Billing Maryland Medicaid: Guidance for SBHCs. Topics for experienced billers. Molly Marra, OHS Maureen Regan, OHS MASBHC 2014

Transcription

1 Billing Maryland Medicaid: Guidance for SBHCs Topics for experienced billers Molly Marra, OHS Maureen Regan, OHS MASBHC 2014

2 Introductions Lelin Chao, M.D. Medical Director, Amerigroup Megan Welter, Health Promotion Consultant, Amerigroup Jeremy Randall, Manager, Medicaid Field Operations, Amerigroup Molly Marra, Chief of Health Services Policy, Maryland Medicaid Maureen Regan, Lead Communications Analyst, Policy and Compliance, Medicaid 2

3 Morning Session Need-to-know terms and acronyms Medicaid 101 SBHC definition, function, and scope of services Enrollment and Billing 101 Resources Q&A 3

4 In this presentation Medicaid New Initiatives Healthcare Reform in Maryland ICD-10 (on hold) New CMS 1500 Form Expanding Access Telemedicine EHR Incentive Program Amerigroup Medicaid Managed Care Organization SBHC and PCP relationship Best practices: billing Resources 4

5 Healthcare Reform March 23, 2010: PPACA becomes law Medicaid expansion: 95,899 Primary Adult Care (PAC) enrollees gained full coverage as of January 1, , 619 new enrollees in Medicaid total (includes PAC) Improved continuity of care between Medicaid and Qualified Health Plans (QHPs) Essential Health Benefits Safety net providers play big role to ensure access as ore individuals and families sign up for coverage 5

6 Enrollment in Medicaid, 2014 and Beyond 1,400,000 1,200,000 1,000, , , , ,000 84, , , , , , ,957 Total New Medicaid Medicaid Expansion Medicaid "Woodwork" Effect Current Medicaid (Excluding PAC)

7 Maryland Medicaid Enrollment by Eligibility Category, ,000, , , , ,000 MCHP 500, ,000 SOBRA - Low Income Women & Children 300,000 TCA - Related Families and Children 200, ,000 Other Elderly Disabled 0 Jul-03 Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 7

8 How to Help with Enrollment Assistance Direct families to Local Health Departments or local Departments of Social Services May also enroll through SAIL: marylandsail.org Open enrollment for QHPs is now closed Special enrollment eligibility may be determined through call center 8

9 ICD-10 (delayed) WHAT: World Health Organization (WHO) adopted ICD-10 in 1990 US last developed country still using ICD-9 (1979) WHY: Better support for analysis, reporting, risk, severity WHEN: HR 4302 delayed ICD-10 implementation until at least October 1,

10 Difference in Diagnosis Codes ICD-9 Diagnosis Codes 3 to 5 digits Alpha on 1 st Character only Limited severity parameters Does not include laterality Limited combination codes ICD-10 Diagnosis Codes 7 digits Alpha or Numeric on ANY Extensive severity parameters Common use of laterality Common combination codes ~ 14,000 codes ~ 70,000 codes 10

11 Example ICD-9 A provider sees a patient in a subsequent encounter for a non-union of an [open] [fracture] of the right [distal] [radius] with intra-articular extension and a minimal opening with minimal tissue damage. ICD-9 Code Description Open Other Fracture of Distal End of Radius (Alone) 11

12 Example ICD-10 A provider sees a patient in a [subsequent encounter] for a [nonunion] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]. ICD-10 Code S52571M Description Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion 12

13 Terminology Changes ICD-9 Term Bunionectomy Amputation Tracheotomy Cesarean section Debridement ICD-10 Term Resection of Metatarsal Detachment Bypass Extraction of Products of Conception Excision, Extraction, Irrigation, Extirpation

14 CMS 1500 Form

15 Changes to the CMS 1500 Form Form only version accepted as of April 1, 2014 Mostly cosmetic and semantic changes Most significant changes apply to block 24 diagnosis pointers Purchase version at nucc.org or through your current vendor Change applies to all payors using CMS 1500 Medicare, Medicaid and MCOs 15

16 Expanding Access Telemedicine Maryland Medicaid telemedicine program began in 2013 Limited to Rural Access and Cardiovascular Disease and Stroke Programs Hub and Spoke model Complemented telemental health program already in existence FQHCs, hospitals, LHDs, and physicians among eligible participants E&M and specialty consultation services covered 16

17 Expanding Access Telemedicine Statewide access beginning October 1, legislation expanded services statewide and merged the two telemedicine programs DHMH/Medicaid does not pay to implement necessary equipment More information: dhmh.maryland.gov/telemedicine 17

18 EHR and Maryland Medicaid What is an Electronic Health Record? Digital version of a patient s paper chart Improve the quality and safety of patient care However, an EHR is NOT an EMR EHRs are intended to be interoperable; they are not simply a way to electronically store records Talk to your SBHC sponsoring entity 18

19 EHR Incentive Program Maryland SBHC sponsoring agencies FQHCs or LHDs received $2,337,500 in EHR incentives Created under the ARRA of 2009 Provide financial incentives for adoption and meaningful use of EHRs Maximum incentive amount is $63,750 over 6 years Eligibility for the Incentive Eligible provider type* Non hospital-based Have 30% or more Medicaid patients Adopt, Implement, or Upgrade an EHR (1 st yr) Meaningfully Use an EHR (2 nd -6 th yr ) *Including: M.D., D.O., nurse practitioner, and certified nurse-midwife 19

20 Assessing EHR Readiness Are there clinical priorities or needs that should be addressed? Are administrative processes organized, efficient, and well documented? Are staff members computer literate and comfortable with information technology? Does the practice have access to high-speed internet connectivity? Does the practice have access to the financial capital required to purchase new or additional hardware? 20

21 Application and Attestation Process Eligible Providers (Eps) must be enrolled with Medicaid FFS and emedicaid at Must have individual NPI and register with CMS Registration System Complete the attestation process for each individual provider at Maryland s Electronic Medicaid Incentive Program Payment (emipp) system at Things you need when attesting EHR certification number Patient volume reports (from an auditable source, e.g. practice management software, billing software, etc) AIU Proof, e.g. receipt or proof of purchase, EHR contract, software license, purchase order or invoice, receipt for training, etc Meaningful Use report (For Stage 1, you must meet 13 Core and 5 Menu Objectives) 21