Public Health Nursing Conference Wyoming Medicaid Covered Services & Billing Requirements August 7, 2013 Presenter: Amy Buxton, Field Representative
Public Health Services Are services provided by a physician or mid-level practitioner in a setting designated by the Department of Health as a Public Health Clinic. Services must be provided directly by a physician / nurse practitioner or by a public health nurse under a physician s immediate supervision (Dr. James Bush) Taxonomy 251K00000X 2
NPI vs. Taxonomy Taxonomy Is a 10 character alpha-numeric code used to identify the type of provider billing or providing services 251K00000X is the taxonomy assigned to Public Health providers It identifies WHAT services can be provided NPI National Provider Identifier In 2009 all medical providers had to notify Wyoming Medicaid of their NPI It identifies WHO provided the services 3
CMS 1500 Provider Manual Located on the Medicaid website http://wymedicaid.acs-inc.com Select Provider Select Provider Manuals and Bulletins (Navigation Bar on Left) Select Nurse Practitioner within the CMS 1500 Provider Manual and Bulletins section Select CMS-1500 Provider Manual Review for New/Updated Information Important Policy Changes/Additions section CMS 1500 Provider Bulletins section Additional Links section Medicaid and State Healthcare Benefit Plans 4
CMS 1500 Provider Manual Chapters 2 9 General Information Contains general Wyoming Medicaid Policy that relates to all providers that bill with the CMS 1500 Claim Form or submit an 837P claims transaction Chapter 2 Getting Help When You Need It Contains phone numbers and websites Chapter 3 Provider Responsibilities Enrollment When to bill a client When NOT to bill a client Record keeping requirements 5
CMS 1500 Provider Manual General Information Chapters 2 9 (continued) Chapter 4 Utilization Review Review of claims and state/fiscal agent access to records Fraud and abuse, and how to report Chapter 5 Client Eligibility Types of eligibility Importance of client identification Eligibility verification 6
CMS 1500 Provider Manual General Information Chapters 2 9 (continued) Chapter 6 Common Billing Information Basic claim information Completing the claim form & examples Cap limits Co-payments Prior authorization Electronic claims with attachments Remittance Advices Adjusting claims Timely filing Failure to notify providers of eligibility 7
CMS 1500 Provider Manual General Information Chapters 2 9 (continued) Chapter 7 Third Party Liability Dealing with other insurance Chapter 8 Electronic Data Interchange (EDI) Wyoming Medicaid electronic services Registering for the Secured Provider Web Portal Chapter 9 Wyoming Specific HIPAA 5010 Electronic Specifications Wyoming Medicaid specific electronic billing and transaction requirements 8
CMS 1500 Provider Manual Covered Services Chapter 10 Covered Services Section 10.15 Physician and Nurse Practitioner Services Covered services and billing requirements specific to physicians and practitioners 10.15.8 Immunizations WyVIP Private stock Administration Billing examples 10.15.19 Public Health Services Definition Non-Covered Services 9
10.15.8 Immunizations Billing Procedures (10.15.8.1) WyVIP supplied vaccines Private Stock - Privately purchased vaccines WyVIP Supplied Provided free of charge to eligible Medicaid clients 18 years and younger Vaccine reimbursement: $0 reimbursement for vaccine (i.e. TDAP, MMR, influenza, etc.) Bill with vaccine procedure code (90477-90748) and SL modifier (indicates WyVIP) Administration reimbursement: reimburses from fee schedule Bill appropriate vaccine administration code 10
10.15.8 Immunizations Private Stock / Privately Purchased Vaccines (10.15.8.1) WyVIP was out of stock The vaccine was not supplied through the WyVIP Program Vaccine reimbursement: reimburses at cost (invoice) or from fee schedule, dependent on procedure code and client s age Bill appropriate vaccine procedure code Do not bill with the SL modifier Administration reimbursement: reimburses from fee schedule regardless of how the vaccine was acquired Bill appropriate vaccine administration code Bill usual and customary charges 11
10.15.8 Immunizations Private Stock / Privately Purchased Vaccines (continued) Private Stock Payment Methodology Clients 19 yrs and older / Fee Schedule No invoices required Vaccine procedure codes Influenza (90656 - $15.00, 90658 - $20.00, 90660 - $15.00) Tetanus (90703 - $15.00) MMR (90707 - $15.00) TD (90714 - $15.00) TDAP (90715 - $30.00) Clients 18 yrs and under / Invoice Invoices required (Medicaid Fee Schedule) Vaccine procedure codes same as above Invoices required / Invoice All other vaccine codes for any age 12
Medicaid Fee Schedule http://wymedicaid.acs-inc.com (Wyoming Medicaid Website) Select Provider Select Fee Schedules Accept the agreement Select Try our procedure code search page Enter procedure code Select Search Review the Procedure Code Legend in the top right corner for important and helpful information 13
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Vaccination Administration Codes (18 or younger, with counseling) Administration Codes Ages 0 18 with Face-to-Face Vaccine Counseling CPT Code Description 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (list separately in addition to code for primary procedure) For each vaccination given, the first or only component (antigen) is billed using 90460, each additional component/antigen is billed using 90461. Like codes must be combined onto one line with multiple units. 90461 is reimbursed at $0, and is used for tracking purposes only. 15
Administration Code Billing Scenario 1 Eligible client is a 4 year old child which received the influenza vaccine with counseling Administration code billing would look like this: Code Units Billed Charge Reimbursement 90460 1 $21.72 $21.72 Explanation Vaccine Total Components 90460 (first/only component) 90461 (additional components) Influenza 1 1 0 The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1 st or only component the client was vaccinated for. 16
Administration Code Billing Scenario 2 Eligible client is a 4 year old child which received an influenza and MMR vaccine with counseling Administration code billing will look like this: Code Units Billed Charge Reimbursement 90460 2 $43.44 $43.44 90461 2 $0.00 $0.00 Explanation The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1 st or only component the client was vaccinated for. The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1 st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The units are combined on the claim to show 2 units of 90460 (1 st components) and 2 units of 90461 (additional components). 17
Administration Code Billing Scenario 3 Eligible client is a 4 year old child which received an MMR, Varicella, and DTAP-IPV vaccine with counseling Administration code billing will look like this: Code Units Billed Charge Reimbursement 90460 3 $65.16 $65.16 90461 5 $0.00 $0.00 Explanation The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1 st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The varicella vaccine has only 1 component, one unit of 90460 is reported to indicate the 1 st /only component. The DTAP-IPV vaccine has 4 components, one unit of 90460 is reported to indicate the 1 st component, and 3 units of 90461 are reported to account for the other 3 components of the DTAP-IPV vaccine. The units are combined on the claim to show 3 units of 90460 (1 st components) and 5 units of 90461 (additional components). 18
Vaccination Administration Codes (19 or older, no counseling provided) Administration Codes Face-to-Face Vaccine Counseling Not Provided CPT Code 90471 90472 90473 90474 Description Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injection); one vaccine (single or combination vaccine/toxoid) Do not report in conjunction with 90473. Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Do not report with 90471. Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). For vaccinations where face-to-face counseling is not provided, 90471 or 90473 is reported for the first vaccine, and 90472 or 90474 (units combined for multiples) for each additional vaccine. 19
Institutional / UB Provider Manual Located on the Medicaid website http://wymedicaid.acs-inc.com Select Provider Select Provider Manuals and Bulletins (Navigation Bar on Left) Select Nursing Home within the Institutional / UB Manual and Bulletins section Select Institutional Manual Review for New/Updated Information Important Policy Changes/Additions section Institutional Provider Bulletins section Additional Links section Medicaid and State Healthcare Benefit Plans 20
Institutional / UB Provider Manual Chapters 2 9 General Information Contains general Wyoming Medicaid Policy that relates to all providers that bill with the UB 04 Claim Form or submit and 837I claims transaction Chapters 2 5 and 7-9 Same as CMS 1500 Provider Manual Chapter 8 Electronic Data Interchange (EDI) Secured Provider Web Portal - access to LT101 Inquiry Chapter 6 Common Billing Information Specific to Institutional / UB providers Chapters 10 21 Covered Services Chapter 19 Skilled Nursing Facility (SNF) & Swing Bed Services 19.3 Evaluations that must be completed 19.3.1 LT101 (Medicaid determination of Medical Necessity) 19.3.2 LT101s are required under the following conditions 21
19.3 LT101 Evaluations 19.3.1 LT101 (Medicaid determination of Medical Necessity) The LT101 is a functional assessment performed by a PHN It is a state requirement for the determination of medical necessity for nursing facility level of care DFS cannot approve nursing facility eligibility to any client who is not clinically eligible based on the LT101 assessment LT101s are valid for 90 days after completion 22
19.3 LT101 Evaluations 19.3.2 LT101s are required under the following conditions Prior to Admission no more than 90 days prior to admission Upon application for nursing facility admission Upon transfer to another nursing facility Upon re-admission to a nursing facility after previous discharge Nursing facility residents shall receive continued stay reviews during the sixth (6 th ) month Significant change in condition Upon re-determination of Medicaid eligibility following a loss of eligibility for any reason DFS shall not grant Medicaid eligibility to a nursing facility resident unless the resident has an LT101 less than 90 days old Upon referral for PASRR Level II evaluation for MI or MR 23
LT101 Process PHNs enter LT101s into the PHNI System PHNI System interfaces with the Medicaid Management Information System (MMIS) Upon receipt of the LT101 record the MMIS determines if the client is in the MMIS (currently or previously eligible) Matching criteria 1. Medicaid Client ID number 2. Last name, first name, date of birth and gender 3. Social Security Number If an exact match is found the LT101 is added to the existing client s record If an exact match is not made one of the following takes place Nothing matches the client is considered new and their client file is created If a partial match occurs the client appears on the Daily LT101 Reject Report Shawn Wyse, Clinical Manager, works this report daily 24
Importance of Data Validity Errors cost us all time and add another task to an already heavy workload we all experience Common Mistakes Inaccurate Medicaid Client ID entered Impact(s): The PHNI System has incorrect information The MMIS finds a match and the LT101 is added to the wrong client s record The nursing facility/swing bed provider cannot get paid PHN receives payment for the wrong client Discovered when: This error is typically caught when the PHN doesn t receive payment or receives payment for the wrong client How to avoid: Conduct an LT101 inquiry on the Secured Provider Web Portal or contact Provider Relations to verify the client s information How to correct: Contact Shawn all the impacts have to be corrected 25
Importance of Data Validity Common Mistakes (continued) Inaccurate LT101 review dates entered Impact(s): The PHNI System has incorrect information The client s record in MMIS contains the incorrect dates The nursing facility s claims deny Discovered when: This error is typically caught when the nursing facility s claims deny How to avoid: Verify review dates prior to submission How to correct: Contact Shawn all the impacts have to be corrected PHNs not indicating Submit for Payment Impact(s): PHN will not receive payment Reimbursement has to be manually forced via MMIS Discovered when: This error is typically caught when the PHN doesn t receive payment How to avoid: Verify the Submit for Payment is selected prior to submission How to correct: Contact Shawn to coordinate payment 26
Importance of Data Validity Common Mistakes (continued) The following mistakes can be twofold meaning the error can be with the data in MMIS or PHN data entry mistakes Misspelling of the client s name or last name/first name transposed and incorrect SSN, DOB, or gender Impact(s): The PHNI System has incorrect information or MMIS has incorrect information Discovered when: Daily LT101 Reject Report is worked PHN may discover the error How to avoid: Possibly validating through Provider Relations How to correct: Shawn will work the report and ensure both systems have the correct information If the error is found prior to submission of the LT101, contact Shawn, for corrections 27
Important Phone Numbers Shawn Wyse, Clinical Manager 307-777-1913 When errors are discovered the same day as submission LT101 corrections Name, DOB, SSN and Gender corrections IVR 800-251-1268 Eligibility, check status, lock-in status, insurance information, claims status Provider Relations 800-251-1268, press 1, 5, 0 (speak to agent) Questions concerning claims, procedure codes, eligibility, payments, verify client information, remittance advices, etc. 800-251-1268, press 3 for Web portal password resets, access to LT101 Inquiry, etc. KePRO 855-294-1196 or fax 855-294-1197 DMEPOS Prior Authorization requests 28
Important Web Resources Wyoming Medicaid http://wymedicaid.acs-inc.com Medicaid provider manuals fee schedule Contact Us IVR Navigation Tips Secured Provider Web Portal Remittance Advice Claims Submission LT101 Inquiry KePRO http://wydoh.kepro.com DMEPOS Prior Authorization requests 29
Questions? 30