On November 23, 2011, PHP changed its claims editing system from Facets Clinical Editor to McKesson Claim- Check.

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1 EDITING RESOURCE AVAILABLE ON PROVLINK On November 23, 2011, PHP changed its claims editing system from Facets Clinical Editor to McKesson Claim- Check. The new editing system includes an online resource, Clear Claim Connection, that provides AMA/CPT, Correct Coding Initiative (CCI), specialty society, and/or PHP rationale for mutually exclusive and incidental (bundling) edits, as well as information regarding claim denials for age and gender edits. Clear Claim Connection contains edits only for professional services at this time. Facility providers who use this tool should be aware that not all edits apply to facility charges. Clear Claim Connection is available on ProvLink. At the home page, choose the option for Claim Connection on the left side of the page. This will take you to Terms of Use and Disclaimer page. If you agree to the terms of use, click Accept to move to the tool. Your Provider Relations representative can help you if you have trouble finding or using Clear Claim Connection on ProvLink. March - April 2012 In This Issue Editing Resource Available on ProvLink (NEW) APC Payment Methodology (NEW) Assistant at Surgery Denials (NEW) Hip Arthroscopy with Removal of Foreign Body (REPEAT) New Patient Visit Frequency Edits (NEW) Observation Care with IV Therapy (NEW) Therapy Modifiers (NEW) OIG Education (NEW) Not All Edits are on CCI List (NEW) PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery 1

2 APC PAYMENT METHODOLOGY PHP will apply CMS s Ambulatory Payment Classification (APC) payment methodology for hospital-based outpatient services for providers who contract with PHP to pay like Medicare or who are subject to Senate Bill 204. PHP will use OPTUM s ECMPro software to duplicate CMS Hospital Outpatient Prospective Payment System (OPPS) methodology. This includes default fee schedules for lab and radiology. Procedures approved for payment in an outpatient hospital are classified into an APC group on the basis of clinical and cost similarity. All services within an APC have the same payment rate. Within each APC, integral items and services are packaged with the primary service. Separate payment may be made for corneal tissue acquisition, brachytherapy sources, certain radiology services, and many drugs. In addition, separate payments may be made for implantable items that are eligible for pass-through payments under APC as determined by CMS. DENIALS FOR ASSISTANT AT SURGERY CODES PHP Payment Policy 03.0 (Assistant for Surgical Procedures) states an assistant at surgery may be reported by an MD, an RNFA, or a PA in the employ of a plan provider for procedures identified with an assistant surgery indicator of 2 on the Medicare Physician Fee Schedule (MPFS). McKesson ClaimCheck allows an assistant to be paid only for codes identified by American College of Surgeons (ACS) as requiring an assistant. PHP will continue to follow its policy of allowing an assistant for all surgery codes with an assistant surgery indicator of 2 on the MPFS. We are in the process of updating McKesson ClaimCheck to allow an assistant for codes not identified by ACS as requiring an assistant but which have an assistant surgery status indicator of 2 on the MPFS. All updates should be completed before the end of March. In the interim, please contact your Customer Service representative if you receive a denial for assistant at surgery for a code with an assistant surgery status indicator of 2 on the MPFS. Please see Payment Policy 03.0 on ProvLink for additional information. 2

3 HIP ARTHROSCOPY WITH REMOVAL OF FOREIGN BODY AAOS (American Academy of Orthopedic Surgeons) states hip arthroscopy with removal of loose or foreign body (CPT code 29861) may be reported with arthroscopic synovectomy (CPT code 29863) only if the loose or foreign body is removed through a separate incision or is five millimeters or greater in size. As reported in the January/February issue of Connections, PHP Medical Directors agree with the AAOS logic and will adopt this edit effective March 1, Arthroscopic removal of loose or foreign body from the hip performed on the same hip during the same operative session as arthroscopic synovectomy will be paid only if the loose or foreign body is five millimeters or greater in size or is removed through a separate incision/portal. The documentation must show the size of the body removed. CPT code will not be paid when reported with CPT code without review of the operative report. NEW PATIENT VISIT FREQUENCY EDITS PHP follows CPT guidelines for determining how often the Evaluation and Management (E&M) codes for new patient visits ( , , , ) and vision services for new patients ( ) may be reported. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the previous three years. CPT states: Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). All E&M codes (including hospital visits), surgery codes, therapy codes, and some test codes are considered face-to-face services. If the patient is seen by a representative for the physician, e.g., an on-call provider or RN or MA who reports a face-toface service, this visit counts as a face-to-face service with the represented physician for the purpose of identifying the patient as an established patient. Interpretation of a diagnostic test, i.e., reading an x-ray or EKG or laboratory test in the absence of an E&M service or other face-to-face service with the patient, does not affect the new patient designation. 3

4 EDITS FOR OBSERVATION CARE BILLED WITH INTRAVENOUS THERAPY CMS s facility edits (Outpatient Coding Edits or OCE edits) show that CPT codes for observation care are incidental to the codes for intravenous (IV) therapy. Medicare Claims Processing Manual (Pub 100-4), Chapter 4, Section , states, "Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). In a Q&A with CMS published 12/20/2011 (Answer ID 9974), CMS states: The hospital must determine if active monitoring is a part of all or a portion of the time for the particular drug administration services received by the patient. Whether active monitoring is a part of the drug administration service may depend on the type of drug administration service furnished, the specific drug administered, or the needs of the patient. For example, a complex drug infusion titration to achieve a specified therapeutic response that is reported with HCPCS codes for a therapeutic infusion may require constant active monitoring by hospital staff. On the other hand, the routine infusion of an antibiotic, which may be reported with the same HCPCS codes for a therapeutic infusion, may not require significant active monitoring. When IV therapy is reported with observation care, and the observation care is a separately identifiable service from IV therapy as defined by CMS, modifier 25 is appended to the code for observation care to allow separate payment for both services. Providers may use either HCPCS code G0378 or CPT codes to bill PHP for observation care; however, regardless of the observation care code used, modifier 25 is required on the code if observation is billed with IV therapy and the two services are separate. CMS has not established an edit for G0378 billed with IV therapy, but CMS does say that IV therapy should not be billed with G0378 unless it is a separate service. For this reason, and because PHP allows G0378 to be used interchangeably with CPT codes for observation care, PHP requires the same edits for G0378 that apply to CPT codes for observation care. If HCPCS G0378 or one of the CPT codes for observation care is billed with IV therapy, and there is no modifier 25 on the code for observation care, only the IV therapy code will be paid. 4

5 THERAPY MODIFIERS GN, GO, GP Effective May 1, 2012, PHP will require modifiers on certain therapy codes to identify the type of treatment provided, either speech therapy (modifier GN), occupational therapy (modifier GO), or physical therapy (modifier GP). The therapy modifiers will not bypass bundling edits. Even when using therapy modifiers, it will be necessary to use a second modifier to show distinct procedural services if separate sessions of therapy are provided on the same date. The therapy codes that will require use of appropriate type of treatment modifiers for all lines of business effective May 1, 2012 are:

6 OIG OFFERS VIDEO AND AUDIO PRESENTATIONS The mission of Office of Inspector General (OIG) is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. Since its establishment in 1976, OIG has been at the forefront of the nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 300 other HHS programs. The OIG has put together eleven short video and audio presentations for health care providers on top health care compliance topics. The latest step in OIG's award-winning Provider Compliance Training initiative, these free videos and audio podcasts, averaging about four minutes each, cover major health care fraud and abuse laws, the basics of health care compliance programs, and what to do when a compliance issue arises. Providence Health Plan is committed to the prevention, detection and reporting of health care fraud, waste and abuse. You, our health plan providers, are a vital part of helping us address this problem. These educational videos are provided on ProvLink for your convenience as continuing education in this important area of health care business. Contact your Provider Relations Representative if you have questions. NOT ALL EDITS ARE ON CCI LIST Not all correct coding edits are contained in the National Correct Coding Initiative (NCCI or CCI ) edits published by CMS. The NCCI policy manual accompanying the edits says, The edits and policies do not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination. If the CPT book or the NCCI policy manual contain coding instructions for certain code pairs, it is possible that no edits will be published for that code pair on the edit list. For example, the CPT book states that a code with separate procedure designation should not be reported with a related procedure. The NCCI manual states, "CMS interprets this designation to prohibit the separate reporting of a separate procedure when performed with another procedure in an anatomically related region through the same incision, orifice, or surgical approach." Therefore, codes with separate procedure designation may be denied when billed with a related service even though no CCI edit exists for the code pair. The NCCI policy manual may be found at the CMS web site: 6

7 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a29 b01 b02 d01 d02 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on codes billed without an appropriate parent code Co or team surgeons not appropriate for code Charges are included in global OB payment Postoperative visit included in global surgery payment New patient visit frequency exceeded per CPT guidelines Pharmacy codes currently invalid Lifetime maximum for procedure exceeded Bundled/global services, services are never paid separately Clinical daily maximum exceeded for this service Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service Procedure is incidental to another procedure Procedure is mutually exclusive to another procedure Postoperative care is included in global surgical payment Preoperative care is included in global surgical payment Assistant surgeon not allowed for this procedure Invalid gender for procedure Age does not fit within range described by procedure Rebundle edit occurred with a claim in history Duplicate unilateral or bilateral procedure Daily maximum for this procedure has been exceeded Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum Mutually exclusive edit with claim in history Incidental edit with claim in history CCI edit, procedure is incidental to another procedure CCI, current claim denied as incidental to claim in history CCI edit, procedure mutually exclusive to another procedure CCI, current claim denied as mutually exclusive to claim in history 7

8 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). A review of the coding applications will be initiated. Service may be allowed and the claim reprocessed. Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you. Appeal If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld. Edit Reviews When there is a high volume of inquiries or appeals about a specific edit combination, PHP Medical Directors will review the edit combination. If the decision is made to reverse the edit, PHP will implement within 7 days. If the decision is made to uphold the edit, we will publish the information in Newsletter. If an edit combination is upheld, we will ask that you not continue to submit individual claims for review unless there is a clear and distinct exception clearly documented. 8

9 PAYMENT RULES Payment Rules are located on ProvLink. Please review these, as they may explain many of the payment applications that affect your claims payment. It is our policy to notify providers via Connections newsletter prior to implementing new payment rules. ELECTRONIC CONTRACT DELIVERY Providence Health Plan offers secure electronic contract delivery. If you have not already done so, please provide your Providence Health Plan Provider Relations Representative with an address for the person in your organization who should receive contract negotiation and contract update information. Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and to your Providence Health Plan Provider Relations Representative. 9