copy of the original remittance advice to:

BBHHF Charity Care Program
Timely Filing
PO Box 2002
Charleston, WV 25327-2002.

You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim, and the dates of service are over 180 days, the claim will be denied for timely filing.

Monday, May 23, 2016

Helpful Tips in Medical coding in hospital billing - what is special days


• Diagnosis Codes: When reporting diagnosis codes a decimal point must not be submitted as the decimal point is implied.

• Single Date: Under 5010, a date range must be supplied and a single date is no longer permitted

• Admission Date: The admission date and hour only are allowed on inpatient claims and cannot be sent on outpatient claims.

• Special Days: 5010 has deleted the ‘Claim Quantity’ segment which contained the total covered days, non-covered days, coinsurance days and the lifetime reserve days. These days will now be sent in the Value information segment. The four valid values are:

o 80 - Covered days

o 81 - Non Covered days

o 82 - Coinsurance Days

o 83 - Lifetime Reserve Days


• Service Facility Location Name: Required when the location of health care service is different than the billing provider. The Service Facility must be a non-person and must contain a valid 9-digit postal code or zip code.

• Outpatient Services “Priority Type of Admission or Visit” and “Point of Origin for Admission or Visit”: Required for outpatient services submitted via paper or electronically for all bill types except 14X (Hospital laboratory Services provided to non-patients [OP/6]).

• National Drug Code (NDC): Drug quantity information is now required when an NDC is submitted.

o As an NDC unit of measurement, milligrams (ME) has been added. However Florida Blue does not recognize the ME unit of measure. Refer to the Billing Drug Services on a Professional claim section below

Friday, May 20, 2016

Coding a Facility Claim Procedure, Modifier and Diagnosis Codes - Basic steps

 -    A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. We have applied procedure code edits to outpatient claims for our Medicare Advantage members since 2008. Effective September 15, 2012, wewill apply these edits to our Commercial outpatient claims.

Complete and accurate procedure code, modifier and diagnosis code usage at the time of billing ensures accurate processing of correct coding initiative edits. Wecan only use the primary modifier submitted with the alternate procedure code for outpatient billing. We encourage you to purchase current copies of CPT, HCPCS and ICD code books.


The correct coding initiative edits and medically unlikely edits will apply to outpatient claims from the following hospitals and facilities:

• Acute care hospitals

• Long term acute care hospitals

• Ambulatory surgical centers

• Psychiatric facilities

• Substance abuse facilities

• Inpatient rehabilitation facilities

• Skilled nursing facilities


Note: Ambulatory surgical centers will follow institutional correct coding initiative edits forour commercial business, while our Medicare Advantage business will process against the professional edits.


Unlisted Procedure Codes

Unlisted procedure codes are not recommended for outpatient claims since they impact reimbursement of the claim. Refer to the outpatient payment programs section of this manual and the participation agreement for coding and reimbursement instructions.


Code Updates

The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) update procedure codes to reflect changes in health care and medical practices. Coding updates occur quarterly with the largest volume effective January 1, of each year. Current Procedural Terminology (CPT) and Healthcare Common Procedure Code System (HCPCS) codes may be added, deleted or revised with each update. International Classification of Diseases-9th Revision-Clinical Modification (ICD-10-CM) updates may occur bi-annually, with the largest volume effective October 1 of each year.


Modifiers

A modifier allows a provider to indicate that a service or procedure is altered by some specific circumstance, but the definition or code is not changed. Modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions are found in the most current CPT and HCPCS coding books.

Weprocess claims using only the first modifier for outpatient institutional claims. While up to three modifiers are accepted, claims are processed using only the first modifier. Therefore, submit the most important modifier affecting reimbursement in the first position on paper and electronic claims.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit an appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation. 4


Modifiers may be used to indicate that:

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual Events Occurred

Tuesday, May 17, 2016

Provider having multiple location - how to enroll


Service Locations:

I have multiple service locations. How do I ensure all mail and checks go to one address?
Checks will be sent to the W9 address listed in the revalidation application. If multiple locations are currently enrolled with separate Medicaid ID numbers, the address to which your checks will be mailed is based on the Pay-To W9 information provided in the revalidation application. If all locations use the same W9 address, then all of your checks will be delivered to that address.

Our current services are provided outside of the office. How do I show this in our revalidation application?
When you revalidate in WV Medicaid, you will record the location of the office administering the provision of services only. Later, when you submit claims to Molina Medicaid Solutions, you will indicate where the services were provided using the National Place of Service code set.

Why do I have to answer the same question when I am adding a rendering provider and I have already provided the information under my service location? There are circumstances where a service location might provide a service that will not include participation by all rendering providers. For instance, a service location may offer Physician Assured Access System (PAAS) services, however not all rendering providers at that location may be eligible to provide PAAS services.


What is the PAAS Program?
The PAAS Program is only applicable to primary care type physicians and provider types. Examples of the provider type, and physician specialties are: Internal Medicine, Family or General Practice, Pediatricians, OB/GYN, FQHC’s, and RHC’s, etc.

I’m not a specialty, or provider type for primary care. How do I answer the questions “Are you a PAAS Provider”, and “Do you want to be a PAAS Provider?
Answer these questions as NO.


Why does the Service Location screen on the PEAP system ask for a minimum and maximum age?
Some provider specialties only accept patients of a certain age. An example would be a pediatrician would only have patients from under 1 year of age to 18 years of age.


Will each service location have to be added? Example we have 41 Service Locations.
Yes every location and Provider at that entity

Sunday, May 15, 2016

Coding tips for Diagnostic Imaging and Laboratory codes


Diagnostic Imaging

If the treating chiropractic provider refers the reading or interpretation of a radiology service to a radiologist, reimbursement for the professional component of that service will only be made to the radiologist, and the treating chiropractic provider should not bill for that component.


Component Modifier Description of Services

• Professional 26 Services rendered by a licensed practitioner to perform the diagnostic interpretation of each study. It is required to document the diagnostic conclusions of the study by a written and signed radiology report.

• Technical TC Radiology services that include providing the facilities, equipment, resources, personnel, supplies and support needed to perform and produce the diagnostic study.

• Global N/A Combines both the technical and professional components in the service provided.


Laboratory

BlueCare, BlueMedicare HMO, BlueMedicare PPO and BlueOptions members covered in-office laboratory services are restricted to:
81000, 81001, 81002, 82947, 82948, 85014, 85025 All other laboratory services should be referred to Quest Diagnostics, Inc.
For BlueChoice and Traditional members, members may be referred to any Florida Blue contracted laboratories, including Quest Diagnostics.

Laboratory services for select health and musculoskeletal conditions may comprise one or more of the procedure codes on the list of in-office laboratory codes. Reimbursement for routine venipuncture for collection of specimen (36415) is only payable when paired with modifier 90 and when the laboratory sample is drawn in the chiropractor’s office, but the sample is sent to an offsite laboratory for processing.

Friday, May 13, 2016

Florida Blue submitting secondary claim address


Filing the Medicare Cross-Over Claim

File the claim to your Medicare carrier for primary payment. Claim information will not be crossed over to the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. Medicare secondary claims will normally be electronically forwarded by GHI (the CMS vendor) directly to the member’s supplement Blue Plan for processing of the secondary benefits. Check the Medicare Remittance Notice to identify whether the claim was crossed over directly to the member’s Medicare supplement Blue Plan. If it did, you do not need to take further action. The paper remittance notice will state “Claim information forwarded to: (Name of secondary payer). “ The 835 (electronic remittance) record can also carry the secondary forwarding information.


You will receive payment or processing information from the member’s supplement plan after they receive the Medicare payment. Please allow 45 days from the Medicare payment date for the secondary claim (Medicare Supplement coverage) to process.

If the claim did not crossover electronically to the secondary payer (Medicare supplement plan), then file the claim to BCBSF with the Medicare Remittance Notice attached. Send the claim to:



Florida Blue P.O. Box 1798 Jacksonville, Florida 32231-0014

Do not send secondary claims directly to the member’s Blue Plan secondary payer.

Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific claim you are filing.


Inquiries around Medicare Crossover Claims

Direct inquiries on secondary claims to Florida Blue unless the member’s Blue Plan have requested specific information from you on a particular claim. Inquiries received on secondary claims by BCBSF will be coordinated with the member’s Blue Plan for resolution.

Example: A provider received the primary Medicare payment. The Medicare Remittance Notice stated, “Claims information was forwarded to: (Name of secondary payer).” It has been 45 days since Medicare’s payment and no communication has been received from the member’s supplement plan. This should be sent to Florida Blue as an inquiry so the member’s Blue Plan can be contacted and a resolution made on the status of the secondary claim. Florida Blue will communicate the resolution back to the provider. 13

Tuesday, May 10, 2016

Claim rejected as Duplicated claim - What are the possible ways to find outcome?

Q: My claim rejected, or was returned to provider, as a duplicate of another claim. Can I resubmit the claim? What steps can I take to avoid duplicate claims?


A: Claim system edits are in place to detect duplicate services. The edits search within paid, finalized, pending, and same claim details in history. This means that unless applicable modifiers and/or condition codes are included in your claim, the edits detect duplicate and repeat services within the same claim, and/or based on a previously submitted claim.

The following reject reason codes are commonly seen with this edit:
• 38005 -- This claim is a duplicate of a previously submitted inpatient claim
• 38031 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim
• 38035 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider
• 38038 – This claim is a possible duplicate of a previously submitted claim
• 38200 -- This is an exact duplicate of a previously submitted claim

The following return to provider (RTP) reason codes are commonly seen with this edit:
• 38032 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
• 38037 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim

Your claim rejected as a duplicate, because one or more of the following items matched the original claim:

• Health Insurance Claim Number (HICN), provider number, type of bill (TOB)--all three positions of any TOB, statement coverage from and through dates, at least one diagnosis or line item date of service, revenue code, HCPCS code, and/or total charges (0001 revenue line).

To prevent duplicate claims, verify status of claim prior to filing.

1. If you use direct data entry (DDE) pdf file, access the beneficiary's HIC number to verify the history of claims submitted and the status/location of those claims. Note: you cannot see claims submitted by other facilities.
2. Check status of claims via the Secure Provider Online Tool (SPOT).
3. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816. There are three breakdowns available: claim status, return to provider and pending claims.
4. Review the remittance advice for the history of the beneficiary's claims.

In addition, if your claim includes repeat services or supplies, append modifiers and/or condition codes, as applicable. For a complete list of coding resources, refer to the Medicare Billing: 837I and Form CMS-1450 Fact Sheet external pdf file

If you submit claims via the electronic data interchange (EDI) gateway, you are provided with confirmation when the batch of claims is received. Please wait for this confirmation, instead of resubmitting the batch of claims. If you make one change to one claim in the batch but resubmit the entire batch, all the claims go to the fiscal intermediary shared system (FISS), resulting in duplicate claims. Do not resubmit the entire batch; resubmit corrected claims only.

Note: If a third party vendor, billing service, or clearinghouse submits claims on your behalf, contact them to ensure they are not resubmitting entire batches of claims as described above. In addition, occasional software glitches can cause the resubmittal of an entire batch. Be aware that these software or vendor issues reflect directly upon the provider and are problematic, at best, and considered possible abuse, at worst.

Listed below are some recommendations, when additional action is required to correct your claim(s):
• You have two options when the original processed claim needs to be updated or corrected.
1. Adjust the original processed claim (TOB xx7) and resubmit.
2. Cancel the original processed claim (TOB xx8) and submit a new claim, but you must wait for the cancelled claim to finalize before the new claim is submitted.
• If two claims were submitted at the same time and resulted in duplicates against each other, submit a new claim.
• If the rejected claim is an exact duplicate to a previously processed/finalized claim, no action is necessary.

Friday, May 6, 2016

Submitting worker compensation claim electronically - what are the attachement required to submit

Electronic Bill Attachments


(a) Required reports and/or supporting documentation to support a bill as defined in Complete Bill Section 3.0 shall be submitted in accordance with this section. Unless otherwise agreed by the parties, all attachments to support an electronically submitted bill must either have a header or attached cover sheet that provides the following information:

(1) Claims Administrator - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224. Loop 2010BB, NM103.

(2) Employer - the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.

(3) Unique Attachment Indicator Number - the Unique Attachment Indicator Number shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the unique Attachment Control Number. It is the combination of these data elements that will allow a claims administrator to appropriately match the incoming attachment to the electronic medical bill. Refer to the Companion Guide Chapter 2 for information regarding the Unique Attachment Indicator Number Code Sets.

(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. If the provider is ineligible for an NPI, then this number is the provider?s atypical billing provider ID. This number must be the same as populated in Loop 2010AA, REF02.

(5) Billing Provider Name.

(6) Bill Transaction Identification Number – This shall be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 transactions, Loop 2300 Claim Information, CLM01.

(7) Document type – use Report Type codes as set forth in Appendix C of the Companion Guides.

(8) Page Number/Number of Pages the page numbers reported should include the cover sheet.

(9) Contact Name/Phone Number including area code.

(b) All attachments to support an electronically submitted bill shall contain the following information in the body of the attachment or on an attached cover sheet:

(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if available)
(6) Claim number (if available)
(7) Unique Attachment Indicator Number
(c) All attachment submissions shall comply with the rules set forth in Section One – 3.0 Complete Bills and Section Three – Security Rules. They shall be submitted according to the protocols specified in the Companion Guide Chapter 8 or other mutually agreed upon methods.

(d) Attachment submission methods:

(1) FAX

(2) Electronic submission – if submitting electronically, the Division strongly recommends using the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) transaction set. Specifications for this transaction set are found in the Companion Guide Chapter 8. The Division is not mandating the use of this transaction set. Other methods of transmission may be mutually agreed upon by the parties.

(3) E-mail – must be encrypted


(e) Attachment types
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other type of attachment)

Saturday, April 30, 2016

Coding a Professional Claim


Procedure Modifier and Diagnosis Codes

A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. Inclusion of a complete and accurate list of diagnosis codes associated with the patient at the time of the encounter, including chronic conditions not necessarily treated at the time of the encounter, is part of correctly coding an encounter. It ensures that we can best match patients with appropriate care and disease management programs and members are properly classified by risk programs. We encourage you to purchase current copies of CPT, HCPCS, and ICD 10 CM code books.

Unlisted Procedure Codes

Report an unlisted code only if unable to find a procedure code that closely relates to or accurately describes the service performed. Whenever you submit an unlisted code, you must include a written description of the services with the claim. Unlisted codes require documentation and therefore should not be submitted electronically; the exception is unclassified HCPCS drug codes (refer to Unclassified Drugs).



Modifiers

A modifier provides a physician with the means to indicate that a service/procedure is altered by some specific circumstance, but not changed in its definition or code. By modifying the meaning of a service, modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions can be found in the most current CPT and HCPCS coding books.

When multiple modifiers are necessary for a single claim line, modifiers should be submitted in the order that they affect payment.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation.

Modifiers may be used to indicate that:

• A service or procedure has both a professional and technical component

• A service or procedure was performed by more than one physician and/or in more than one location

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual events occurred