1 / 45

DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Outpatient Prospective Payment System Billing G

DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Outpatient Prospective Payment System Billing Guide May 2005. OPPS. Montana Medicaid uses Medicare’s Outpatient Prospective Payment System since August 2003

adamdaniel
Télécharger la présentation

DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Outpatient Prospective Payment System Billing G

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Outpatient Prospective Payment System Billing Guide May 2005

  2. OPPS • Montana Medicaid uses Medicare’s Outpatient Prospective Payment System since August 2003 • Medicaid uses a Montana specific conversion factor and updates quarterly along with Medicare • Medicaid deviates from Medicare in some cases (I.e. therapies, obstetric observation, inpatient only) • Payment is lower of OPPS payment (fees and APCs) or your charges • Charge cap does not apply to line level • Appropriate and accurate coding is the key to proper reimbursement under OPPS

  3. OPPS/APC • Some services paid by fee schedule • Therapies (speech, physical, occupational) • Laboratory • Diagnostic • If there is no APC, Medicare fee or Medicaid fee (RBRVS), some services pay hospital specific outpatient cost to charge ratio • Drugs and Biologicals • Devices • Ambulatory Payment Classification • Payment based on CPT/HCPCS codes • Status Indicator tells the method of payment • Each service is eligible for potential payment • Emergency room • Treatment Room • Provider-based clinic • Cancer care • Ambulatory Surgery • Capture every charge every time to insure payment

  4. APC Status Indicators • C – Inpatient only services • G – Drugs & biologicals paid by report (hospital specific outpatient cost to charge ratio) • H – Devices paid by report • K – Drugs and biologicals paid by APC • M – Paid by a Medicaid specific fee or not a covered service (fee schedule will show as not allowed) • N – Service is bundled into an APC (If all your codes are N on your claim, your claim will pay at zero)

  5. APC Status Indicators (con’t) • Q – Lab fee schedule (60% for non-sole community, 62% for sole community) • S – Significant procedure paid by APC that the multiple procedure discount DOES NOT apply to • T – Significant procedure paid by APC that the multiple procedure discount DOES apply to • V – Medical visits in the clinic, critical care or emergency department (includes codes for direct admits) • X – Ancillary services paid by their own APC • Y – Medicaid fee for therapies (90% of RBRVS office fee)

  6. 0-Bundled code pays zero 1-Priced using QMB Pricing 2-Lab panel bundled 4-Priced using RBRVS 5-Anesthesia pricing 7-APC priced 8-APC priced 9-Lower level screening fee A-Manually priced B-By report C-Maximum fee D-Percent of charges E-Reimbursement Rate G-Billed Charges H-Denied I-Medicare Coins and deductible K-Medicare allowed amount M-Medicare prevailing P-DRG R-DRG w/cost outlier U-DRG priced by proration V-Mid-level priced Z-ATP Bundled Allowed Charge Source Codes• Allowed Charge Source codes tell MMIS how to price a claim-this is what PR sees

  7. HOSPITAL OUTPATIENT MODIFIERS Medicaid uses Medicare Outpatient Claim Edits Medicaid does not allow reporting separate codes for related services when there is 1 code that includes all related services Medicaid does not allow breaking out bilateral procedures when 1 code is appropriate

  8. OPPS Modifiers • The paper UB-92 can accommodate 1 modifier • The 837 can accommodate 4 modifiers • Always report the payment modifier 1st as Medicaid processes the claim using only the first modifier

  9. OPPS Modifiers • Modifiers are used to indicate that: • A service was provided more than once • A bilateral procedure was performed • A service or procedure has been increased or reduced • Only part of a service was performed • A distinct procedure was performed • A service was discontinued

  10. Common Outpatient Modifiers • Level I Modifiers • 25 – significant separate E&M service • 27 – multiple E&M same day • 50 – bilateral procedure • 52 – reduced services • 58 – staged or related service • 59 – distinct procedure • 73 – procedure terminated prior to anesthesia • 74 - procedure terminated after anesthesia • 76 – repeat procedure by same physician • 77 – repeat procedure by another physician • 91 – repeat clinical diagnostic lab test

  11. Modifiers More Modifiers • Level II Modifiers • LT – left side • RT – right side • LC – left circumflex coronary artery • LD – left anterior descending coronary artery • RC – right coronary artery • GN – service under speech language pathology plan of care • GO - service under occupational therapy plan of care • GP - service under physical therapy plan of care

  12. Modifiers Approved for Hospital Outpatient Use • 25-significant, separately identifiable E&M service by the same physician on the same day • Only used with E&M codes 92002-92014, 99201-99499, G0101, G0175 & G0264 • The Outpatient Code Editor (OCE) only requires the modifier if procedures with a status of “T” or “S” are present

  13. Modifiers Approved for Hospital Outpatient Use • 27-multiple outpatient hospital E&M encounters on the same day • Only used with E&M codes 92002-92014, 99201-99499, G0101, G0175 & G0264 • Use on the second E&M code for the same date of service

  14. Modifiers Approved for Hospital Outpatient Use • 50 – Bilateral Procedure • Used to report bilateral procedures performed at the same operative session • Bill one line with the procedure code • RT & LT are not used when 50 is used • DO NOT use if the code description indicates “bilateral”

  15. Modifiers Approved for Hospital Outpatient Use • 59 – Distinct Procedural Service • Used to report two procedures that are not normally reported together • Different session or patient • Different procedure or surgery • Different site or organ system • Separate incision • Separate injury that is not normally encountered or performed by the same physician on the same day

  16. Modifiers Approved for Hospital Outpatient Use • 76- Repeat procedure by same physician • 77- Repeat procedure by another physician • Use 76 to indicate that a procedure or service was repeated in the same session on the same day by the same physician • Use 77 to indicate that a procedure performed by one physician had to be repeated in a separate session on the same day by another physician • Attach modifier to the second procedure • Enter the number of times the procedure was repeated in the unit column • Can be used for procedures performed by the physician or performed by the technician (e.g., EKGs)

  17. Modifiers Approved for Hospital Outpatient Use • 91- Repeat Clinical Diagnostic Lab • Use when the same lab test is repeated on the same day to obtain subsequent test results • Do not use when tests are re-run to confirm initial results, when there were testing problems with specimens or equipment or for any other reason when a one-time result is all that is required • Attach modifier to the second lab test • Enter the number of times the subsequent lab test was done in the unit column

  18. Observation Services • Four qualifying conditions for payment • Chest Pain • Asthma • Congestive Heart Failure • Obstetric Complications (pre-delivery complications) • Starting April 1, 2005, the qualifying diagnosis must be in either: • Admitting diagnosis (FL 76); or • Principal diagnosis (FL 67)

  19. Observation Services • Medicare/Medicaid Rules • OBS services must be reasonable and necessary • There must be a physician order prior to initiation • Physician order must be by a physician with privileges • Physician must be actively directing patient care • During OBS, patients must be actively assessed • Observation is not a substitute for inpatient • Observation is not for continuous monitoring • Observation is not for patients waiting for NH placement • Observation is not to be used for convenience or as routine prior to IP status

  20. Observation Services • Four ways to reimbursement • Direct admit for qualifying condition pays observation (APC 339-$342.11) • ED, clinic or critical care admit for qualifying condition pays observation (APC 339-$342.11) • Direct admit for non-qualifying condition pays APC 600 (Low Level Clinic Visit-$43.13) • ED, clinic or critical care admit for a non-qualifying condition pays APC 600 (Low Level Clinic Visit-$43.13) • Also pays any other separately payable codes on the claim

  21. Qualifying Observation Requirements • Chest Pain • Required Diagnosis: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 786.05, 786.50, 786.51, 786.51, 786.59 • These diagnostic tests are NO LONGER REQUIRED: 2 sets of cardiac enzymes (either two CPK 82550, 82552, or 82553) or two troponin (84484 or 84512) and two sequential electrocardiograms • Asthma • Required Diagnosis: 493.01, 493.02, 493.11, 493.12, 493.21, 493.22, 493.91, 493.92 • These diagnostic tests are NO LONGER REQUIRED: A breathing capacity test (94010) or pulse oximetry (94760 or 94761 or 94762)

  22. Qualifying Observation Requirements • Congestive Heart Failure • Required Diagnosis: 391.8, 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.33, 428.30, 428.31, 428.31, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 • These diagnostic tests are NO LONGER REQUIRED: A chest x-ray (71010, 71020 or 71030) and an electrocardiogram (93005) and pulse oximetry (94760, 94761, or 94762)

  23. Qualifying Observation Requirements • Obstetric Complications (Pre-delivery) • Required Diagnosis: • 640.00, 640.03, 640.80, 640.83, 640.90, 640.93, 644.00, 644.03, 644.10, 644.13, 630.00, 631.00, • 641.03, 641.13, 641.23, 641.30, 641.33, 641.83, 641.93, 642.03, 642.13, 642.23, 642.33, 642.43, • 642.50, 642.53, 642.60, 642.63 642.70, 642.73, 642.93, 643.00, 643.03, 643.10, 643.13, 643.20, • 643.23, 643.80, 643.83, 643.90, 643.93, 644.20, 645.13, 645.23, 646.03, 646.10, 646.13, 646.20, • 646.23, 646.33, 646.43, 646.53, 646.60, 646.63, 646.70, 646.73, 646.80, 646.83, 646.93, 647.03, • 647.13, 647.23, 647.33, 647.43, 647.53, 647.63, 647.83, 647.93, 648.03, 648.13, 648.23, 648.33, • 648.43, 648.53, 648.63, 648.73, 648.83, 648.93, 651.03, 651.13, 651.23, 651.33, 651.43, 651.53, • 651.63, 651.83, 651.93, 652.03, 652.13, 652.23, 652.33, 652.43, 652.53, 652.63, 652.73, 652.83, • 652.93, 653.03, 653.13, 653.23, 653.33, 653.43, 653.53, 653.63, 653.73, 653.83, 653.93, 654.03, • 654.13, 654.23, 654.33, 654.43, 654.53, 654.63, 654.73, 654.83, 654.93, 655.03, 655.13, 655.23, • 655.33, 655.43, 655.53, 655.63, 655.73, 655.83, 655.93, 656.03, 656.13, 656.23, 656.33, 656.43, • 656.53, 656.63, 656.73, 656.83, 656.93, 657.03, 658.03, 658.13, 658.23, 658.33, 658.43, 658.83, • 658.93, 659.03, 659.13, 659.23, 659.33, 659.43, 659.53, 659.63, 659.73, 659.83, 659.93, 660.03, • 660.13, 660.23, 660.33, 660.43, 660.53, 660.63, 660.73, 660.83, 660.93, 661.03, 661.13, 661.23, • 661.33, 661.43, 661.93, 662.03, 662.13, 662.23, 662.33, 663.03, 663.13, 663.23, 663.33, 663.43, • 663.53, 663.63, 663.83, 663.93, 665.03, 665.83, 665.93, 668.03, 668.13, 668.23, 668.83, 668.93, • 669.03, 669.13, 669.23, 669.43, 669.83, 669.93, 671.03, 671.13, 671.23, 671.33, 671.53, 671.83, • 671.93, 673.03, 673.13, 673.23, 673.33, 673.83, 674.03, 675.03, 675.13, 675.23, 675.83, 675.93, • 676.03, 676.13, 676.23, 676.33, 676.43, 676.53, 676.63, 676.83, 676.93, 792.3, 796.5, V28.0, • V28.1, V28.2, V61.6

  24. Billing for Obstetric Observation • Direct Admit for Qualifying Condition • Revenue Code 762 with G0263 • Units = 1, charges are necessary on this line (even $1) • DO NOT BILL USING G0244 • Must have qualifying diagnosis for Obstetric Complications (pre-delivery complications) • If qualifying condition is obstetric complications, you must also have a 2nd revenue code 762 with 99234, 99235,or 99236 • Units = 1-72, must have actual charges on this line

  25. Billing for Obstetric Observation • ED, Clinic or Critical Care Admit for Qualifying Condition • DO NOT BILL USING G0244 • Must have qualifying diagnosis code for Obstetric Complications (pre-delivery complications) • Must bill either an ED visit with rev code 45X or a clinic visit with rev code 51X or critical care visit • Must use modifier 25 with the E&M code for the visit • If qualifying condition is obstetric complications, you must also have a 2nd revenue code 762 with 99234, 99235 or 99236 • Units = 1-72, actual charges are necessary on this line

  26. Billing for Other Covered Observation Services • Direct Admit for Qualifying Condition • Revenue Code 762 with G0263 • Units = 1, charges are necessary on this line (even $1) • Revenue Code 762 with G0244 • Units = 8-72, actual charges must be on this line • Must have Medicare required tests for Chest Pain, Asthma or Congestive Heart Failure under appropriate revenue codes or must have qualifying diagnosis for Obstetric Complications • G0244 is the code that drives payment. G0244 is not payable if billed with services that have a status indicator of “T” (other than 90780) • If qualifying condition is obstetric complications, you must also have a 3rd revenue code 762 with 992XX (99217-99220 or 99243-99236) • Units = 1, charges are necessary in this field (even $1)

  27. Billing for Other Covered Observation Services • ED, Clinic or Critical Care Admit for Qualifying Condition • Revenue Code 762 with G0244 • Units = 8-72, actual charges MUST be on this line • Must have Medicare required tests for Chest Pain, Asthma or Congestive Heart Failure under appropriate revenue codes or must have qualifying diagnosis code for Obstetric Complications • Must bill either an ED visit with rev code 45X or a clinic visit with rev code 51X or critical care visit • Must use modifier 25 with the E&M code for the visit • If qualifying condition is obstetric complications, you must also have a 2nd revenue code 762 with 992XX (99217-99220 or 99243-99236) • Units = 1, charges are required on this line (even $1) • G0244 is the code that drives payment. G0244 is not payable if billed with services that have a status indicator of “T” (other than 90780)

  28. Billing for Other Covered Observation Services • Direct Admit for Non-Qualifying Condition • Revenue Code 762 with G0264 • Units = 1 (one), actual charges MUST be on this line • Must have 762 with 992XX (99217-99220 or 99243-99236) for all non-qualifying conditions • Units = hours, charges are necessary (even $1) • If there are other services on the claim with status codes of “S” or “T” you must use modifier 25 with G0264

  29. Billing for Other Covered Observation Services • ED, Clinic or Critical Care Admit for Non-Qualifying Condition • Revenue Code 45X or 51X with the appropriate CPT code • Units = 1 (one), actual charges MUST be on this line • Must have 762 with 992XX (99217-99220 or 99243-99236) for all non-qualifying conditions • Units = hours, charges are necessary on this line (even $1) • The OCE requires modifier 25 if procedures with a status of “T” or “S” are present

  30. Outpatient Lab • Clinical diagnostic laboratory services including automated multichannel test panels (commonly referred to as "ATPs") and lab panels are reimbursed on a fee basis • The fee for a clinical diagnostic laboratory service is the lesser of the provider's charge or the applicable percentage of the Medicare fee schedule as follows: • 60% of the prevailing Medicare fee schedule where a hospital laboratory acts as an independent laboratory, i.e., performs tests for persons who are non-hospital patients; • 62% of the prevailing Medicare fee schedule for a hospital designated as a sole community hospital or • 60% of the prevailing Medicare fee schedule for a hospital that is not designated as a sole community hospital

  31. Outpatient Lab • For clinical diagnostic laboratory services where no Medicare fee has been assigned, the fee is 62% charges for a hospital designated as a sole community hospital or 60% of charges for a hospital that is not designated as a sole community hospital • Specimen collection is reimbursed $3.00 for drawing a blood sample through venipuncture or for collecting a urine sample by catheterization. • No more than one collection fee is allowed for each patient visit, regardless of the number of specimens drawn. • Crossover claims are not subject to lab panel bundling logic

  32. Outpatient Lab Bundling • If a claim has procedure codes that bundle to multiple lab panels, the program will bundle the codes into a regular panel (if all the codes are present) • The remaining codes will bundle into an ATP • The OB panel (80055) pays a fee schedule price of $44.69 for both non-sole and sole community hospitals • The General Health panel (80050) pays a fee schedule price of $56.77 for both non-sole and sole community hospitals • Lower of pricing applies to bundling. • If the total billed charge for all bundled lines on the claim is less than the allowed charge for the lab panel, the claim pays the billed charge

  33. Outpatient Lab Reimbursement • Allowed Charge Source codes tell ACS and the Department how the system reimbursed your lab claim • 2 is Panel bundled • 7 or 8 are APC • A is manually priced • M is Medicare fee • Z is ATP bundled • If the allowed chg source code on the line is 7, 8 or A the line is excluded from bundling • If the line has a modifier of 76 or 91 the line is excluded from bundling • Bundling only occurs on procedures with the same date of service

  34. Outpatient Lab Reimbursement • For multi-procedure panels, the highest number of tests is priced first. • For example, 80438 is 84443x3 and 80439 is 84443x4. These lines would group to panel 80439 if 4 tests are present rather than panel 80438 and 1 individual 84443. • System logic always bundles to the highest level. • If the procedure code is a component of a Panel or ATP, the system prices to APCs 1st, Lab Panel 2nd , ATPs 3rd and individual fees last.

  35. Outpatient Lab Billing • You need to bill one line with the procedure code and multiple units. If you bill the same code on more than 1 line, your remittance advice will show the bundled payment on the 1st line and will show the additional lines as denied (even though they did not) • Lines that have been bundled will show reason code 042 and remark code M75 • The remittance advice will NOT show the panel or ATP code to which the lines bundled • The current remittance advice shows revenue codes for UB-92 claims, it does not display the procedure codes that bundled

  36. Tidbits ***

  37. ED Definitions • “Emergency Medical Condition” means • A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part; or

  38. More ED definitions • That there is inadequate time to effect a safe transfer to another hospital before delivery; or • With respect to a pregnant woman who is having contractions: • That transfer may pose a threat to the health of safety of the woman or the unborn child. • Some intoxicated individuals may meet the definition. • Individuals expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would meet the definition.

  39. Common Claim Edits • 102 – Duplicate claim • 112 – A readmission has been detected • 119 – Claim is for a potentially unbundled service • 120 – Date of service is more than 365 days from date received • 215 – Claim should pay by APC or OPPS but system could not group. These hit for 4 reasons: • Invalid bill type (usually you see 851 which should be 131) • Bad date- the span date doesn’t match the line dates • There is no APC to group to (department boo-boo) • Revenue code 636 is used wrong-this rev code can only be used for RX or vaccination codes, not for the injections • 280 (physician claim) - diagnosis code or procedure code is not on emergent list • 335 – Procedure code requires review (unlisted code)

  40. Common Claim Edits • 342 – Diagnosis code requires a review (these are almost always V codes) • 343 – Diagnosis code may not be a covered service • 345 – Sterilization review • 347 – Hysterectomy review • 370 – Abortion review • 371 – DRG = 468 (this DRG pays % of charges so is always reviewed for correct coding) this means that there was a procedure on the claim that was not related to the main diagnosis and procedures • 460 – Claim requires a prior authorization

  41. Common Claim Edits • 472 – This exception will post when the PASSPORT provider number is missing or invalid • 487 – This edit will fail when the client is a Team Care client and the Team Care provider did not submit the claim or did not refer the client and the service requires PASSPORT approval • 905 – Line dates of services are inconsistent with the header level dates of service or the line level date of service is blank (usually see on bundled claims) • 920 – Diagnosis code and procedure don’t match- this means that a claim hit before or after the new quarterly grouper was installed and a diagnosis code on the claim now needs a fifth digit or is invalid or the provider used an invalid diagnosis code • 928 – Inpatient only services performed in an outpatient setting-needs review to determine if appropriate • 929 – E&M code on the same date as a surgical or significant procedure without modifier 25 or 27 present on the E&M code (must be on the E&M code – not on the code with a SI of T or S)

  42. The ICN • Format: R YY JJJ MM BBB SSSSSS • R = Type of medium on which claim came into system • 0=paper • 2=electronic • 4=system generated (usually an adjustment) • YY = Year • JJJ = Julian Date • MM=Microfilm machine number • 00=electronic • 11=paper claims • 22=system generated

  43. More ICN • BBB=Batch range • 100 and 900=pharmacy • 200=HCFA 1500 • 300=UB92 Inpatient • 350=UB92 outpatient • 375=UB92 Laboratory • 400=Nursing Home • 500=Dental • 600=Institutional Crossover • 700=Professional Crossover (799=electronic x-over) • 800=Adjustments • SSSSSS=Sequence Number

  44. Resources • www.mtmedicaid.org • www.cms.hhs.gov/providers/hopps/cciedits/ • www.cms.hhs.gov/providers/hopps Addendums A & B • www.cms.hhs.gov/manuals/transmittals/ • Program Memorandum Transmittal A-01-80 • Program Memorandum Transmittal A-03-066 • Medicare Part A Hospital Bulletin 905 • Medicare Part A Hospital Bulletin 1187 • Medicare Part A Hospital Bulletin 1149 • Medicare Part A Hospital Bulletin 1242 • Medicare Part A Hospital Bulletin 1313 • Med-Manual §3112.8 Outpatient Observation Services • Transmittal R404CP • Medlearn Matters Article MM3610

  45. Contacts • Debra Stipcich, Transplant and PPS Hospital Program Officer; (406) 444-4834; dstipcich@mt.gov • Rena Steyaert, Claims Resolution Specialist; (406) 444-7002; rsteyaert@mt.gov • ACS, Inc. Provider Relations; (800) 624-3958 in-state; (406) 442-1837 out of state

More Related