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Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal HP Enterprise Services

Medi-Cal 2010 Reimbursements. Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal HP Enterprise Services November 2010. 1. 1. Paper Claim Submission. Clear and Scannable Send Only Necessary Documentation Do Not Use Highlight Markers Do Not Use Pencils

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Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal HP Enterprise Services

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  1. Medi-Cal 2010 Reimbursements Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal HP Enterprise Services November 2010 1 1

  2. Paper Claim Submission Clear and Scannable Send Only Necessary Documentation Do Not Use Highlight Markers Do Not Use Pencils Do Not Submit Handwritten Forms 2 2

  3. Multiple Procedure Billing Use a Single Claim Line to bill the same Lab Procedure, more than once, on the same day Indicate Quantity in the Units Column Exceptions are Surgical Pathology CPT-4 codes 88300 through 88309 when billed for separate sites must be billed on separate claim lines with a maximum of one unit for each line. See: path bil cms 2, path surg 2 3 3

  4. Claim Form Units Field • Be sure to state the total number of units • On Appeals submit the original claim with the total number of units • Corrected if necessary • Medi-Cal will only pay what is billed See: appeal form 1 4

  5. Maximum Reimbursement • Laboratory Services are paid at the least amount of the following: • The amount billed • The charge to the general public • Medicare’s maximum allowance • Medi-Cal’s maximum allowance See: Oct. 2008, Bulletin 412 Cal.Code Regs., tit. 22, § 51529, subd.(a)(2)(B)

  6. Maximum Reimbursement (cond’t) • The Department is currently asking for Data on what Laboratories are charging other Payers

  7. Non Split – Billable Lab Codes • Effective in the near future the Medi-Cal Lab Code Split Billing Component will be made consistent with Medicare • The ZS Modifier will be eliminated • This is being addressed by the “Office of HIPAA Compliance” (OHC) • There is no current Timeline • Providers will be notified at least 3 Months prior to implementation 7

  8. Laboratory Reservation System • Ways of exempting possible Excluded Entities are being studied • These Include: • SNFs • Transplant Patients • Cancer Patients

  9. ICD-9-CM Code Revisions for Selected CPT-4 Procedures • 82728 - Ferritin • 83001 - FSH • 83002 – LH • 83009, 83013, 83014, 87338 and 87339 – Helicobacter Pylori Related Codes • 86304 - CA 125 Tumor Antigen • 83876 - Myeloperoxidase • 84146 - Prolactin • 86304 – CA 125 See: path chem 1-7

  10. ICD-9-CM Code Reminder • Medi-Cal Claims require Diagnosis Codes to the highest Specificity as indicated in the International Classification of Diseases, 9th Revision, Clinical Modification, 6th Edition (ICD-9-CM)

  11. 2010 CPT-4 / HCPCS Update • Effective September 1, 2010 • The following Pathology and Laboratory codes have been added: G0430, G0431, S3713, 83987, 86305, 86780, 86825, 86826, 87150, 87153, 87493, 88387, 88388, 89398 • The following Pathology and Laboratory codes have been deleted: 82307, 86781 See: June 2010 GM Bulletin 432

  12. 2010 CPT-4 / HCPCS Update(cont’d) • Billing Information: • 86305 is restricted to female recipients with one of the following ICD-9-CM diagnosis codes: 183.0, 198.6 or 236.2. • CPT-4 code 86780 is not reimbursable if billed in conjunction with 80055. • CPT-4 codes 87150 and 87493 are not reimbursable if billed in conjunction with a code in the range 83890 – 83914. See: July 2010 GM Bulletin 433

  13. 2010 CPT-4 / HCPCS Update(cont’d) • CPT-4 code 89398 (unlisted reproductive medicine laboratory procedure) requires an approved TAR. • HCPCS Level II code S3713 is reimbursable once in a lifetime and is restricted to the following diagnoses: 153.0 – 153.4, 153.6 – 154.0, 159.0, 230.4, 235.2, 239.0. See: July 2010 GM Bulletin 433

  14. Pathology Billing Restrictions Update See: April 2010 GM Bulletin 430

  15. CLIA Waived Billing Updates See: path bil 6 and 7 http://www.cms.gov/CLIA/downloads/waivetbl.pdf

  16. Genital Wart Surgical Pathology • Effective for Dates of Service on or after March 1, 2010 • For FPACT Claims • Use CPT-4 88305 (88304 will no longer be reimbursed) • Required secondary ICD-9-CM • 078.0 • 078.10 • 078.11 See: FPACT Manual, lab 19

  17. BRCA1 and BRCA2 Gene Sequence Analysis • Payable on or after DOS May 1, 2010: • Requires a Treatment Authorization Request (TAR) • Bill with HCPCS code S3820 • Once In a Lifetime Procedure See: path bil 15 and 16

  18. H1N1 Testing • Retroactive for Dates of Service on or after July 24, 2009. • H1N1 RT-PCR testing is a Medi-Cal benefit • Use CPT-4 87798 • ICD-9-CM 488.1 • Reimbursable for 2 units with modifier 59 See: path immun 1

  19. HIV Drug Resistance Testing • Effective for Dates of Service on or after September 1, 2010 • Will no longer require Medical Justification • CPT-4 Codes affected: • 87901 • 87903 • 87904 See: path micro 8 - 10

  20. Trofile Testing • Initial Testing • Reimbursement is made with Documentation According to the guidelines of The Department of Health and Human Services • Use of a CCR5 Inhibitor is Being Considered or • Patient Exhibits Virologic Failure on a CCR5 Inhibitor See: path micro 10

  21. Trofile Testing (cond’t) • Subsequent Testing • Requires a TAR • All claims must be accompanied by a Report • Bill with CPT-4 87999 See: path micro 11

  22. Compatibility Testing • CPT-4 codes 86920, 86921, 86922 and 86923 are all “By Report” codes • Crossmatch documentation must be submitted with the claim in order to be reimbursed See: path chem 7

  23. Cystic Fibrosis Reimbursement • Issues with Underpayment and Overpayment problems are being researched • Corrections will be forthcoming

  24. Fiscal Intermediary (FI) Transition • Will be Complete in June 2011 • Will Appear Seamless to Providers

  25. National Correct Coding Initiative (NCCI) • Is owned by CMS • Automated System of Edits • Controls specific Code Pairs that cannot be reported on the same day • Legislation has Mandated Implementation by all Medicaids • Implementation set by CMS for Medicaids was October 1, 2010

  26. NCCI and Medi-Cal • Medi-Cal has received a Waiver for the October 1, 2010 Implementation Date • Many Edits have been implemented • Look for Medi-Cal implementation late 2011

  27. ICD-10 • Two components • ICD-10-CM (Clinical Modification) • Replaces ICD-9-CM Volumes 1 and 2 • For all US healthcare treatment settings • ICD-10-PCS (Procedural Classification System) • Replaces ICD-9-CM Volume 3 • For reporting Hospital Inpatient procedures only • Is not Applicable to Clinical Laboratories

  28. ICD-10 • Has been the Standard In other countries for up to 15 Years • Offers significant Improvements through greater Information Specificity • Expandable to capture Advancements in Medicine • Includes updated Terminology and Classification of Diseases • Provides more Extensive Data

  29. ICD-10-CM (cont’d) • Increased Information for Public Health, Bio-surveillance, Quality Measurement • ICD-9-CM running out of Codes • CPT-4 remains the procedure coding standard regardless of whether the services were provided in the inpatient or outpatient setting.

  30. ICD-9-CM vs ICD-10-CM ICD-9-CM ICD-10-CM 5 Position 7 Position (one alpha) (all alphanumeric) 13,000 Possible Codes 68,000 Possible Codes • No clear mapping between the Two • General Equivalence Tables (GEMS) from The National Center for Health Statistics (NCHS)

  31. ASX X12N Version 5010 • Is an Electronic Transaction Standard • Is Required to accommodate ICD-10-CM • Corrects Many of the Flaws of the Current 4010A1 Version • Increases the Field Size for ICD Codes from 5 bytes to 7 bytes

  32. 5010 (cond’t) • Adds a Version Indicator to the ICD Code to Indicate Version 9 or 10 • Increases the Number of Diagnosis Codes Allowed on a Claim • Includes Data Modifications in the Standards Adopted by CMS

  33. 5010 / ICD-10-CM & Medi-Cal • Both are Enhancements Required in the New FI Contract • Mandated Compliance Dates: • All Claims Must Compliant with 5010 on January 1, 2012 • All Claims Must Use ICD-10-CM Diagnosis Codes on October 1, 2013 • Medi-Cal Will Not be Directly Accepting 5010 Formatted Claims until January 1, 2012

  34. 5010 / ICD-10-CM & Medi-Cal (cont’d) • Crossover Claims will be Converted by Group Health Incorporated (GHI) to the 4010A1 Format before they Reach Medi-Cal • Implementation is Expected to allow Providers as Much Testing Time as Possible.

  35. 5010 / ICD-10-CM & Medi-Cal • Questions should be directed to the Telephone Service Center (1-800-541-5555) • For Updates Watch the Medi-Cal Web Site and the Medi-Cal Updates

  36. Electronic Health Records (EHR) • Efforts to Standardize Transport of Health Data Including Laboratory Results at the National and State Levels is ongoing • Two Approaches: • Standard Format Transmitted from Laboratories • Network Transforms Data into Standardized Format Ref: CAeHealth.org

  37. Bernie Betlach CLS, MT(ASCP) Medical Lab Consultant HP Enterprise Services 3215 Prospect Park Drive Rancho Cordova, CA 95670 916-636-1025 bernie.betlach@hp.com 37 37

  38. HAPPY HOLIDAYS FROM ALL OF US AT HP Enterprise Services The Medi-Cal Account HAPPY HOLIDAYS FROM EDS MEDI-CAL 38 38

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