DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Medicaid PPS Hospital Billing Guide April 1, 20

1. DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION Medicaid PPS Hospital Billing Guide April 1, 2006

2. OPPS Outpatient Prospective Payment System

3. General • Montana Medicaid uses Medicare’s Outpatient Prospective Payment System for reimbursing PPS hospitals since August 2003 • Medicaid uses a Montana specific conversion factor ($47.75) for PPS hospitals and updates quarterly along with Medicare • Medicaid deviates from Medicare in some cases (i.e. therapies, obstetric observation, inpatient only) • Payment for PPS hospitals is the lower of OPPS payment (fees and APCs) or your total claim charges • Charge cap does not apply to line level • Appropriate and accurate coding is the key to proper reimbursement

4. OPPS/APC for PPS Facilities • Some services paid by fee schedule • Therapies (speech, physical, occupational) • Laboratory • Diagnostic • If there is no APC, Medicare fee or Medicaid fee (RBRVS), some services pay hospital specific outpatient cost to charge ratio • Drugs and Biologicals • Devices • Ambulatory Payment Classification • Payment based on CPT/HCPCS codes • Status Indicator tells the method of payment • Each service is eligible for potential payment • Emergency room • Treatment Room • Provider-based clinic • Cancer care

5. Paint a Picture With your Claim • Code every service every time for proper payment • Where did your patient come into your facility? • ER, clinic, direct admit? • What happened to the patient? • Surgery? • Clinic visit? • Treatment room? • What resources did you use? • Supplies? • Pharmaceuticals? • Blood products? • Your claim should tell the story of what happened to your patient.

6. C – Inpatient only services G – Drugs & biologicals paid by report (hospital specific outpatient cost to charge ratio) H – Devices paid by report K – Drugs and biologicals paid by APC M – Paid by a Medicaid specific fee or not a covered service (fee schedule will show as not allowed) N – Service is bundled into an APC (If all your codes are N on your claim, your claim will pay at zero) Q – Lab fee schedule (60% for non-sole community, 62% for sole community) S – Significant procedure paid by APC that the multiple procedure discount DOES NOT apply to T – Significant procedure paid by APC that the multiple procedure discount DOES apply to V – Medical visits in the clinic, critical care or emergency department (includes codes for direct admits) X – Ancillary services paid by their own APC Y – Medicaid fee for therapies (90% of RBRVS office fee) APC Status Indicators

7. Modifiers

8. HOSPITAL OUTPATIENT MODIFIERS • Medicaid uses Medicare Outpatient Claim Edits • www.cms.hhs.gov/providers/hopps/cciedits/ • These edits apply to both CAH and PPS hospitals • Medicaid does not allow reporting separate codes for related services when there is 1 code that includes all related services • Medicaid does not allow breaking out bilateral procedures when 1 code is appropriate • The paper UB-92 can accommodate 1 modifier • The 837 can accommodate 4 modifiers • Always report the payment modifier 1st as Medicaid processes the claim using only the first modifier

9. Level I Outpatient Modifiers • Level I Modifiers • 25 – significant separate E&M service • 27 – multiple E&M same day • 50 – bilateral procedure • 52 – reduced services • 58 – staged or related service • 59 – distinct procedure • 73 – procedure terminated prior to anesthesia • 74 - procedure terminated after anesthesia • 76 – repeat procedure by same physician • 77 – repeat procedure by another physician • 91 – repeat clinical diagnostic lab test

10. Level II Outpatient Modifiers • Level II Modifiers • LT – left side • RT – right side • LC – left circumflex coronary artery • LD – left anterior descending coronary artery • RC – right coronary artery • GN – service under speech language pathology plan of care • GO - service under occupational therapy plan of care • GP - service under physical therapy plan of care

11. Common Outpatient Modifiers • 25-significant, separately identifiable E&M service by the same physician on the same day • Only used with E&M codes 92002-92014, 99201-99499, G0101, G0175 & G0264 to indicate that the patient’s condition required a separately identifiable E&M service the same day a procedure was performed • Examples: • 99212-25 Office/outpatient visit, est. • 77412 Radiation treatment, 3 or more treatment areas

12. Common Outpatient Modifiers • 50 – Bilateral Procedure • Used to report bilateral procedures performed at the same operative session • The 2nd (or bilateral) procedure is identified by 50 added to the CPT code on a single line. Units are “1”. • DO NOT use if the code description indicates “bilateral” such as 27395 • Use when body parts have both right and left and you are doing separate services on each side. Do not use RT or LT with 50 • Examples: • 28285-50 repair of hammertoe, or • 64721-50 carpal tunnel surgery

13. Common Outpatient Modifiers • 59 – Distinct Procedural Service • Used to report two procedures that are not normally reported together but could be performed under certain circumstances • Different session or patient encounter • Different procedure or surgery • Different site or organ system • Separate incision • Separate injury that is not normally encountered or performed by the same physician on the same day • Examples: • 93017 cardiac stress test • 93005-59 EKG

14. Common Outpatient Modifiers • 91- Repeat Clinical Diagnostic Lab • Use when the same lab test is repeated on the same day to obtain subsequent test results • Do not use when tests are re-run to confirm initial results, • when there were testing problems with specimens or equipment or • for any other reason when a one-time result is all that is required • Attach modifier to the second lab test • Enter the number of times the subsequent lab test was done in the unit column • Examples: • 82550 Creatinine Kinase (bill 1 unit) • 82550-91 CPK (bill however many additional tests were performed

15. Observation

16. Observation Services • Four qualifying conditions for payment • Chest Pain • Asthma • Congestive Heart Failure • Obstetric Complications (pre-delivery complications) • Starting April 1, 2005, the qualifying diagnosis must be in either: • Admitting diagnosis (FL 76); or • Principal diagnosis (FL 67)

17. Observation Services • Medicare/Medicaid Rules • OBS services must be reasonable and necessary • There must be a physician order prior to initiation • Physician order must be by a physician with privileges at your hospital • Physician must be actively directing patient care • During OBS, patients must be actively assessed • Observation is not a substitute for inpatient • Observation is not for continuous monitoring • Observation is not for patients waiting for NH placement • Observation is not to be used for convenience or as routine prior to IP status

18. Observation Services • Beginning January 1, 2006 the OCE will determine if a claim qualifies for observation • Code your claim to tell us if this was a direct or outpatient admission • Bill ALL observation regardless if you think it qualifies or not • Beginning January 1, 2006 the following codes will be discontinued: • G0244, G0263, G0264 • 99217-99220 • Bill ALL observation regardless if you think it qualifies or not • Beginning January 1, 2006 you do not have to bill G codes for Obstetric observation – it is up to you

19. Outpatient Admissions to Observation • All observation services must be on a 13X bill type • Use G0378 to report the observation of patients admitted through an outpatient setting such as Emergency room, Critical care clinic, Provider-based clinic • Bill the first date of service (the date admitted to an observation bed) on this line • Bill your units of observation on this line (for obstetrics bill 1 unit) • Bill charges observation charges on this line (for obstetrics bill $1) • Bill your ER, CC or Provider based visit on a separate line • Bill all other services as normal • If Obstetric observation, you must have a line with 99234-99236 • Bill the first date of service (the date admitted to an observation bed) on this line • Bill total units of observation on this line • Bill observation charges on this line

20. Direct Admissions to Observation • All observation services must be on a 13X bill type • Use both G0378 and G0379 to report the observation of patients admitted directly • Bill the first date of service (the date admitted to an observation bed) on both lines • Bill total units of observation on the line with G0378 (for obstetrics bill 1 unit) • Bill observation charges on the line with G0378 (for obstetrics bill $1) • Only 1 unit of service and $1 in charges are reported on G0379 • Bill all other services as normal • If Obstetric observation, you must have a line with 99234-99236 • Bill the first date of service (the date admitted to an observation bed) on this line • Bill total units of observation on this line • Bill observation charges on this line

21. Provider-Based

22. Provider-Based Services • You may not self-attest for Medicaid • Medicaid requires notification and verification from Medicare prior to billing • Medicaid requires re-enrollment of all your providers with new tax ID numbers (the hospital may not have to re-enroll if they are the primary tax ID number) • Billing is allowed from the date of Medicaid receipt of verification – not from date of Medicare approval • Provider-based rules are the same for Medicaid as they are for Medicare with few exceptions • Including notifying the patient prior to service that there are 2 cost shares ($4 for the 1500 and $5 for the UB) for each visit

23. Provider Based Billings • Claims are billed for all of your provider-based facilities and clinics similar to how you would bill a claim in the Emergency Department • There is both a UB and a 1500 for each billable visit • 1500 claim must have place of service “22” outpatient • UB claim uses revenue code 510 for the facility side of the office visit-this is the only clinic visit revenue code allowed for provider-based facilities • Procedures that the doctor or midlevel performed (10021 to 69990) are also billed on the UB • All other services are billed on the UB

24. Provider-Based Billing Exceptions • Obstetrics • Billing for complete service, antepartum, delivery and postpartum • Bill as usual which means a global bill with POS 21 on the 1500 side and delivery paid as a DRG on the UB side • Billing for incomplete services, antepartum or postpartum • Bill appropriate code for number of visits on 1500 and UB. • Codes such as 59425 are not turned on for facility side so bill a matching E&M on the UB side • VFC • Where there is an E&M • Bill E&M and administration code on the 1500 with POS 22, bill E&M and injectibles on UB • Where there is an not an E&M • Bill administration code with modifier SL and the VFC code on the 1500 with POS 22, bill administration code on the UB, SL does not apply on the UB side • If you cannot bill a 1500, you cannot bill a UB and visa-versa

25. Provider-Based Billing Issues • Inpatient Bundling • Lab and diagnostic services provided 72 hours prior to inpatient stays must be bundled • Outpatient visits 24 hours prior to inpatient stays must be bundled • This includes provider-based services – the UB portion of the provider-based visit must be bundled into the inpatient claim • Audit • Medicaid has started an audit of provider-based billing • Issues identified so far: • Billing 1500 with place of service 11 • Billing lab, supplies and J-codes on 1500 • Not bundling visit into inpatient claim when 24 hours previous • Providers have not notified Medicaid of provider-based status

26. Sterilization and Hysterectomy

27. Sterilization and Hysterectomy • Informed Consent to Sterilization (MA-38) or Medicaid Hysterectomy Acknowledgement (MA-39) must be attached to the claim without exception • The forms must be legible, complete and accurate. • Revisions are not accepted for any reason • The physician must sign and date the form the same day the recipient is informed that the procedure would render them permanently incapable of reproducing • The recipient must be informed orally and in writing • The form bust be signed prior to the procedure • Make sure birth date and date of signature are accurate

28. MA-38 Form • Informed Consent to Sterilization (MA-38) • It is the provider’s responsibility to obtain a correctly completed form from the primary or attending physician • Elective sterilizations are still subject to the 30 day waiting period • For retroactively eligible clients, the physician must certify in writing that the surgery was performed for medical reasons and must document: • Client was informed prior to the hysterectomy that the operation would render them permanently incapable of reproducing, or • Reason for the sterilization was a life-threatening emergency or the client was already sterile and the reason for the prior sterility

29. MA-39 Form • Medicaid Hysterectomy Acknowledgement (MA-39) • Complete only one section of this form. Section A, B or C • If no prior sterility or life-threatening emergency exists, client and physician must sign and date Section A prior to the procedure • Oral and written consent prior to the procedure still applies for Section A • The client does not need to sign the form when sections B or C are used • For retroactively eligible clients, the physician must certify in writing that the surgery was performed for medical reasons and must document: • Client was informed prior to the hysterectomy that the operation would render them permanently incapable of reproducing, or • Reason for the hysterectomy was a life-threatening emergency or the client was already sterile and the reason for the prior sterility

30. Common Claim Edits

31. 102 – Duplicate claim Reason code – B13 Remark code – M86 112 – A readmission has been detected Reason code -133 119 – Claim is for a potentially unbundled service Reason code – B13 Remark code – M2 120 – Date of service is more than 365 days from date received Reason code – 29 280- (physician claim) - diagnosis code or procedure code is not on emergent list Reason code – 40 Remark code – N59 215 – Claim should pay by APC or OPPS but system could not group. These hit for 4 reasons: Invalid bill type (usually you see 851 which should be 131) Bad date- the span date doesn’t match the line dates There is no APC to group to (department boo-boo) Revenue code 636 is used wrong-this rev code can only be used for RX or vaccination codes, not for the injections 335 – Procedure code requires review (unlisted code) Common Claim Edits

32. 342 – Diagnosis code requires a review (these are almost always V codes) Reason code 125 Remark code N10 343 – Diagnosis code may not be a covered service Reason code - 47 345 – Sterilization review Reason code – 17 Remark code N3 347 – Hysterectomy review 370 – Abortion review Reason code – 17 Remark code – N3 371 – DRG = 468 (this DRG pays % of charges so is always reviewed for correct coding) this means that there was a procedure on the claim that was not related to the main diagnosis and procedures 483 – Units billed exceed allowed units Reason code – 119 Remark code – M53 460 – Claim requires a prior authorization Reason code 62 Remark code M62 Additional Common Claim Edits

33. 472 – This exception will post when the PASSPORT provider number is missing or invalid Reason code – 15 Remark code M68 487 – This edit will fail when the client is a Team Care client and the Team Care provider did not submit the claim or did not refer the client and the service requires PASSPORT approval Reason code – 15 Remark code M68 905 – Line dates of services are inconsistent with the header level dates of service or the line level date of service is blank (usually see on bundled claims) Reason code – 16 Reason code MA122 920 – Diagnosis code and procedure don’t match- this means that a claim hit before or after the new quarterly grouper was installed and a diagnosis code on the claim now needs a fifth digit or is invalid or the provider used an invalid diagnosis code Reason code - 11 928 – Inpatient only services performed in an outpatient setting-needs review to determine if appropriate Reason code 58 Remark code M77 929 – E&M code on the same date as a surgical or significant procedure without modifier 25 or 27 present on the E&M code (must be on the E&M code – not on the code with a SI of T or S) Reason code 97 Remark code 144 More Claim Edits

34. Contacts • ACS, Inc. Provider Relations; (800) 624-3958 in-state; (406) 442-1837 out of state • Brett Williams, Hospital and Clinic Bureau Chief • Deborah Lane, Hospital and Clinic Analyst • Rena Steyaert, Claims Resolution Specialist; (406) 444-7002; rsteyaert@mt.gov • Debra Stipcich, Transplant and PPS Hospital Program Officer; (406) 444-4834; dstipcich@mt.gov • Mary Patrick, Hospital and Transplant Case Manager; (406) 444-0061; mpatrick@mt.gov • Bob Wallace, Rural Health Program Officer (CAH, FQHC, RHC); (406) 444-7018; bwallace@mt.gov • John Hein, ASC/IHS Program Officer (also ESRD and Freestanding Dialysis); (406) 444-4349; jhein@mt.gov • Thom Warsinski, Cost Settlement Program Officer; (406) 444-2850; twarsinski@mt.gov