ACA Preventive Services & Associated Coding and Billing

Transcription

1 ACA Preventive Services & Associated Coding and Billing A Resource manual CBA CENTER High-Impact HIV Prevention Capacity Building Assistance for Healthcare Organizations A Center of Excellence

2 TABLE OF CONTENTS SECTION 1 I. ACA Essential Services...Page 01 A. Overview ACA 10 Essential Services B. Description of Specific Preventive Provisions within Essential Services 1. Ambulatory Patient Services 2. Emergency Services 3. Hospitalization 4. Maternity and Newborn Care 5. Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment 6. Prescription Drugs 7. Rehabilitative and Habilitative Services and Devices 8. Laboratory Services 9. Preventive and Wellness Services and Chronic Disease Management 10. Pediatric Services, Including Oral and Vision Care SECTION 2 II. Third Party Payers and Payment for Preventive Service...Page 15 A. Provider Payment Guidelines for Preventive Services B. Medicaid Mandatory and Optional Services and Preventive Services C. Medicare Preventive Services and Guidance D. Private Health Insurance Plans and Preventive Services SECTION 3 III. Eligible Preventive Activities and Current Procedural Terminology (CPT) Coding, and Billing For HIV and HIC Preventive Services...Page 19 A. HIV testing and Prevention Benefits Under ACA B. The Current Status and Capacity for Billing HIV or HIC Related Preventive Services C. Medication Adherence/Management Programs Under Medicaid and Medicare D. Coding for Routine HIV Testing in Health Care Settings E. U.S. Preventive Services Task Force Recommendations on HIV Related Preventive Services Such as Screenings, Counseling Services, and Preventive Medications. ACA Preventive Services & Associated Coding and Billing A Resource manual

3 ACA Essential Services A. Overview ACA 10 Essential Services Organization Title Resource U.S. Department of Health and Human Services What Marketplace health plans cover Centers for Medicare and Medicaid CMS, The Center for Consumer Information & Insurance Oversight, Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage Centers for Medicare and Medicaid Medicaid.gov, Prevention of Chronic Disease Centers for Medicare and Medicaid Frequently Asked Questions on Health Insurance Market Reforms and Marketplace Standards FAQs Centers for Medicare and Medicaid CMS, CCIIO Sub-Regulatory Guidance: Process for Obtaining Recognition as Minimum Essential Coverage Guidance Downloads/mec-guidance pdf U.S. Department of Health and Human and Human Services, AIDS.gov The Affordable Care Act and HIV/AIDS U.S. Department of Health and Human Services, Health Resources and Services Administration Key Provisions of the Affordable Care Act for the Ryan White HIV/AIDS Program U.S. Department of Health and Human Services, Health Resources and Services Administration Affordable Care Act & HIV/AIDS Web Sites Locator Tool ACA Preventive Services & Associated Coding and Billing A Resource manual Page 1

4 B. Description of Specific Preventive Provisions within Essential Services 1. Ambulatory Patient Services: Preventive Provisions Covered Screenings Value-based Insurance Designs (VBID) & Preventive Care Benefits Ambulatory Surgical Centers Initial Preventive Physical Examination (IPPE) ACA and HIV Preventive Services Covered by Private Health Plans under the Affordable Care Act Kaiser Family Foundation CMS, The Center for Consumer Information & Insurance Oversight, Affordable Care Act FAQs, Affordable Care Act Implementation FAQs - Set 18 Centers for Medicare and Medicaid and FAQs implementation_faqs18.html Medicare Learning Network Quick Reference Information: Preventive Services Centers for Medicare and Medicaid Table CMS FQAs: Preventive Services Centers for Medicare and Medicaid FAQ CMS, Preventive Services and Screenings (Medicare) Centers for Medicare and Medicaid ACA Preventive Services & Associated Coding and Billing A Resource manual Page 2

5 1. Ambulatory Patient Services CMS, The Center for Consumer Information & Insurance Oversight, Affordable Care Act FAQs Set 5 and Set 6 (related to VBID) Centers for Medicare and Medicaid FAQs implementation_faqs5.html and implementation_faqs6.html Fact sheets: CMS Finalizes Hospital Outpatient and Ambulatory Surgical Centers Policy and Payment Changes for 2015 Centers for Medicare and Medicaid Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services Centers for Medicare and Medicaid Manual Downloads/clm104c18.pdf Medicare Learning Network Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination (IPPE) Centers for Medicare and Medicaid Table Network-MLN/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 3

6 2. Emergency Services Out of Network Emergency Services Emergency Psychiatric Demonstration ACA and HIV CMS, The Center for Consumer Information & Insurance Oversight, Affordable Care Act FAQs, Emergency Services, Set 1 Centers for Medicare and Medicaid FAQs implementation_faqs.html#out-of-network Emergency Services ER Access & Doctor Choice Services Affordable Care Act Medicaid Emergency Psychiatric Demonstration, ACA Section 2707 CFDA Announcement, Centers for Medicare and Medicaid Regulation ebacce4e8be28debb4671c720b81c0 The Affordable Care Act and Emergency Care American Journal of Public Health Article How the Affordable Care Act is changing emergency medicine MultiBriefs Publications Article The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 4

7 3. Hospitalization Group Health Plans and Hospitalization Services Requirement Hospital Readmissions ACA Minimum Value and Hospitalization Services o Hospital Quality Provisions o ACA and HIV Group Health Plans that Fail to Cover In-Patient Hospitalization Services Internal Revenue Service Federal Notice CMS Readmissions Reduction Program Centers for Medicare and Medicaid Summary/ Guidance AcuteInpatientPPS/Readmissions-Reduction-Program.html Obama Administration Closing Health Law Loophole For Plans Without Hospitalization, IRS Notice Kaiser Family Foundation Summary IRS Guidance on Group Health Plans That Fail to Cover Hospitalization, Physician Services, and the ACA Minimum Value Requirement ADP Research Institute Article Selected Medicare Hospital Quality Provisions under the ACA Association of American Medical Colleges The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 5

8 4. Maternity and Newborn Care Prenatal Care Visits and Screenings Rh Incompatibility Screening Gestational Diabetes Screening Breast Support and Counseling, Supplies and Equipment Newborn Gonorrhea Preventive Medication Other Screenings For Children, Including Immunizations Tobacco Cessation Coverage Pregnancy Assistance For Students Maternal and Newborn Home Visitation Post-Partum Depression Services Affordable Care Act (ACA) Maternal, Infant, and Early Childhood Home Visiting Program o Pre-exposure Prophylaxis and Pregnancy and Breastfeeding o ACA and HIV The Center for Consumer Information & Insurance Oversight, Affordable Care Act Implementation FAQs - Set 12 Centers for Medicare and Medicaid and FAQs implementation_faqs12.html How the Affordable Care Act (ACA) affects pregnant women and families Babycenter.com Fact sheet American Congress of Obstetricians and Gynecologists Health Care reform FAQs for Women American Congress of Obstetricians and Gynecologists FAQs Preventive Services Covered by Private Health Plans under the Affordable Care Act Kaiser Family Foundation ACA Preventive Services & Associated Coding and Billing A Resource manual Page 6

9 4. Maternity and Newborn Care Women's Preventive Services Guidelines Agency: Department of Health and Human Services Office: Health Resources and Services Administration Catalog of Federal Domestic Assistance, Affordable Care Act (ACA) Maternal, Infant, and Early Childhood Home Visiting Program Agency: Department of Health and Human Services Office: Health Resources and Services Administration Notice 405b962e3f69a46bdc6eb26a71dedf Prevention Provider Information Sheet PrEP During Conception, Pregnancy, and Breastfeeding Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 7

10 5. Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment Requirements For Mental Health and Substance Abuse Benefits Effect of ACA on the Mental Health Parity and Addiction Equity Act o Emergency Psychiatric Demonstration o ACA and HIV Preventive Services Covered by Private Health Plans under the Affordable Care Act Kaiser Family Foundation Essential Health Benefits, Actuarial Value & Accreditation Standards Centers for Medicare and Medicaid PowerPoint CMS, The Center for Consumer Information & Insurance Oversight, The Mental Health Parity and Addiction Equity Act (MHPAEA) Centers for Medicare and Medicaid Protections/mhpaea_factsheet.html CMS, The Center for Consumer Information & Insurance Oversight, Affordable Care Act Implementation, Affordable Care Act implementation FAQs - Set 7 Centers for Medicare and Medicaid and FAQs implementation_faqs7.html ACA Preventive Services & Associated Coding and Billing A Resource manual Page 8

11 5. Mental Health and Substance Use Disorder Services, Including Behavioral Health Treatment CMS, The Center for Consumer Information & Insurance Oversight, Affordable Care Act Implementation, FAQs - Set 18, the effect of the Affordable Care Act on MHPAEA? Centers for Medicare and Medicaid and FAQs implementation_faqs18.html Affordable Care Act Medicaid Emergency Psychiatric Demonstration, CFDA, ACA Section 2707 Centers for Medicare and Medicaid Regulation ebacce4e8be28debb4671c720b81c0 The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 9

12 6. Prescription drugs Options for Prescription Drug Benefit Cost Sharing and Prescriptions Medicare Prescription Drug Donut Hole Medicare Part D Medication Therapy Management (MTM) o Pre-exposure Prophylaxis and Pregnancy and Breastfeeding o ACA and HIV o Ryan White ADAP and ACA Essential Health Benefits, Actuarial Value & Accreditation Standards Centers for Medicare and Medicaid PowerPoint Key Facts You Need to Know About: Cost-Sharing Charges Center on Budget and Policy Priorities and FAQs CMS Press release: 7.9 million people with Medicare have saved over $9.9 billion on prescription drugs Centers for Medicare and Medicaid Press Release Medicare Part D Medication Therapy Management (MTM) Programs Centers for Medicare and Medicaid Prevention Provider Information Sheet PrEP During Conception, Pregnancy, and Breastfeeding Centers for Disease Control and Prevention, National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov Ryan White & the Affordable Care Act: Frequently Asked Questions (ADAP) Services, Health Resources and Services Administration FAQs ACA Preventive Services & Associated Coding and Billing A Resource manual Page 10

13 7. Rehabilitative and Habilitative Services and Devices Supplementing Options for Habilitative Services Rehabilitative Secondary Prevention Programs ACA and HIV Essential Health Benefits, Actuarial Value & Accreditation Standards Centers for Medicare and Medicaid PowerPoint AHA Presidential Advisory: Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond America Heart Association Article Patient Protection and Affordable Care Act: Potential Effects on Physical Medicine and Rehabilitation US National Library of Medicine National Institutes of Health Article The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 11

14 8. Laboratory services Clinical Laboratories Public Health Laboratories Rural Laboratory Services Epidemiology-Laboratory Capacity Grants. ACA and HIV Clinical Labs Under ACA: Challenge And Opportunity Sidley Austin LLP Article 1e954831e633/Presentation/PublicationAttachment/635ce2e1-61e4-4be8-a065-1f84f047ceaf/Law360_Clinical%20Labs%20 Under%20ACA_Challenge%20And%20Opportunity.pdf The Affordable Care Act, Meaningful Use, and Their Impact on Public Health Laboratories Public Health Reports Commentary Obamacare Preventive Care ObamacareFacts The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 12

15 9. Preventive and Wellness Services and Chronic Disease Management ACA Covered Prevention and Wellness Services ACA Covered Prevention Screenings Developing Effective Prevention and Wellness Programs Annual Wellness Visit (AWV) ACA and HIV Prevention and Wellness Services, HHS.gov/HealthCare Prevention and Wellness Kaiser Family Foundation Summary of ACA Provisions Obamacare Preventive Care ObamacareFacts Developing Effective Prevention and Wellness Programs American Academy of Nursing Guidance Medicare Learning Network, Quick Reference Information: The ABCs of Providing the Annual Wellness Visit (AWV) Centers for Medicare and Medicaid Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN pdf The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov ACA Preventive Services & Associated Coding and Billing A Resource manual Page 13

16 10. Pediatric Services, Including Oral and Vision Care ACA Prevention Services for Children Supplementing Options for Pediatric Oral and Vision Pediatric Recommended Core Measures ACA and HIV How the Affordable Care Act (ACA) affects pregnant women and families Babycenter.com Fact sheet Essential Health Benefits, Actuarial Value & Accreditation Standards Centers for Medicare and Medicaid PowerPoint Clinical Quality Measures (CQMs) Pediatric Recommended Core Measures Centers for Medicare and Medicaid Chart CoreSetTable.pdf The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov Fact sheet ACA Preventive Services & Associated Coding and Billing A Resource manual Page 14

17 SECTION 2 Third Party Payers and Payment for Preventive Service A. Provider Payment Guidelines for Preventive Services Medicaid Provider Payment Medicaid.gov, Provider Payments Essential Coverage Regulatory Guidance ACA related Policy and Payment Changes for 2015 Claims Processing for Preventive and Screening Services ACA Benefits, Actuarial Value and Accreditation Standards Payment Reform and New Models Centers for Medicare and Medicaid Guidance CMS, CCIIO Sub-Regulatory Guidance: Process for Obtaining Recognition as Minimum Essential Coverage Centers for Medicare and Medicaid Guidance Downloads/mec-guidance pdf Fact sheets: CMS Finalizes Hospital Outpatient and Ambulatory Surgical Centers Policy and Payment Changes for 2015 Centers for Medicare and Medicaid Medicare Claims Processing Manual Chapter 18 - Preventive and Screening Services Centers for Medicare and Medicaid Manual Downloads/clm104c18.pdf ACA Preventive Services & Associated Coding and Billing A Resource manual Page 15

18 SECTION 2 A. Provider Payment Guidelines for Preventive Services Essential Health Benefits, Actuarial Value & Accreditation Standards Centers for Medicare and Medicaid PowerPoint ACA: Premium Tax Credits and the Reconciliation Process Services, Health Resources and Services Administration Guidance Payment Reform and New Models of Care Rand Corporation Medicare Payment Innovations in the ACA: Research Insights for Policy Academy Health Brief pdf ACA Preventive Services & Associated Coding and Billing A Resource manual Page 16

19 SECTION 2 B. Provider Payment Guidelines for Preventive Services Major Medicaid Provisions Related to ACA Medicaid Mandatory and Optional Benefits Prevention of Chronic Disease Under Medicaid Medicaid Essential Health benefits Medicaid.gov, Affordable Care Act Centers for Medicare and Medicaid Medicaid Benefits Centers for Medicare and Medicaid Medicaid.gov, Prevention of Chronic Disease Centers for Medicare and Medicaid Essential Health Benefits in the Medicaid Program Centers for Medicare and Medicaid, Center for Medicaid and CHIP Services Guidance pdf ACA Preventive Services & Associated Coding and Billing A Resource manual Page 17

20 SECTION 2 C. Medicare Preventive Services and Guidance Medicare Learning Network Quick Reference Information: Preventive Services Centers for Medicare and Medicaid Table The Affordable Care Act & Medicare Centers for Medicare and Medicaid D. Private Health Insurance Plans and Preventive Services Private health plans under ACA Private health insurance and coverage under Ryan White Preventive Services Covered by Private Health Plans under the Affordable Care Act Kaiser Family Foundation Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program (PDF - 35 KB) Services, Health Resources and Services Administration Guidance ACA Preventive Services & Associated Coding and Billing A Resource manual Page 18

21 SECTION 3 Eligible Preventive Activities and Current Procedural Terminology (CPT) Coding, and Billing For HIV and HIC Preventive Services A. HIV testing and prevention benefits under ACA ACA and HIV CDC HIV Prevention Efforts Under ACA Ryan White HIV/AIDS Preventive Services Under ACA Specific Subgroups HIV Preventive Activities Under ACA HIV Prevention Counseling The Affordable Care Act and HIV/AIDS and Human Services, AIDS.gov December 17, 2013 Dear Colleagues Letter regarding ACA Services, Centers for Disease Control and Prevention Guidance The Affordable Care Act Helps People Living with HIV/AIDS Centers for Disease Control and Prevention Prevention of HIV/AIDS, Viral Hepatitis, STDs, and TB Through Health Care, HIV/ AIDS Preventive Services Centers for Disease Control and Prevention Table ACA Preventive Services & Associated Coding and Billing A Resource manual Page 19

22 SECTION 3 A. HIV testing and prevention benefits under ACA Key Provisions of the Affordable Care Act for the Ryan White HIV/AIDS Program Services, Health Resources and Services Administration Ryan White and Affordable Care Act Outreach, Enrollment and Benefits Counseling Services, Health Resources and Services Administration Table Ryan White & the Affordable Care Act: What You Need to Know Services, Health Resources and Services Administration Guidance Coverage Guide for HIV Testing Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV The AIDS Institute FINAL.pdf Kaiser Family Foundation Issue Brief Affordable Care Act Rules on Expanding Access to Preventive Services for Women Services Health Reform : Improving Access To HIV Prevention, Care, And Treatment For Women National Alliance of State and Territorial AIDS Directors ACA Preventive Services & Associated Coding and Billing A Resource manual Page 20

23 SECTION 3 B. The Current Status and Capacity for Billing HIV or HIC Related Preventive Services HIV Billing and Coding Resources Private Health Plans and ACA Local Health Departments and ACA Coordination Between Ryan White and Medicaid Ryan White and ACA Billing and Reimbursement Tools Ryan White ACA Related Policies HIV Billing and Coding Resources, Billing Coding Webinar for HIV Outpatient Services HIV Medicine Association Webinar Preventive Services Covered by Private Health Plans under the Affordable Care Act Kaiser Family Foundation Billables Project Health Department Immunization Services Reimbursement Centers for Disease Control and Prevention Guidance Innovative Projects to Improve Reimbursement for Immunization Services in Public Health Department Clinics STD Billing and Reimbursement Toolkit Third-Party Billing for Public Health STD Services Region 1 STD Related Reproductive Health Training and Technical Assistance Center Webinar JSI Research & Training Institute, Inc. Report PH-STD-Services-Final-March-2014.pdf ACA Preventive Services & Associated Coding and Billing A Resource manual Page 21

24 SECTION 3 B. The Current Status and Capacity for Billing HIV or HIC Related Preventive Services Engaging Safety Net Providers in Expanded Coverage: Tips on Enhancing Billing Capacities National Academy for State Health Policy Billing for Clinical Services: Health Department Strategies for Overcoming Barriers National Association of County and City Health Officials Brief Billing Task Analysis Resource National Association of County and City Health Officials Toolkit Issue Brief: Billing and Reimbursement, Health Departments and Capacity For Third Party Billing And Reimbursement: A Status Report and Resources For Capacity Building National Alliance of State and Territorial AIDS Directors Brief Joint CMCS and HRSA Informational Bulletin, Coordination between Medicaid and Ryan White HIV/AIDS Programs Services, Health Resources and Services Administration Bulletin HRSA TARGET Center: Topic: Billing & Reimbursement Services, Health Resources and Services Administration Guidance Ryan White & the Affordable Care Act: What You Need to Know (Policy guidances) Services, Health Resources and Services Administration Guidance ACA Preventive Services & Associated Coding and Billing A Resource manual Page 22

25 SECTION 3 c. Medication Adherence/Management Programs Under Medicaid and Medicare Part D Medication Therapy Management Program Medicaid Drug Adherence and Medications Therapy Management Services CMS, Medication Therapy Management Centers for Medicare and Medicaid Focus On Strategies To Increase Prescription Drug Adherence Amerigroup Public Policy Institute Brief 10-Focus-on-Strategies-to-Increase-Prescription-Drug-Adherence.pdf D. Coding for Routine Hiv Testing in Health Care Settings CPT coding for ACA Preventive Services HIV Coding Resources IPPE Coding Coding for Routine HIV Testing List of ACA Preventive Services and CPT Codes Region 1 STD TAC Table HIV Billing and Coding Resources, Billing Coding Webinar for HIV Outpatient Services HIV Medicine Association Webinar ACA Preventive Services & Associated Coding and Billing A Resource manual Page 23

26 SECTION 3 D. Coding for Routine Hiv Testing in Health Care Settings Coding guide for routine HIV testing in health care settings American Academy of HIV Medicine Guidance HIV/AIDS Care: The Service (CPT) Code Series 1A Aids Education and Training Centers, National Center for HIV Care in Minority Communities PowerPoint Medicare Learning Network Quick Reference Information: The ABCs of Providing the Initial Preventive Physical Examination (IPPE) Centers for Medicare and Medicaid Table Network-MLN/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf E. U.S. Preventive Services Task Force Recommendations on HIV related preventive services such as screenings, counseling services, and preventive medications. U.S. Preventive Services Task Force, USPSTF A and B Recommendations Services, Agency for Healthcare Research and Quality (AHRQ) Guidelines ACA Preventive Services & Associated Coding and Billing A Resource manual Page 24

27 Developed by CBA and CAI for CDC This publication was supported by the Grant or Cooperative Agreement Number, U65PS004408, funded by the Center for Disease Control and Prevention. It s contents are solely the responsibility of the authors and do not necessarily represent the official views of the Center for Disease Control and Prevention or the Department of Health and Human Services. A Center of Excellence