Hospital Modernization Workshop Presentation 2016
Transcription
Hospital Modernization Workshop Presentation 2016
Hospital Modernization Workshop Presented by The Department of Social Services & Hewlett Packard Enterprise 1 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 CT interChange MMIS 2 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. CT interChange MMIS 3 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. CT interChange MMIS 4 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. CT interChange MMIS 5 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. CT interChange MMIS 6 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. CT interChange MMIS 7 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. CT interChange MMIS 8 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”. CT interChange MMIS 9 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. CT interChange MMIS 10 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”. CT interChange MMIS 11 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. CT interChange MMIS 12 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”. CT interChange MMIS 13 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. CT interChange MMIS 14 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. CT interChange MMIS 15 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. CT interChange MMIS 16 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. – CT interChange MMIS 17 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 CT interChange MMIS 18 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. CT interChange MMIS 19 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. CT interChange MMIS 20 Reimbursement Methodology CT interChange MMIS 21 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. CT interChange MMIS 22 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”. CT interChange MMIS 23 Reimbursement Methodology - CT Fee Schedules CT interChange MMIS 24 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. CT interChange MMIS 25 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. CT interChange MMIS 26 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. CT interChange MMIS 27 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. CT interChange MMIS 28 Reimbursement Methodology - Fixed Fee Based on RCC • Example: Fixed fee based on RCC – RCC 424 procedure code 97001 and 421 procedure code 97002. CT interChange MMIS 29 Claim Examples CT interChange MMIS 30 Claim Examples • Example 1: Payment type “APC” procedure code 99283 “Emergency dept visit ”, on CT Addendum B. CT interChange MMIS 31 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 CT interChange MMIS 32 Claim Examples • Example 2: Payment type “APC” with a status indicator of J2 and N “Packaged” procedure code 99283 and A4206. CT interChange MMIS 33 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. CT interChange MMIS 34 Claim Examples • Example 3: Payment type “APC” with SI “Q4”. Procedure codes 81015 and 85018, with procedure code 99283. CT interChange MMIS 35 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. CT interChange MMIS 36 Claim Examples • Example 4: Payment type “APC” with RCC 450 and procedure code 99283 and RCC 981 with procedure code 99284. CT interChange MMIS 37 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. CT interChange MMIS 38 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”. CT interChange MMIS 39 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. CT interChange MMIS 40 Claim Examples • Example 6: Payment Type – APC - PR –Procedure code 90675 and J3145. CT interChange MMIS 41 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”. CT interChange MMIS 42 Claim Examples • Example 7: Payment Type – APC – FS procedure code 36415 and 80047. Allows at CT Lab Fee Schedule. CT interChange MMIS 43 Claim Examples • Example 8: Payment Type - FS - procedure code 78267. CT interChange MMIS 44 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. CT interChange MMIS 45 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.” CT interChange MMIS 46 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.” CT interChange MMIS 47 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. CT interChange MMIS 48 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) CT interChange MMIS 49 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). CT interChange MMIS 50 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. CT interChange MMIS 51 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. CT interChange MMIS 52 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. CT interChange MMIS 53 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. CT interChange MMIS 54 Discounts and Outliers CT interChange MMIS 55 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. CT interChange MMIS 56 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. CT interChange MMIS 57 Discounts and Outliers • Example 1: Discounting Factor 1 – No discount applied, allows 100% of APC. CT interChange MMIS 58 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 CT interChange MMIS 59 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 CT interChange MMIS 60 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. CT interChange MMIS 61 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. CT interChange MMIS 62 CT interChange MMIS 63 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. CT interChange MMIS 64 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. CT interChange MMIS 65 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. CT interChange MMIS 66 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. CT interChange MMIS 67 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