West Virginia Medicaid National Provider Identifier (NPI), Clinical Auditing Solution, Billing Instructions & Medicaid Redesign West Virginia Medicaid - Provider Workshops Spring 2007 Page 1
Topics of Discussion Welcome & Introductions National Drug Code (NDC) Billing Requirement WVMMIS Clinical Auditing Solution National Provider Identifier (NPI) Billing Instructions Medicaid Redesign Questions & Answers West Virginia Medicaid - Provider Workshops Spring 2007 Page 2
National Drug Code (NDC) Effective on dates of service July 1, 2007 and after If billing for a drug, you must bill with the appropriate NDC number Not Required for Inpatient Services The NDC number being submitted must be the actual NDC number on the package or container from which the medication was administered. Unit of Measurement is also required when billing the NDC number West Virginia Medicaid - Provider Workshops Spring 2007 Page 3
Clinical Auditing Solution What is ClaimCheck? Provides a bundling/unbundling solution Automated claims auditing system Fully integrated within Unisys claims processing system What claims are audited? Professional claims Current claims History paid claims What medical criteria is used? American Medical Association guidelines (CPT4) CMS guidelines (HCPCS) Medicare CCI standards West Virginia Medicaid - Provider Workshops Spring 2007 Page 4
National Provider Identifier (NPI) Monthly mailings to providers that have not submitted their NPI. Monthly conference call occurring for providers that have not submitted their NPI. To answer questions regarding NPI Enumeration. As of March 15, 2007, Unisys has received 18,800 NPI s (75%) Confirmation letters will be sent to all providers listing the NPI that is loaded into the system. For those providers with one NPI linked to many Medicaid # s, a letter will be sent to them indicating the proper taxonomy code that will be required for billing. West Virginia Medicaid - Provider Workshops Spring 2007 Page 5
Changes to the CMS 1500 (8/05) Block 17 17a Referring physician s Medicaid number OR 17b Referring physician s NPI Block 24 24a Effective 7-1-07, enter in the NDC code if billing for a drug 24d NDC unit of measurement goes in the shaded area 24i Enter 1D if entering in the Medicaid Provider number. Enter ZZ if entering the taxonomy code for the servicing provider 24j Rendering Medicaid Provider number in shaded area Rendering provider s NPI in unshaded area West Virginia Medicaid - Provider Workshops Spring 2007 Page 6
Changes to CMS 1500 cont. Block 32 (Not Required) 32a Enter servicing facility NPI 32b Enter servicing facility Medicaid ID# Block 33 33a Enter NPI number of the servicing, rendering, or group pay-to 33b Enter 1D and group Medicaid # or enter ZZ followed by the appropriate taxonomy code. (Note: There is no space between the qualifier and the value) West Virginia Medicaid - Provider Workshops Spring 2007 Page 7
Changes to UB04 Block 8 8a Enter in the member s Medicaid ID# Block 43 If billing for a drug, enter in the NDC code Line 23 If billing for a continuous bill, enter 1 of 3 Block 51 Required until May 23, 2007 Block 56 NPI required on or after May 23, 2007 West Virginia Medicaid - Provider Workshops Spring 2007 Page 8
Changes to UB04 cont. Block 57 Enter in the servicing provider s taxonomy code if applicable Block 76 Enter 1D if entering in the Attending Physician s Medicaid ID# Enter XX if entering in the Attending Physician s NPI Block 78 Enter in the 10 digit PAAS referral number West Virginia Medicaid - Provider Workshops Spring 2007 Page 9
Changes to ADA 2006 Block 49 Enter the Group Practice NPI, required on or after 5-23-07 Block 52A Enter the Group Practice Medicaid ID#, required up to 5-23-07 Block 54 Enter the Dentist s NPI Block 56A Enter the taxonomy code of the individual dentist if applicable Block 58 Enter the Individual Dentist s Medicaid ID# West Virginia Medicaid - Provider Workshops Spring 2007 Page 10
WV MMIS CLINICAL AUDITING SOLUTION What is ClaimCheck? Provides a bundling/unbundling solution Automated claims auditing system Fully integrated within UNISYS claims processing system Why is a clinical auditing solution important? Current standard coding principles are applied Consistent auditing criteria Eliminates costly overpayments and post audit reviews Automates the claim review process What Medical Criteria is used? American Medical Association guidelines (CPT4) CMS guidelines (HCPCS) Medicare CCI standards What claims are audited? Professional Claims Current claim History paid claims REBUNDLING Procedure unbundling occurs when two or more procedure codes are used to report a service when a single, more comprehensive procedure code exist that more accurately represents the service performed by a provider. Unbundled services will be bundled to the comprehensive CPT/HCPCS procedure code. Occasionally, the correct procedure code that most accurately represents the service is not present on the claim. In these instances, the procedure code(s) will be added to the claim. Example: A provider submits procedures 27705 and 27707. 27705 Osteotomy; tibia 27707 Osteotomy; fibula 27709 Osteotomy; tibia and fibula Auditing logic: Separate reimbursement is not considered for 27705 and 27707 when performed in the same surgical session. These services will be denied and a new line will be added to the claim with 27709. Spring Workshops 2007 1
WV MMIS CLINICAL AUDITING SOLUTION INCIDENTAL SERVICES Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Separate reimbursement will not be considered for incidental procedures when reported with related primary procedure(s) with the same date of service. Example: A provider submits procedures 52450 and 52000. 52000 Cystourethroscopy (separate procedure) 52450 Transurethral incision of prostate Auditing logic: Separate reimbursement is not considered for 52000 as it is incidental to 52450. MUTUALLY EXCLUSIVE Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In a mutually exclusive relationship, the procedure with the higher RVU is typically recommended for reimbursement. Mutually exclusive edits are developed between procedures based on the following CPT description verbiage: Limited/Complete Partial/Total Single/Multiple Unilateral/Bilateral Initial/Subsequent Simple/Complex Superficial/Deep With/Without Example: A provider submits procedures 28225 and 28226. 28225 Tenolysis, extensor, foot; single tendon 28226 Tenolysis, extensor, foot; multiple tendons Auditing logic: Reporting a tenolysis of a single tendon and a tenolysis of multiple tendons represents an overlap of services. 28225 is mutually exclusive to the more comprehensive procedure 28226. Spring Workshops 2007 2
WV MMIS CLINICAL AUDITING SOLUTION AGE CONFLICT An age conflict occurs when the provider assigns an age-specific procedure to a patient whose age is outside of the designated age range. Age edits include auditing for the following categories, as defined in the Medicare Code Editor (MCE): NEONATE PROCEDURE; AGE SHOULD BE 0-30 DAYS. PEDIATRIC PROCEDURE; AGE SHOULD BE 31 DAYS-17 YRS. MATERNITY PROCEDURE; AGE SHOULD BE 12-55 YRS. ADULT PROCEDURE; AGE SHOULD BE OVER 14 YRS. Example: A provider submits procedure 43831 for a 45 year-old patient. 43831 Gastrostomy, open; neonatal, for feeding Auditing logic: Due to the age conflict procedure 43831 would be denied. GENDER CONFLICT A gender conflict occurs when the provider submits a gender-specific procedure for a patient of the opposite sex. Example: A provider submits procedure 58150 for a male patient. 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); Auditing logic: Due to the gender conflict 58150 would be denied. PRE-OPERATIVE AUDIT and POST-OPERATIVE AUDIT Evaluation & Management services that are reported during the associated surgical pre/post operative periods will be denied. Pre and post operative timeframes are: Minor surgical procedures have a 0-day pre operative and 0-day post operative timeframe or Minor procedures have a 0-day preoperative and 10-days post operative timeframe. Major surgical procedures have a 1-day pre operative, and 90-days post operative timeframe. Spring Workshops 2007 3
WV MMIS CLINICAL AUDITING SOLUTION DECISION FOR SURGERY The current WV Medicaid rule allows reimbursement to providers for an E&M service with modifier 57 one day prior to and the day of a major surgical procedures. Any E&M service submitted with modifier 57 will suspend for manual processing. ASSISTANT, CO-, TEAM SURGEON REQUIRING DOCUMENTATION The current WV Medicaid rule requires physicians to provide documentation when certain surgeries require an assistant surgeon, co-surgeon, or team surgeon. The service codes requiring documentation can be found in the RBRVS file on the BMS website. These services will suspend for manual review. MODIFIERS Modifiers can be used to bypass edits as indicated below: MODIFIER DESCRIPTION 24 Unrelated E&M service during a post operative period 25 Significant, separately identifiable E&M provided the day of a procedure 57 Decision for surgery 59 Distinct procedural service Spring Workshops 2007 4