Payment Policy 19.0 (Service Codes): Updated to reflect process changes since the implementation of Claim- Check.

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1 ANNUAL PAYMENT POLICY REVIEW PHP has completed its annual review of payment policies. The updated policies will be posted on ProvLink in January. Changes have been made to the following policies: Payment Policy 19.0 (Service Codes): Updated to reflect process changes since the implementation of Claim- Check. Payment Policy 58.0 (Documentation Guidelines): Added documentation guidelines for therapy services. See related article in this newsletter: Time-Based Therapy Codes. Payment Policy 70.0 (Locum Tenens): Providers credentialed with PHP may retain substitute providers who share the same type of license to cover as locum tenens as long as all other requirements stated in the policy are met. HOLIDAY SCHEDULE PHP will be closed on the following holiday: New Year: January 1, 2013 January-February 2013 In This Issue Annual Payment Policy Review (NEW) Time-Based Therapy Codes (NEW) RVU Change for G0438 and G0439 (NEW) Illegible Records May Result in Refund Request (NEW) Modifier 33 (REPRINT) Hearing Screening (NEW) G0402-G0405 (REPRINT) Global Pyament for OB Care (NEW) CCI Edits Updated Quarterly (NEW) PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery 1

2 TIME-BASED THERAPY CODES Documentation for therapy visits, including (but not limited to) occupational therapy, physical therapy, speech therapy, and rehabilitation therapy, must include the following elements: Date of visit. Identification of each specific intervention/modality provided. Total visit time. This includes all time spent providing direct services to the patient, for both timed and untimed codes. Time spent during rest periods or waiting for equipment may not be counted in the total minutes. Total time-based code minutes. This includes the total minutes spent providing only time-based code services. The amount of time for each specific intervention/modality may be recorded to assist with the correct coding process, but it is not a requirement. Time spent during rest periods or waiting for equipment may not be counted in the total minutes. Legible signature and professional identification of the provider of service. The combined time for time-based therapy codes must total at least 8 minutes for a time-based code to be reported. Records must be complete and legible and support all services billed. See Payment Policy 58.0 (Documentation Guidelines for Medical Services) for additional information. PHP WILL PAY CONTRACTED RVU FOR MEDICARE ANNUAL WELLNESS VISIT Effective January 1, 2013, the RVU (relative value unit) paid for HCPCS codes G0438 and G0439 will be at the standard contracted rate. Either the usual CPT code for preventive services ( ) or HCPCS code G0438 or G0439 may be reported, but not both. HCPCS G0438 or G0429 may only be used for Providence Medicare patients. The guidelines outlined in PHP Payment Policy 87.0 (Wellness Visits for Medicare Advantage), which is available on ProvLink, must be followed to bill HCPCS codes G0438 or G

3 ILLEGIBLE RECORDS MAY RESULT IN REFUND REQUEST To support services billed to PHP, medical records must be complete and legible and must include the legible identity of the provider and the date of service. Incomplete or illegible records may result in denial of payment for services billed to PHP. A refund will be requested if services have already been paid. PHP Payment Policy 58.0 (Documentation Guidelines for Medical Services), which is posted on ProvLink, describes the documentation requirements for services billed to PHP. For a claim to be valid, there must be sufficient documentation in the provider's or hospital's records to verify the services were performed, were "reasonable and necessary," and required the level of care that was delivered. However, even if the note is complete and the documentation describes in detail all services performed, it cannot support the services billed if the note cannot be read by a reviewer. MODIFIER 33 PREVENTIVE SERVICES Modifier 33 is used to identify a service that was originally intended to be preventive but, due to findings during the visit or procedure, the focus changed to an illness-related visit or procedure. Modifier 33 was developed to identify services that should be paid as preventive according to government mandates for payment of preventive services. Modifier 33 should not be used on codes that are specifically identified as preventive. For example, modifier 33 would not be appended to CPT code 99395, as this code is already identified as a preventive service. However, if the patient presents for an annual exam, and during the course of performing the annual exam the physician finds a medical problem that needs to be addressed, the physician may elect to report CPT code instead of the code for a preventive visit. In this case, the provider would append modifier 33 to CPT code to identify the original intent of the visit as a preventive service. Both services (preventive and problem-focused) must be provided to report with modifier 33. All claims billed to PHP with modifier 33 added to a CPT code will be pended for manual review. Chart notes may be requested to verify the nature of the service. 3

4 HEARING SCREENING CODE CPT code is listed on PHP Payment Policy 13.0 (Bundled and Adjunct Services). This code is used to report screening test, pure tone, air only. The 2012 Coders Desk Reference for Procedures shows that this test involves the use of calibrated equipment where Earphones are placed, and the patient is asked to respond to tones of different pitches and intensities. If the patient fails to respond appropriately, additional testing is indicated. PHP Medical Directors recently reviewed this edit and determined that may be paid if the documentation shows pure tone screening audiometry was performed. Hearing screening performed by whispered voice or tuning fork is considered part of an evaluation and management (E&M) service and may not be reported separately. Code will remain on Payment Policy 13.0, and providers will need to submit an appeal with chart notes to obtain payment for this service. Payment will be allowed only after review of chart notes confirms documentation of pure tone screening test. G0402-G0405 FOR MEDICARE MEMBERS HCPCS codes G0402-G0405 were created by CMS to allow Medicare members one preventive medicine service with routine electrocardiogram (ECG) per lifetime. Because PHP pays annual preventive medicine services for its Medicare members, PHP does not recognize codes G0402-G0405. Providers may use CPT codes for preventive medicine services ( ) and CPT codes for ECG ( ) when billing PHP for screening services for Medicare members. Claims submitted with G0402-G0405 will be denied with instructions to resubmit using CPT codes. PHP also pays G0438 and G0439 for a comprehensive wellness visit as outlined in PHP Payment Policy 87.0 (Wellness Visits for Medicare Advantage). The guidelines outlined in Payment Policy 87.0, which is available on ProvLink, must be followed to bill these codes. 4

5 GLOBAL PAYMENT FOR OBSTETRICAL CARE Reimbursement for obstetrical care is made on a global basis. The practitioner provides care to the member throughout the pregnancy and bills a single global fee after delivery for antepartum visits, delivery services, and routine postpartum care. PHP considers all pregnancy-related antepartum visits to be included in the global obstetrical package or global antepartum care, including the initial visit to confirm pregnancy and hospital visits prior to delivery that are within 48 hours of delivery. The initial visit to confirm pregnancy is paid outside of the global obstetrical payment only if performed by a provider who is not billing obstetrical care. The comprehensive global obstetrical care codes (i.e., 59400, 59510, 59610, or 59618) may be used only if the member has been with PHP at least 7 months (2 months for OHP) at the time of delivery, one provider group performs all the maternity care, and the patient is seen for at least 10 prenatal visits. If the patient is seen for fewer than 10 prenatal visits, the appropriate component codes for obstetrical care should be used. Refer to Payment Policy 07.0 (Global Payment for Obstetrical Care) on ProvLink for additional information. CCI EDITS UPDATED QUARTERLY National Correct Coding Initiative (NCCI or CCI) edits are updated quarterly, and, with only a few exceptions, PHP adopts those edits as they are updated. PHP clinical edits may differ in some cases from CCI edits; if that is the case, PHP clinical edits supersede CCI edits. The majority of PHP professional edits are available on ProvLink by using the tool called Claim Connection. Contact your Provider Relations representative if you have questions about how to use this tool. Facility edits and edits that are not administered through ClaimCheck are not available on Claim Connection. Contact your Provider Relations representative if you have any questions about an edit. 5

6 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 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 Chemo admin code not allowed with this drug 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 6

7 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. 7

8 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. 8