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Hospital, ASC, and PRTF Billing Training 2018
Presented by Field Representatives
Kinzie Baker &
Liz Lovell-Poynor
Wyoming Medicaid General Manual
Chapter 1- General Information
Chapter 2-Getting Help When You Need It
Chapter 3-Provider Responsibilities
Chapter 4-Utilization Review
Chapter 5-Client Eligibility
Chapter 6-Common Billing Information
Chapter 7- Third Party Liability
Chapter 8-Electronic Data Interchange (EDI)
Chapter 9-Wyoming HIPPA Electronic Specifications
Chapter 10-Important Information
Provider Notifications
RA Banner
RA Payment Summary
* Bulletins
Provider Contact
It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information. Why it is important to update provider contact information?
o To receive up-to-date policy information o Receive updates when Medicaid needs a copy of your new license o Any other communication which needs to occur between Wyoming Medicaid
and providers To update your provider contact information, please do the following:
o Email, mail a request on office letterhead and include the following: NPI/Provider number & Name Provide contact information Update needed
Physical, correspondence, or financial address, provider phone or fax number, or email addresses on file
Date this change needs to go into effect Pay-to Providers can also update their contact information by logging into the
Provider Web Portal and going to “Update Provider Demographics” Email addresses on file can also be updated by speaking to a representative at
Provider Relations by calling 800.251.1268 options 1, 5, and then 0.
Quick Reference
When to write for help
Online resources
https://wymedicaid.portal.conduent.com/
Requesting a provider training visit
Getting Help
Provider Responsibilities
Eligibility
When can a client be billed?
Issues most commonly heard in call center:
Clients requested to troubleshoot claims or check PA status
Client billed or sent to collection
Billing and coding questions
Recordkeeping
Notes
Common Billing Information
Service Thresholds
Under 21
Over 21
NDC Conversion
Attachments
See Web Portal Tutorial
Adjustments and Voids
Sterilization, Hysterectomy and Abortion Consent Form
Requesting Replacement RA’s
Timely Filing
Telehealth
Attachment Troubleshooting
Paper-Attachment Cover Sheet
TCN
How to get the TCN
ACN (Attachment Control Number)
Electronic Attachments
How to complete
Common Attachment Issues: Incomplete
ACN does not match
Legibility issues
Information on form does match claim
Rendering/treating provider listed as Pay-to
No Attachment indicated on claim
Adjustments & Voids
Paper Complete all required
information Attach corrected clean claim
and indicate on form Included all attachments
originally sent
Electronic How to complete
6-Adjustment 7-Replacement
Common Issues: All lines not included on
electronic adjustment
No changes made to the claim
Too many changes being made
Not all corrections made
Not attaching supporting documents
Notes
Third Party Liability
Third Party Payers
Unreported coverage
Provider not enrolled/No Opt out option
How to indicate TPL on a claim
Medicare/ No Opt out option
Outpatient Services
For ASCs, Critical Access Hospitals, & General Hospitals
Reimbursement is based off of OPPS – a Medicare based outpatient hospital reimbursement methodology.
For Critical Access Hospitals, General Hospitals, and ASCs
Not all codes covered by Medicare will be covered by Medicaid
If a code isn’t covered by WY Medicaid, providers may submit an appeal to Medical Policy requesting it to be reviewed.
Outpatient Policies
All services provided by the hospital/ASC on the same day must be billed on a single claim Does not apply to reference labs billing only lab tests with type of
bill 14X
Claims will deny if the principal diagnosis field is blank, there are no diagnoses, or the entered diagnosis code is not valid for the dates of service Record dx codes to the greatest level of specificity, using up to 7
digits
Outpatient Policies
The status indicator directs payment of the line item
Review the status indicator using the APC online fee schedule
Status indictor N – means it’s a packaged or bundled service, it’s considered in the reimbursement calculation for other services but is not paid separately, will pay $0.00
Review IOCE Status Indicators
NDC must be an 11-digit identifier
Instructions for converting 10-Digit NDCs to 11-digits available in Section 6.8.1 of the Institutional Manual
Document & bill with NDC of the administered drug
Bill with applicable procedure code information (DOS, CPT/HCPCS, modifier(s), and units)
Requirement does not apply to OPPS packaged services (Status indicator N)
If 2+ NDCs are being billed for a procedure code, repeat the procedure code on separate lines for each unique NDC
Use modifier KP (1st drug of a multi-drug) on the 1st line
Use modifier KQ (2nd/subsequent drug of a multi-drug) on 2+ lines
Use appropriate units. Incorrect units effect the rebate
NDCs and J-Codes
May not require a CPT/HCPCS code
Hospitals & ASCs are advised to use procedure codes as they may affect payment
Ensure accuracy of codes, units, & appropriateness of accompanying revenue codes
Packaged Revenue Codes
Revenue Code
Procedure Code
Modifiers Date of Service
Units Total
Charge Payment Method
Payment Amount
0250 8/16/17 1 26.57 APC
Bundled 0.00
0272 8/16/17 1 16.66 APC
Bundled 0.00
0361 64493 50 8/16/17 1 1186.73 APC
Priced 520.85
0636 J2001 8/16/17 8 26.57 APC
Bundled 0.00
0636 Q9966 8/16/17 10 351.34 APC
Bundled 0.00
Bundled Services Example
Inpatient Services
Critical Access Hospitals, General Hospital, & PRTFs
Client initially seen in an outpatient setting & admitted as an inpatient at the same facility within 24 hours of outpatient services
Combine the services & bill on one (1) claim
Outpatient services will be considered in the Level of Care claims reimbursement calculations
Section 12.6.2
Outpatient Followed by Inpatient
Coverage Period (FL 6) for the claim must be the date the client was seen for outpatient services through the inpatient discharge date
The admit date (FL 12) must be the date the client was admitted to inpatient services
Newborn (age is 29 days or less) birth weight in grams must be populated with Value Code 54
All outpatient services should be on the claim using the correct dates of service
Value codes & accommodation units must total the number of days within the coverage period. “Admission date” & “from” dates are not required to match The number in FLs 18-41 is added to the number of days represented in
the covered days. The sum must equal the total number of days reflected in the statement covers period field (FL 6)
Use Value Code 81 (non-covered days) to account for outpatient days
How to Bill
Client received outpatient services 07/05/17
Admitted to Inpatient on 07/06/17, discharged 07/08/17
Coverage period: 07/05/17-07/08/17
Admit Date: 07/06/17
Value 80 (covered days): 2
Value 81 (non-covered days): 1
Room and board units: 2
Outpatient to Inpatient Example
Admitted to Inpatient on 01/04/18
Coverage period 01/04/18-01/06/18
Admit Date 01/04/18
Value 80 (covered days) 3
Value 81 (non-covered days) 0
Room & Board Units: 3
Claim denied with EOB 030 – The number of days billed is not equal to the room and board units.
Outpatient to Inpatient Example
Medicaid will reimburse regardless of admitting dx
Rev Code 0762
Procedure Code G0378 – Hospital observation services, per hour
Appropriate for all conditions or types of admission to observation
Units = # of hours client is in observation
Procedure code G0379 – Direct admission for hospital care
Appropriate for direct admission to the hospital for observation. Ex. Referral from community physician, not admittance through ER or clinic
Units = 1
Either packaged or paid separately under an APC category, dependent on other services billed on the claim
Observation Services
Services will be packaged unless:
8+ units G0378 or appropriate obstetric dx code with 1+ unit G0378; and
No services with status code “T” provided on the same DOS; and
1+ of 99205 or 99215 are billed on the day of or day prior to the observation services
OR…
G0378 Observation Reimbursement
Services will be packaged unless (cont.): No services with status code “T” on the same DOS as
G0378; and
8+ units G0378 billed on the same DOS or day after a high level emergency department visit or critical care service OR an appropriate obstetric dx code is billed with 1+ unit G0378; and
1+ of the codes 99284, 99285, and/or 99291 are billed on the day of or day prior to observation services
G0378 Observation Reimbursement
Observation charges billed with one of the codes (99205, 99215, 99284, 99285, or 99291) but not meeting the other criteria will be priced as packaged
Services will packaged unless:
Both G0378 & G0379 have the same DOS; and
No services with a status indicator of “T” or “V” or procedure codes triggering an APC category of 0617 (critical care) were provided on the same day or day prior to the observation
Payment will be determined by the number of observation hours indicated which will control the APC category G0379 will fall into
G0379 Observation Reimbursement
Observation Example
Clinic billed 99213
Hospital billed observation with Rev 0762 & G0378 – 20 units
None of the codes billed on the same DOS have a “T” status indicator
The observation claim will be packaged when pricing because it doesn’t meet all the criteria to be priced separately.
Rev 0762 & G0378 – 10 units DOS 7/5/17
Rev 0762 & G0379 – 1 unit DOS 7/5/17
Billed with laboratory, radiology, ER, & drug codes
OPPS Status Indicators:
Q1 – STV Packaged Codes,
Q4 – Cond Packaged Lab Services,
N – Bundled Incidental Services, and
J2 – Hospital Part B Services that may be paid through Comprehensive APC
Observation Example
Level of Care (LOC) reimbursement is based on the principal diagnosis (FL 67 on the UB-04)
Medicaid uses 10 LOCs with rates based on either hospital-specific or statewide rates.
Criteria for each LOC can be found in Section 12.6.3
Claim reimbursed as a whole
Any error on a line item may cause the whole claim to deny
Level of Care for Inpatient Claims
Rev 0919 – Psychiatric/psychological services (room & board)
Prior authorization required – contact WYhealth/Optum 1-888-545-1710
Residential Treatment Center (RTC) services & educational services are not covered
PRTF services must: Be provided under the direction of a physician
Provider active treatment
Be provided before the individual reaches age 21 (per CFR 42§441.151) OR
If the individual was receiving services just prior to turning 21
Services must cease at the time the individual no longer requires services or the date at which the individual reaches age 22.
PRTFs
Wyoming Medicaid Website
Welcome Page Manuals and Bulletins
Fee schedule NCCI Denials Contact us Forms
Provider Training Web Tutorials
https://wymedicaid.portal.conduent.com/index.html
Notes
Provider Portal
Claim Submission Refer to:
https://wymedicaid.portal.conduent.com/Training/Institutional_Tutorial_5.10.17.pdf
Attachments
Refer to: https://wymedicaid.portal.conduent.com/Training/Electronic_Attachments.pdf
Registering and adding users Refer to:
https://wymedicaid.portal.conduent.com/Training/Web_Portal_Registration_2_15_18.pdf
Continuity of Care Document – CCD Viewer
The CCD is a HITSP standard patient summary document that contains the following information from the THR Gateway: • Problems • Family History • Immunizations • Vital Signs • Social History • Test Results • Medications • Procedures • Alerts • Allergies/Adverse Reactions • And more…
To request THR CCD Viewer access, please send an e-mail containing: • Clinic Name • Address • Phone Number • Provider Names • Provider Email Addresses • Primary Contact To Andrea Bailey at: [email protected] Visit the website at: http://wyomingthr.wyo.gov/cc
d-viewer
The Program Integrity (PI) unit is responsible, through a coordinated process of education, reviews, audits, and appropriate corrective action plans, for ensuring the integrity and accountability of all payments made for healthcare services on behalf of a recipient.
What is the Program Integrity Unit?
Learn more about PI or report suspected abuse, fraud, or waste by visiting:
https://health.wyo.gov/healthcarefin/program-integrity/
Providers new to Medicaid should view the “Wyoming Medicaid Program Integrity” presentation.
Resources
Provider Relations 1.800.251.1268 (Option 1,5,0) o 9-5 MST Monday - Friday
o Fax Number
o 307.772.8405
EDI Services 1.800.672.4959 (Option 3) o 9-5 MST Monday – Friday
o EDI Enrollment Form
o Trading Partner Agreement
o WINASAP Software & Technical Support for WINASAP
o Technical Support for Vendors, Billing Agents, and Clearinghouses
o Provider Web Portal Registration
o Technical Support for Provider Web Portal & Password Resets
*Medical Policy 1.800.251.1268 (Option 1,1,4,3) o 9-5 MST Monday – Friday o Prior Authorizations (PAs) Requests for: o Surgeries requiring PAs o Hospice Services: Limited to Clients Residing in a Nursing Home
o Status of a Pending PA o How to Complete a PA Request o Authorizations of Medical Necessity for services prior to 11/1/17 o Denials for:
o WATRS -Ambulance claims/ regarding trip report o Invoices
* Third Party Liability (TPL) 1.800.251.1268 (option 2) o 9-5 MST Monday – Friday o Client accident covered by liability or casualty insurance or legal liability is being pursued o Estate and Trust Recovery o Medicare Buy-In status o Reporting client TPL o New insurance coverage o Policy no longer active o Problems getting insurance information needed to bill o Questions or problems regarding third party coverage or payers o WHIPP program
Questions???
