HOSPITAL OUTPATIENT BILLING REIMBURSEMENT GUIDE ??2007-04-20mountain state blue cross blue shield hospital outpatient billing reimbursement guide outpatient prospective payment system

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  • MOUNTAIN STATE BLUE CROSS BLUE SHIELD

    HOSPITAL OUTPATIENT BILLING & REIMBURSEMENT

    GUIDE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)

    WEST VIRGINIA SMALL BUSINESS PLAN

  • Hospital Outpatient Billing and Reimbursement Guide (OPPS) for Mountain State Blue Cross Blue Shield This WVSBP OPPS Hospital Outpatient Reimbursement Guide (OPPS) is a modified version of the PEIA Outpatient Hospital Prospective Payment Billing Manual and the Hospital Manual titled United States Government Services, LLC, Hospital Manual. The contents have been modified to reflect the general guidelines for reimbursement under OPPS for MSBCBS WVSBP products.

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  • Hospital Outpatient Billing and Reimbursement Guide (OPPS) for ________________________________________________________________________ Mountain State Blue Cross Blue Shield

    Table of Contents MSBCBS West Virginia Small Business Plan Hospital Outpatient Prospective Payment System .........................................................................................4

    Introduction..................................................................................................................4 Implementation ...........................................................................................................4

    Coverage in General ..........................................................................................................5 Facilities reimbursed through OPPS........................................................................5 Included Services .......................................................................................................5 Excluded Services......................................................................................................5

    Coding and Billing .............................................................................................................8 Outpatient Code Editor (OCE) ..................................................................................8 Bill Types ...................................................................................................................14 Line Item Dates of Service ......................................................................................14 Reporting of Service Units.......................................................................................14 Reporting of HCPCS Codes ...................................................................................15 Coding for Clinic and Emergency Department Visits...........................................18 Modifiers ....................................................................................................................18 Observation Services...............................................................................................24 Drugs and Biologicals ..............................................................................................24 Pass Through Services............................................................................................37 Billing for Blood and Blood Products......................................................................37 Billing for Devices.....................................................................................................41 Partial Hospitalization Services ..............................................................................42 Procedures for Submitting Late Charges V. Adjustments...................................42

    Payment..............................................................................................................................42 APC Payments..........................................................................................................42 Fee Schedule Services............................................................................................43 Outlier Payments ......................................................................................................43Update Process ........................................................................................................44

    General ...............................................................................................................................44 National Provider Identification Number................................................................44 Website References and Updates Number ..........................................................45

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  • Hospital Outpatient Billing and Reimbursement Guide (OPPS) for Mountain State Blue Cross Blue Shield

    MSBCBS West Virginia Small Business Plan Hospital Outpatient Prospective Payment System

    Introduction Mountain State Blue Cross Blue Shield (MSBCBS) is allowed by law to reimburse providers for services rendered to beneficiaries participating in the West Virginia Small Business Plan (WVSBP) product using rates established by the West Virginia Public Employees Insurance Agency (PEIA). Beginning with dates of service on and after January 1, 2005, the PEIA Plan adopted Medicare's Hospital Outpatient Prospective Payment System (OPPS). PEIA previously reimbursed professional services and diagnostic services based on its RBRVS fee schedule and other services based on a discount from charge. Effective April 1, 2007, MSBCBS will exercise the ability to adopt the PEIAs rates and implement the OPPS as modified by the PEIA to reimburse hospitals for outpatient services furnished to WVSBP enrollees. This Hospital Outpatient Billing & Reimbursement Guide (OPPS) for the WVSBP is a modified version of the PEIA outpatient hospital billing manual and the United Government Services Hospital Manual (January 2004). Modifications include:

    Changes to reflect the PEIAs modifications due to benefit structure Types of hospitals that are included and excluded from OPPS reimbursement Types of services that are included and excluded in OPPS reimbursement Modifications due to MSBCBS processing

    MSBCBS OPPS for WVSBP intends to follow Medicare billing requirements for billing hospital outpatient claims. The claims submission details below have been largely copied from the Medicare Claims Processing manual, Chapter 4. Implementation MSBCBS intends to reimburse providers for hospital outpatient services furnished to WVSBP enrollees on or after April 1, 2007 using the PEIAs OPPS methodology and rates. Upon their implementation, the PEIA established provider specific conversion factors that were essentially budget neutral with respect to the reimbursement level of the services paid through the OPPS. The conversion factors are updated on an annual basis with consideration of each hospitals cost of providing services and the hospitals cost relative to Medicare reimbursement.

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  • Hospital Outpatient Billing and Reimbursement Guide (OPPS) for ________________________________________________________________________ Mountain State Blue Cross Blue Shield

    Coverage in General Actual payment is subject to member eligibility, coverage under the members contract, MSBCBS medical and reimbursement policy for commercial, WVSBP and FreedomBlue (Medicare Advantage) products, medical necessity determination, timely filing and other billing requirements, and other party liability. Facilities reimbursed through OPPS The OPPS applies to all West Virginia hospital outpatient departments except:

    Critical Access Hospitals (CAHs), Skilled Nursing Facilities (SNFs), Hospice Facilities, Psychiatric Hospitals, Rehabilitation Hospitals, Veterans Administration (VA) Hospitals.

    In addition, partial hospitalization services furnished by Community Mental Health Centers (CMHCs) are not reimbursed via OPPS. Included Services The services reimbursed under OPPS by APC are the items and services provided in an hospital outpatient department including: Surgical procedures, radiology, radiation therapy, clinic visits, surgical pathology, chemotherapy, emergency room visits, implants, supplies and diagnostic services and tests. Excluded Services The following services are excluded from the scope of services paid as APCs through OPPS:

    Services already paid under fee schedules or other payment systems including, but not limited to: o Screening mammography, o End Stage Renal Disease (ESRD) o Professional services of physicians and non-physicians paid under the

    Medicare physician fee schedule, o Non-implantable Durable Medical Equipment (DME), orthotics,

    prosthetics and prosthetic devices, prosthetic implants, and take-home surgical dressings will be paid under the DME fee schedule.

    Hospital outpatient services furnished to SNF inpatients as part of his/her resident assessment or comprehensive care plan;

    Services and procedures that require inpatient care will be paid percentage of charge if services are covered and appropriate in the outpatient setting;

    Hospice service; Home health care services; Freestanding psychiatric facility services Freestanding substance abuse and rehabilitation facility services; Ambulance services, physical, speech, and occupational therapy services;

    and

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