Hospital Modernization Workshop Presentation 2016

Hospital Modernization Workshop
Presented by
The Department of Social Services
& Hewlett Packard Enterprise
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Training Topics
• Outpatient Hospital Modernization Overview
– CT Addendum B
• Reimbursement Methodology
– APC
– CT Fee Schedule
– Fixed fee Based on Revenue Center Codes (RCC)
• Claim Examples
• Discounts and Outliers
• Explanation of Benefit (EOB) Codes
• Remittance Advice
• NCCI/MUE
• Hospital Billing Changes
• Upcoming Changes – Prior Authorization
• Hospital Modernization Web Page
• Questions
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Outpatient Hospital Modernization Overview
• In accordance with section 17b-239 of the Connecticut General
Statues, as amended, the Department of Social Services (DSS)
is modernizing outpatient hospital reimbursement under the
Connecticut Medical Assistance Program (CMAP) from the
current model to an Outpatient Prospective Payment System
(OPPS) similar to Medicare.
–This implementation is scheduled for Dates of Service (DOS)
July 1, 2016 and forward.
–It impacts general acute care hospitals, chronic disease
hospitals, psychiatric hospitals and children’s general
hospitals.
• Outpatient and outpatient crossover claims that overlap July 1,
2016 will process based on the details. DOS prior July 1, 2016
will process as they do currently and DOS July 1, 2016 and
forward will process based on the APC grouper.
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Outpatient Hospital Modernization Overview
• DSS will be implementing 3M CMS OCE/APC v17.1 APC grouper
software version to process the majority of outpatient hospital
claims.
–DSS plans to stay current with Medicare and update the
system with January updates and also implement quarterly
changes as administratively feasible.
• What are the goals of the conversion to an APC model?
–Reimbursement policies aligning more closely with Medicare.
–Greater accuracy in matching reimbursement amounts to
relative cost and complexity.
–Equity and consistency of payments among providers while
maintaining access to quality care.
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Outpatient Hospital Modernization Overview
• What are the characteristics of APC payment?
–Most reimbursements under the CMAP OPPS system will be
through one of the following payment methods:
 Ambulatory
Payment Classification (APC).
 Fixed
fee based on Revenue Center Codes (RCC) and/or
RCC/CPT combination.
 Fee
schedule based on the Healthcare Common Procedural
Coding System (CPT/HCPCS).
• In addition to those payment methods outpatient services could
be manually priced and paid based on Prior Authorization (PA),
and additional allowances can come from outliers and discounts.
• Hospitals will be paid under CT OPPS which will utilize
Connecticut’s Addendum B to determine the method of payment
for all outpatient services.
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CT Addendum B
• DSS will maintain CT Addendum B which lists HCPCS and CPT
codes.
• CT Addendum B document is an excel file that will have 3 tabs:
1. CT Addendum B version with the list of all the procedure
codes, a short description, payment type, status indicator,
APC code, relative weight, payment rate and CT fee
schedule.
2. CT Addendum B Legend with field descriptions and valid
values.
3. CT fee schedule legend with the fee schedules and
descriptions.
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CT Addendum B
• Field 1: Procedure Code - The five digit CPT or HCPCS code billed by
the hospitals in conjunction to the revenue center code (RCC).
• Field 2: Short Description - Short description of the CPT or HCPCS
billed.
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CT Addendum B
• Field 3: Payment Type - Identifies the payment method used by DSS to
determine how the CPT or HCPCS code will be reimbursed.
Payment Type
Description
APC
Reimbursed using APC methodology
APC-FS
APC (packaged) except when considered APC payable by the grouper
then reimbursed based on the Lab fee schedule.
APC-PR
APC reimbursed based on payment rate
FS
Reimbursed using CT Fee schedule in Field 8
FS-CMAP
Reimbursed based on the CT fee schedule listed in CT Fee Schedule
field. These codes are not on CMS' version of CT Addendum B.
L1
Reimbursed based on the Lab fee schedule, if modifier L1 is present on
the detail.
MP
Manually priced by DSS
No
Not covered by CT Medicaid (payment denied).
PA
Reimbursed based on amount authorized via the prior authorization
process.
RCC
Reimbursed using RCC rates on Outpatient Fee schedule.
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CT Addendum B
• Payment Type - APC
–If the payment type is APC Payment, it will be reimbursed
using APC methodology
–Example: Procedure code 99283 “Emergency dept visit ”,
payment type indicator “APC”.
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CT Addendum B
• Payment Type - APC - FS
–Example: Procedure code 36415 “Routine Venipuncture”,
payment type “APC-FS” and status indicator “Q4”.
–If the APC grouper returns a status indicator “N” the detail
will be packaged and zero pay (no separate reimbursement).
–If the outpatient claim is for a 'non-patient‘. APC grouper
returns the service as APC payable, in this case will be
reimbursed based on payment type “APC-FS” using the CT
lab fee schedule.
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CT Addendum B
• Payment Type APC-PR – Line item paid based on CMS
payment rate.
− Example:
Procedure code J0695 “Inj Ceftolozane
Tazobactam”, payment type “APC-PR”. Allowed amount is
$4.28.
• Payment Type – FS – Line item paid based on CT policy (CT
fee schedule payment).
− Example:
Procedure code 77062 “Breast tomosynthesis bi”,
payment type “FS”.
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CT Addendum B
• Payment Type - NO – Line item denied based on CT policy.
−Example: Procedure code 61796 “Srs cranial lesion simple”,
payment type “No”.
−Example: Procedure code 89290 “Biopsy Oocyte Polar Body”,
payment type “No”. Medicare does reimburse based on the
grey amounts in APC and relative weight, but Medicaid will
deny the service based on CT policy.
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CT Addendum B
• Field 4 – Status Indicator
−The status indicator returned by the APC grouper and as
identified on CMS addendum B. The list of status indicators
can be found on the CMS Web site under Addendum D1.
−The hospital can click on the following link:
https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Me
dicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Downloads/CMS-1633-FC2016-OPPS-FR-Addenda.zip
−Then select “Accept” then “Open” and then select “2016 OPPS
FR Addendum D1”.
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CT Addendum B
• Status Indicator N – Packaged – Line item details that
return a “N” status indicator will be zero paid, because the
reimbursement for these items and/or services are included in
the APC payment for another detail on the same date.
–The cost of the packaged services are allocated to the APC
but are not paid separately. Some examples of packaged
items are:
 ancillary
services;
 implantable
 most
medical devices;
clinical diagnostic laboratory tests; and
 recovery
room use.
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CT Addendum B
• Status indicator is “Q1, Q2, Q3 or Q4” on CT Addendum B,
but the APC grouper could return detail line with an “N” status.
–Example: Procedure code 77071 “X-ray Stress View”,
payment indictor “APC” and status indicator “Q1”.
 If
there is a procedure code with a status indicator of a APC
Payable: APC payment on another detail of the claim, the
APC grouper would return a status indicator of “N” and the
detail will be packaged. The detail will zero pay.
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CT Addendum B
• Field 5 – APC
–The APC group assigned by APC grouper software for that
procedure code.
–Refer to Medicare Addendum B for the APC group number and
Medicare Addendum A for the APC descriptions.
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
• Field 6 – Relative Weight
–The relative weight assigned by CMS for the APC group
assigned. This amount is used in the calculation of the APC
payment.
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CT Addendum B
• Field 7 – Payment Rate
–For procedure codes with a payment type APC-PR this field is
the rate that the procedure code will be reimbursed.
Payment rate is based from CMS rates identified on CMS
addendum B.
–
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CT Addendum B
• Field 8 – CT Fee Schedule
–Identifies which fee schedule will be utilized for a given
HCPC/CPT code billed when the payment type field 3
indicates “FS”.
Field 8
CT Fee Schedule
Clinic/OP – BH
Clinic and Outpatient Hospital - Behavioral Health fee schedule
Clinic/OP – BH if RCC=900 Clinic and Outpatient Hospital - Behavioral Health fee
or 91x
schedule, only if it is billed with a Behavioral Health RCC (900
or 91x). All other instances are not covered
Clinic/OP – BH if RCC=919 Clinic and Outpatient Hospital - Behavioral Health fee
schedule, only if it is billed with a Behavioral Health RCC 919.
All other instances are not covered
Dialysis
Clinic-Dialysis fee schedule
FP/OFOUT
For 340B providers use the Clinic-Family Planning fee
schedule. For all others providers use the Physician Office and
Outpatient fee schedule
LAB
Lab fee schedule
LAB - ModL1
Lab fee schedule only if modifier L1 is present
MEDS - DME
MEDS-DME fee schedule
MEDS - Hearing Aid
MEDS-Hearing Aid/Prosthetic Eye fee schedule
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CT Addendum B
• Field 8 – CT Fee Schedule
Field 8
CT Fee Schedule
NDC
OFOUT
NDC — average wholesale price (AWP) minus 16.5%
Physician Office and Outpatient
PHRAD
Physician Radiology
RCC 401*
The procedure code must be billed with RCC 401.
RCC 403*
The procedure code must be billed with RCC 403.
RCC 771*
The procedure code on CT Addendum B must be billed with RCC
771.
RCC 901*
The procedure code must be billed with RCC 901.
RCC 953*
The procedure code must be billed with RCC 953.
Therapy RCC*
The procedure code on CT Addendum B must be billed with the
corresponding therapy RCCs (421, 423, 424, 431, 433, 434 or
441, 443, 444)
• RCC 771 is only covered for clients ages 0-18.
• * Fixed Fee Based on RCC and/or RCC/CPT combination.
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CT Addendum B
 Example:
Payment type “FS” procedure code 77062 “Breast
tomosynthesis bi”.
 This
will be reimbursed using the allowance from the
Physician Radiology Fee Schedule.
 Example:
Payment type “FS” procedure code 92590
“Hearing aid exam one ear”.
 This
will be reimbursed using the allowance from the
Physician Office and Outpatient Fee Schedule.
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Reimbursement Methodology
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Reimbursement Methodology - APC
• Calculate the detail Base APC Payment
–Procedure code 99283 “Emergency Department Visit” has an
APC Weight 2.6582 and using a Provider Wage Adjusted
Conversion factor as 82.74.
 Base
APC Payment = (Provider Wage Adjusted Conversion
Factor * units) * APC Weight.
 Base
APC Payment = (82.74*1) * 2.6582
 Base
APC Payment of $219.94
• Outpatient claims will pay allowed greater than billed at the
detail for each procedure code, but be capped at the header
billed amount.
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Reimbursement Methodology - CT Fee Schedules
• Details paid off of CT Fee schedule are based on HCPCS/CPT
procedure codes.
–Hospitals already use the CT fee schedule for laboratory
services.
• CT fee schedules can be accessed and downloaded by going to
the Connecticut Medical Assistance Program (CMAP) Web site
www.ctdssmap.com.
• From this Web page, go to the hospital modernization page and
on the right hand side under Helpful Information & Publications
click on “CT Fee Schedule”, Click on the “I accept” button then
select the appropriate fee schedule.
• To access the CSV file, press the control key while clicking the
CSV link, then select “Open”.
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Reimbursement Methodology - CT Fee Schedules
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Reimbursement Methodology - CT Fee Schedules
• Hospital claims will be reimbursed using the Mod1 and Rate
Type field to determine the allowance in the Max Fee field.
• Mod1 – Modifier TC – Technical Component is not required on
the claim, but the hospital will be reimburse based on the TC
Mod1 line, if there is no TC in the Mod1 field, the hospitals
would refer to the blank line for their allowance.
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Reimbursement Methodology - CT Fee Schedules
• Rate Types Field - Under each fee schedule there are different
rate types. The hospital will need to refer to the rate type
under the fee schedule to determine the allowance.
Rate Types
Descriptions
Fee Schedule
DEF
Default Rate
Meds-DME & Meds-Hearing
Aid/Prosthetic and Phys Off
and Outpatient.
OMH
Outpatient Mental Health*
Clinic and Outpatient Fee
schedule
OEC
Outpatient Enhanced Clinic*
Clinic and Outpatient Fee
schedule
OCD
Outpatient Chronic Disease*
Clinic and Outpatient Fee
schedule
DC
Dialysis Clinic
Clinic – Dialysis
FP
Family Planning
Clinic – Family Planning
RAD
Radiology*
Physician Radiology
* New rate types as of 7/1/2016.
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Reimbursement Methodology - Fixed Fee Based
on RCC and/or RCC/CPT combination
• DSS has determined that certain services will be Reimbursed
using RCC rates on Outpatient Fee schedule.
–The following RCCs will be excluded from APC methodology
and pay based on a RCC Fixed Fee:
Description
Diagnostic Mammography*
Screening Mammography
Physical Therapy
Occupational Therapy
Speech Therapy
CARES**
Vaccine Administration
RCCs
401*
403
421, 423, 424
431, 433, 434
441, 443, 444
769**
771
Electro Shock
901
Tobacco Cessation – Group Counseling
953
• *Change from cost to charge ratio to fixed fee for DOS
7/1/2016 and forward.
• **Hospital specific.
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Reimbursement Methodology - Fixed Fee Based
on RCC
• Example: Fixed fee based on RCC – RCC 424 procedure code
97001 and 421 procedure code 97002.
• Hospitals can refer to the Outpatient Fee Schedule for a list of
fixed fees for the RCCs.
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Reimbursement Methodology - Fixed Fee Based
on RCC
• Example: Fixed fee based on RCC – RCC 424 procedure code
97001 and 421 procedure code 97002.
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Claim Examples
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Claim Examples
• Example 1: Payment type “APC” procedure code 99283
“Emergency dept visit ”, on CT Addendum B.
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Claim Examples
• Example 1 - The claim went through APC grouper and
procedure code 99283 came back with a status indicator as “V”
which is still APC Payable.
 Base
APC Payment = (Provider Wage Adjusted Conversion
Factor * units) * APC Weight.
 Base
APC Payment = ($91.62*1) * 2.6582
 Base
APC Payment = $243.54
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Claim Examples
• Example 2: Payment type “APC” with a status indicator of
J2 and N “Packaged” procedure code 99283 and A4206.
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Claim Examples
• Example 2: Payment type “APC” with a status indicator of
J2 and N “Packaged” procedure code 99283 and A4206.
• Detail one paid at APC, detail 2 zero paid.
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Claim Examples
• Example 3: Payment type “APC” with SI “Q4”. Procedure
codes 81015 and 85018, with procedure code 99283.
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Claim Examples
–Procedure code 81015 and 85018 went through APC grouper
and returned SI “N” APC Packaged and posted EOB code
8620 “APC Packaged Service” and zero paid.
–Procedure code 99283 went through APC grouper and
returned SI “V” which is still APC payable.
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Claim Examples
• Example 4: Payment type “APC” with RCC 450 and procedure
code 99283 and RCC 981 with procedure code 99284.
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Claim Examples
• Example 4 Cont:
–Procedure code 99283 and 99284 went through APC grouper
and returned SI “V” which is still APC payable, but line 2 RCC
981 denied EOB code 4151 “Billing Provider Not Authorized to
Bill for Submitted Service for Client”.
–RCC 981 - For dates of service July 1, 2016 and forward,
hospitals should no longer bill RCC 96X, 97X, and 98X on
their outpatient hospital claims, they will be denied.
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Claim Examples
• Example 5: Payment type “APC” with Status indicator
“Q1.”
–Example: Procedure code 77071 “X-ray Stress View”,
payment indictor “APC” and status indicator “Q1”.
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Claim Examples
• Example 5: Payment type “APC” with Status indicator
“Q1” .
–Example: Procedure code 77071 and 99283
 If
there is a procedure code with a status indicator of a APC
Payable: APC payment on another detail of the claim, the
APC grouper would return a status indicator of “N” and the
detail will be packaged. The detail will zero pay.
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Claim Examples
• Example 6: Payment Type – APC - PR
–Procedure code 90675 and J3145.
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Claim Examples
• Example 7: Payment Type – APC – FS billing only procedure
code 36415 and 80047 for a non-patient.
• Claim processed change indicator to “A”.
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Claim Examples
• Example 7: Payment Type – APC – FS procedure code 36415
and 80047. Allows at CT Lab Fee Schedule.
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Claim Examples
• Example 8: Payment Type - FS - procedure code 78267.
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Claim Examples
• Example 9: Payment Type – No
–Example: Procedure code 61796 “Srs cranial lesion simple”,
payment type “No”.
−Service denied EOB 4185 “Service Not Covered under APC
Addendum B.
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Claim Examples
• Example 10: Multiple Outpatient Hospital E/M Encounters
on the same date can be billed on the same or different
claim. Hospital bills RCC 450 procedure code 99283 twice to
identify 2 separate E/M visits.
–Claims still require the condition code G0 “Distinct Medical
Visit” when billed with the same RCC code and Modifier 27 “
Multiple Outpatient E/M Encounters on the Same Date.”
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Claim Examples
• Example 10 Cont:
• Claims billed without Condition code G0 will deny with EOB 312
“Multiple Medical Visits with Same RCC and Same Day Require
Condition Code G0.”
• Claims billed without modifier 27 the E/M code could deny with
EOB 5000 “Possible Duplicate of a Paid Claim or Claim that is
Currently in Process.”
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Claim Examples
• Example 11: Greater than billed detail vs header.
Outpatient claims will pay the APC allowed amount greater than
billed at the detail for each procedure code, but claims will be
capped at the header billed amount.
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Guidelines for Observation Services
• In order to be reimbursed for observation services, a patient
must be in observation status for a minimum of eight hours in
addition to any time that the patient spent in the ED or any
other licensed hospital space prior to receiving observation
services.
–As part of observation services, CMS created “J2”
(Observation Services Related) status indicator to identify
specific combinations of services or Comprehensive
Observation Services APC (C-APC).
• Comprehensive observation services will be reimbursed if the
following criteria are met:
–Claim does not contain a HCPCS code with SI “T” (Significant
Procedure Subject to Multiple Procedure Discounting)
reported on the same day or one day prior to the date
associated with HCPCS code G0378 (observation services per
hour)
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Guidelines for Observation Services
–The claim contains eight or more units of services described
by G0378.
–The claim contains one of the following codes provided on the
same date of service or one day before the date of service for
G0378:
 HCPC
G0379
 CPT
99281 – 99285 (Emergency department visit).
 CPT
G0380 – G0384 (Hosp Type B ED visit).
 CPT
99291 (critical care, E/M of the critically ill or critically
injured patient; first 30-74 minutes).
 HCPC
code G0463 (hospital outpatient clinic visit for
assessment and management of a patient).
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Guidelines for Observation Services
− The claim does not include a HCPCS code with the SI of “J1”
(outpatient services paid through a Comprehensive APC).
–Billing for observation services must be reported using the
appropriate combination of Revenue and Healthcare Common
Procedural Coding System (HCPCS) codes(s) from the
following:
1. Revenue
2. HCPCS
hour:
Code 762 - Observation Room.
code G0378 - Hospital Observation Services, per
Report G0378 when observation services are rendered to
a patient in observation status.
The unit of services must equal the number of hours the
patient was in observation status.
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Guidelines for Observation Services
3. HCPCS
Code G0379 - Direct admission of patient for
hospital observation care:
Report G0379 for observation services when a patient is
directly admitted to observation status after being seen
by a physician in the community.
• G0378 needs to be on the same claim for the same date of
service as a G0379.
• Provider bulletin 2016-XX “Observation Guidelines” is
tentatively scheduled to be posting in June 2016 with these
guidelines.
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Guidelines for Observation Services
• Example 12: Claim for Observation Services, RCC 450 with
procedure code 99284, RCC 762 procedure code G0378 and 17
units and RCC 762 procedure code G0379.
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Guidelines for Observation Services
• Example 12 Cont:
• APC grouper returns a SI “N” for Procedure code 99284 and
G0378 and G0379 returns status indicator “J2” Observation
Services Related” and is APC payable.
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Discounts and Outliers
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Discounts and Outliers
• In addition to a base detail APC price, detail pricing can be
impacted by a discount factor and outlier threshold values.
• The Base APC payment amount is calculated first, followed
by adjustments related to the discount factor or an outlier
payment.
• Discount factors returned from the APC grouper will apply
to the detail base payment and could result in a:
1.
decrease,
2.
increase to the Base APC payment or result in
3.
no discount being applied.
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Discounts and Outliers
• The following Discounting Factors are returned from the APC
grouper and will be applied to the detail base APC payment:
Discount Factor
Formula
Description
1*
1.0
No discount applied
2*
(1.0 + D(U-1)/U
The first unit pays at 100%,
additional units pay at 50%.
4
(1+D)/U
Detail results in a payment of
150% of 1 unit.
5*
D
50% discount applied
8
2.0
200% payment of the APC
payment
9
2D/U
Detail results in a payment of
100% of 1 unit.
D = discounting fraction (currently 0.5).
U = number of units.
* Most frequently seen.
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Discounts and Outliers
• Example 1: Discounting Factor 1 – No discount applied, allows
100% of APC.
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Discounts and Outliers
• Example 2: Discounting Factor 2 – The first unit pays at 100%,
additional units pay at 50%.
•.
• When units billed are greater than 1, the percentage of the
APC-based fee will decrease. Using discount factor 2 for
example; 1 unit = 100%, 2 units = 75%, 3 units = 66%, etc.
Base APC Payment = [(Provider Wage Adjusted Conversion Factor *
units) * APC Weight] * Discounting % based on Discount Factor
Base APC Payment = [($91.62*2) * 0.9447] * Discount Percentage
Base APC Payment = $173.11 * 75%
Base APC Payment = $129.83
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Discounts and Outliers
• Example 3: Discounting Factor 5 –Allows 50% of APC payment.
 Base
APC Payment = (Provider Wage Adjusted Conversion
Factor * units) * APC Weight.
 Base
APC Payment = [($91.62*1) * 10.2104] * Discount
Percentage
 Base
APC Payment = $935.47 * 50%
 Base
APC Payment = $467.74
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Discounts and Outliers
• Outlier adjustments ensure that outpatient services with
variable and potentially significant costs do not pose
excessive financial risk to providers.
• Similar to Medicare, in order for an outpatient claim to
qualify for an outlier payment, two thresholds must both be
met:
–Multiple Threshold – The multiple threshold is met when
the cost of furnishing an APC service or procedure
exceeds the APC payment amount based on a defined
multiplier.
–Fixed-Dollar – The fixed-dollar threshold is met when the
cost of furnishing an APC service or procedure exceeds
the APC payment amount plus a fixed amount.
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Discounts and Outliers
• The hospital outlier policy is calculated on a service basis
using both fixed-dollar currently set to $2,900.00 and
multiplier thresholds set at 1.75 to determine outlier
eligibility.
• Outlier adjustment calculations will be applied to all details
on the claim, even when the claim contains multiple dates
of service.
• If the fixed-dollar threshold and multiplier threshold is less
then the total line cost which is calculated based on the
equation (Covered charges * Hospital Cost-to-ChargeRatio) an outlier add-on will apply.
• ((Covered charges * Hospital Cost-to-Charge-Ratio) – 1.75
* APC payment) * 50% = outlier add-on payment.
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Explanation of Benefit Codes
• Provider Manual Chapter 12 – Claim Resolution Guide
−New Explanation of Benefit (EOB) codes for hospital
modernization will be added to provider manual chapter 12.
−The provider manual will provide a detailed description of
the cause of each EOB and more importantly, the necessary
correction to the claim, if appropriate, in order to resolve
the error condition.
−This guide also provides tips by identifying where providers
can go to find additional information to assist with
correcting their claims.
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Explanation of Benefit Codes
• EOB code 0304 “APC - Service considered an inpatient
procedure.”
–Cause
 An
outpatient claim was submitted with an inpatient
procedure code that returned a status indicator C
"Inpatient Procedure". Refer to Addendum E on the
www.cms.gov Web site for a list of procedure codes that
are considered a inpatient procedure.
−Resolution
 Verify
the procedure code submitted on the claim. If it is
incorrect, correct the claim and resubmit. If the patient
expired prior to admission, please verify if the claim was
submitted with modifier CA “Procedure Payable Inpatient.”
If the procedure is correct and the client is not expired, it
is not a payable service when submitted as an outpatient
claim.
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Explanation of Benefit Codes
• EOB code 0304 “APC - Service considered an inpatient
procedure.”
–Cause
 An
outpatient claim was submitted with an incorrect
patient status when billing for an inpatient procedure and
the client is expired.
−Resolution
 Please
verify the patient status on the claim, correct and
re-submit claim.
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Explanation of Benefit Codes
• EOB code 0338 “APC - Service must be billed with procedure
code.”
–Cause
 An
outpatient claim was billed with a service that must
have a procedure code.
−Resolution
 Verify
as to whether the service required a procedure
code. Add the procedure code and resubmit the claim.
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Explanation of Benefit Codes
• EOB code 3013 “Service requires a professional prior
authorization.”
–Cause
 The
outpatient claim was submitted with a procedure code
that requires a professional Prior Authorization (PA) and
there is no PA record on file in an approved status.
−Resolution
 Determine
whether the service billed requires PA by
reviewing the provider fee schedules located at
www.ctdssmap.com. If Prior Authorization is required, the
hospital should verify that the physician obtain PA. If the
physician does not obtain PA, the service is not payable.
CT interChange MMIS
68
Explanation of Benefit Codes
• The PA field will indicate which services require a physician PA
to allow both the physician and the hospital outpatient claim.
CT interChange MMIS
69
Explanation of Benefit Codes
• Reminder:
–EOB code 5077 “Inpatient stay denied due to a paid
outpatient claim within 3 days prior to inpatient admission
and EOB code 5078 “Outpatient claim denied due to a paid
inpatient claim within 3 days after an outpatient claim” post
and pay period ends on July 1, 2016.
• For admissions July 1, 2016 and after the outpatient or
inpatient claim will begin to deny with either EOB code 5077 or
5078.
CT interChange MMIS
70
Remittance Advice
CT interChange MMIS
71
Remittance Advice
• New look to Remittance Advice (PDF).
CT interChange MMIS
72
NCCI/MUE
CT interChange MMIS
73
NCCI/MUE
• To comply with federal legislation, DSS has adopted the Centers
for Medicare and Medicaid Services (CMS) National Correct
Coding Initiative (NCCI) standard payment edits. With the
hospitals moving to payment via HCPCS and CPT codes, the
hospital will be subject to NCCI edits.
• The NCCI edits are designed to promote correct coding and to
control improper coding that could lead to inappropriate
payments.
–Medically unlikely edits (MUE) - MUE edit occurs when a
provider bills more than the maximum units of service for a
HCPCS/CPT code than would be reported under most
circumstances for a single beneficiary on a single date of
service. For codes if the incorrect units will deny with EOB
code 770 “MUE Units Exceeded”; however, billing with
appropriate modifiers on multiple lines could allow additional
units to pay.
CT interChange MMIS
74
NCCI/MUE
−A complete list of the modifiers has been added to the
Hospital Provider Manual chapter 8 “Provider Specific Claims
Submission Instructions” found on the www.ctdssmap.com
Web site or they can be found on the CMS Web site
www.cms.gov.
• Quarterly MUE updates are published and available to the
hospitals, please refer to refer to the CMS MUE tables by
clicking on the link below to obtain published quarterly
additions, deletions, and revisions.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Data-and-Systems/National-Correct-Coding-Initiative.html
CT interChange MMIS
75
NCCI/MUE
− Procedure-to-procedure (PTP) edits define pairs of
HCPCS/CPT codes that should not be reported together on
the same date of service for a variety of reasons and prevent
reimbursement for both procedures.
• Visit the CMS Web site
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitE
d/index.html for:
–Instructions on how to use NCCI.
–How to locate the NCCI Tables Manual.
–How to look up PTP code edits.
–Use of bypass modifiers.
CT interChange MMIS
76
NCCI/MUE
–Medicaid NCCI procedure-to-procedure edits have a single
column 1/column 2 correct coding edit (CCE) file.
• For some code pairs when indicated by modifier 1 “Allowed”, a
modifier may be used to bypass CCE.
CT interChange MMIS
77
Hospital Billing Changes
CT interChange MMIS
78
Hospital Billing Changes – RCC Updates
Effective July 1, 2016:
• Outpatient hospitals should bill
• Outpatient hospitals should no
RCC
RCC*
Descriptions
the following therapy RCCs:
Description
longer bill the following
therapy RCCs:
421
Physical Therapy visit
420
Physical Therapy
423
Physical Therapy Group
422
Physical Therapy/Hour
424
Physical Therapy Evaluation
429
Other Physical Therapy
431
Occupational Therapy visit
430
Occupation Therapy
433
Occupational Therapy Group”
432
Occupation Therapy/Hour
434
Occupational Therapy Evaluation
439
Other Occupation Therapy
441
Speech Therapy visit
440
Speech Pathology
443
Speech Therapy Group
442
Speech Pathology /Hour
444
Speech Therapy Evaluation
449
Other Speech Pathology
*However, these RCCs will still be accepted from Medicare on a Medicare
crossover claim.
CT interChange MMIS
79
Hospital Billing Changes – RCC Updates
• While the rate and payment method is staying the same there
are additional billing requirements related to the following
therapy CPT/HCPCS codes should be billed with either the
following physical therapy RCCs; 421 “Phys Therapy visit”, 423
“Phys Therapy Group” and 424 “Phys Therapy Evaluation” or
occupation therapy RCCs; 431 “Occup Therapy visit”, 433
“Occup Therapy Group” and 434 “Occup Therapy Evaluation”:
CT interChange MMIS
80
Hospital Billing Changes – RCC Updates
• Speech Therapy CPT/HCPCS to RCC restrictions. The following
speech therapy CPT/HCPCS codes should only be billed with one
of the following RCCs; 441 “Speech Therapy visit”, 443 “Speech
Therapy Group” and 444 “Speech Therapy Evaluation”:
• The following CPT/HCPCS codes are limited to RCC 771 “Vaccine
Administration”:
CT interChange MMIS
81
Hospital Billing Changes – RCC Updates
• The following CPT/HCPCS codes are limited to RCC 401
“Diagnostic Mammography”:
77051
77055
77056
G0204
• The following CPT/HCPCS codes are limited to RCC 403
“Screening Mammography”:
77052
77057
G0202
CT interChange MMIS
82
G0206
Hospital Billing Changes – RCC Updates
• Behavioral Health CPT/HCPCS to RCC restrictions:
Billable CPT/HCPC
RCC
901
905
906
907
913
900
914
915
916
919
Description
Electroshock Therapy
Intensive Outpatient Program (IOP) - MH
Intensive Outpatient Program (IOP) - SA
Extended Day Treatment (EDT)
Partial Hospitalization Program (PHP)
Psych Treatment
Individual Therapy
Group Therapy
Family Therapy
Other BH (Med Management)
H0031, H0032, H2014, 0359T,
H0046 and H0032 with modifier TS
919
Other BH (Autism)
96101, 96116, and 96118
918
Psychiatric Testing
90870
S9480
H0015
H2012
H0035
90791,90792 and 90785
90832-90838
90853
90846, 90847, 90849
99201- 99205, 99211 - 99215
• These updates are published under provider manual chapter 8
“Hospitals”.
CT interChange MMIS
83
Hospital Billing Changes – Billing Claims
• Hospitals are reminded all outpatient services for a single date
of service must be billed on one claim to process using CMAP
OPPS methodology.
–Except multiple Outpatient Hospital E/M Encounters on the
Same Date can be billed on a different claim. These claims
would require the modifier 27 and the condition code G0 if
billing same department.
–If the hospital needs to submit late changes they should
adjust the original claim and add those additional late
services.
 Hospitals
should not be billing late charges on a separate
claim, in most cases, the subsequent claim will deny.
CT interChange MMIS
84
Hospital Billing Changes – Billing Claims
• For DOS 7/1/2016 and forward, hospitals will no longer need to
lump the total charges under the first NDC code and then enter
zero charge in the additional RCC line with the NDC codes.
Previous billing instructions:
Example
DOS
RCC
Units
NDC Code
00264196510
Procedure
Code
J3490
Billed
Amt.
$750
9/1/2015
250
1
9/1/2015
250
1
63323030201
J3490
$500
9/1/2015
250
2
00264196510
J3490
$1250
9/1/2015
250
1
63323030201
J3490
$0
Change to
• Hospitals can bill the same RCC code (i.e. RCC 250) on multiple
details with different National Drug Codes (NDCs), but with the
same HealthCare Common Procedure Coding System (HCPCS)
code (i.e. J3490) on multiple detail lines.
CT interChange MMIS
85
Upcoming Changes
CT interChange MMIS
86
Upcoming Changes – Prior Authorization
• Prior Authorization (PA) will continue to be required for services
specified by DSS. There will be no changes in prior
authorization for lab, physical therapy, occupational therapy
and speech pathology.
• Behavioral Health Services will continue to require PA, but the
CT Behavioral Health Partnership will begin to authorize services
based on procedure codes for some RCCs.
• Effective for dates of service July 1, 2016 and forward, the CPT
codes for nuclear cardiology procedures will no longer require
prior authorization for HUSKY A, B, C, D and limited eligibility
members. Refer PB 2016-16 “Changes to Prior Authorization
Requirements for Advanced Imaging and Nuclear Cardiology
Services” for a list of procedure codes.
CT interChange MMIS
87
Upcoming Changes – Prior Authorization
• Effective for dates of service July 1, 2016 and forward,
advanced imaging procedures will no longer require PA for
HUSKY A, B, C, D and limited eligibility members who are 18
years of age and under at the time of service for Computed
Tomography (CT) - Computed Tomographic Angiography (CTA),
Magnetic Resonance Imaging (MRI), Magnetic Resonance
Angiography (MRA), Positron Emission Tomography
(PET)/Computed Tomography (CT).
–The list of procedure codes that no longer require PA under
PB 2016-16 “Changes to Prior Authorization Requirements for
Advanced Imaging and Nuclear Cardiology Services.”
CT interChange MMIS
88
Hospital Modernization Web Page
CT interChange MMIS
89
Hospital Modernization Web Page
• Comprehensive information on CT OPPS can be found on the
“Hospital Modernization” page on the Web site
www.ctdssmap.com. Please refer to this page often, as this
will be continue to be updated throughout the year.
• The link has two options - “Inpatient Payment Methodology”
and “Outpatient Payment Methodology”.
• The Web page has been updated and includes Quick links,
CMAP’s version of CT Addendum B, Provider Type and Specialty
to RCC crosswalk, DRG Provider Publications, Hospital
Modernization FAQs, Important Messages, Provider Manual
updates, Provider Training, and Contact Information.
• CT Addendum B will be updated periodically, please always
refer to the most current version for your date of service.
CT interChange MMIS
90
Hospital Modernization Web Page
• The Web page will be continuously updated throughout the
year. Please refer to this page periodically for any updates.
CT interChange MMIS
91
Hospital Modernization Web Page
• The Web page will be continuously updated throughout the
year. Please refer to this page periodically for any updates.
CT interChange MMIS
92
Questions
• Where to go for more information: www.ctdssmap.com
–Hospital Modernization Web Page.
–Provider Bulletins:
 2015-87
“Outpatient Hospital Modernization –
Outpatient Prospective Payment System (OPPS)”
 2016-25
“Update Regarding Outpatient Hospital
Modernization - Outpatient Prospective Payment System
(OPPS)”
 2016-XX
“Observation Guidelines”*
 2016-XX
“Outpatient Hospital Modernization –
Behavioral Health Services” *
*A tentative target date for the posting of these new bulletins
is June 2016.
CT interChange MMIS
93
Questions
–Provider Manuals
 New
Chapter 7 “Hospital Outpatient: New Requirements
Eff, 7-1-16”.
 Updates
to Chapter 8 and Chapter 12.
• Email address to submit questions related to Hospital
Modernization, [email protected].
• DSS Reimbursement Home Page:
http://www.ct.gov/dss/cwp/view.asp?a=4598&q=538256
• Provider Assistance Center (PAC): Monday through Friday, 8
a.m. to 5 p.m. (EST), excluding holidays:
–1-800-842-8440
–1-800-688-0503 (EDI Help Desk)
CT interChange MMIS
94
Questions
• Questions & Answers
CT interChange MMIS
95