Presented by Blue Cross and Blue Shield of Kansas

2016 Ambulatory Surgery Center (ASC) Webinar Presented by Blue Cross and Blue Shield of Kansas

Presenters • Janne Denton, BSN RN • Contract & Specialty Provider Consultant • Connie Winkley • Education and Communications Coordinator • Misty Tillman • Provider Program Specialist

Today's Agenda • BCBSKS Website/BlueAccess/Availity • Institutional Relations Department • Billing Overview • Quality-Based Reimbursement Program (BCBSKS) • Medical Policies • 2017 Contract Changes • Questions and Answers

BCBSKS Website/BlueAccess/Availity • BCBSKS Public Website – www.bcbsks.com • Includes information for providers which does not require secure access including: • Newsletters • Workshops and Training • Medical Policies • ASK/EDI • ICD-10 • Pre-Service Review • FAQs • Glossary • Access to other blue plans pre-services review information. • eNews – Sign up so that you are not left behind!

BCBSKS Website/BlueAccess/Availity • Availity Web Portal - Secure Website • BCBSKS moved secure information to Availity in August 2013 • The following BCBSKS Member information can be found on the Availity Web Portal: • Eligibility and Benefits • Claims Status • Requires secure log in • Access granted from the facility's Availity Access Administrator (AA) • Several payers use Availity, including other Blue Plans and CMS/Medicare • Recent changes to the Availity Web Portal includes the ability to add your favorite tools to you home page.

BCBSKS Website/BlueAccess/Availity • BlueAccess – BCBSKS Secure Website • Accessible only by logging onto the Availity Web Portal • The following information can be found on BlueAccess: • Remittance Advice • Institutional Provider Manual • Patient ID (BCBSKS Member) Search • Pre-Service Review • Institutional Providers General Policies and Procedures • Other secure documents

Institutional Provider Relations Department • Functions of the Institutional Provider Relations Dept: • Liaison between provider and BCBSKS • Manage facility contracts • Provide Training and Education • Communication • Inquiries

Institutional Provider Relations Department • Provider Types: • Ambulatory Surgery Centers (ASCs) • Birthing Centers • Dialysis Centers • Home Health Agencies • Hospice Facilities • Hospitals (Acute, Rehab, Psych, Military and VA) • Substance Abuse

Institutional Provider Relations Department • Institutional Provider Relations Department Staff • Director – Angie Strecker • Manager – Teresa Van Becelaere • Provider Consultants: • Cindy Garrison – Topeka – Northern KS Hospitals • Sally Stevens – Wichita – Southern KS Hospitals • Janne Denton – Topeka – Ancillary Provider • Education and Communication Coordinator – Connie Winkley • Claims Research Analyst – Katie Dennison • Provider Program Specialist – Misty Tillman

Institutional Provider Relations Department • Institutional Provider Relations Department Staff: • Support Staff: • Administrative Coordinator – Topeka – Dona Hewes • Administrative Assistant – Topeka - Melanie Moriarty • Administrative Assistant – Wichita – Kristi Donelan

Institutional Provider Relations Department • ICD-10 Systems and Hospital Audits • Administrator – Rhonda Knoerschild • Senior Field Representative – Todd Colglazier • ICD-10 Coding Specialist – Sheryl Wilson • Administrative Assistant – Mary Schneider

Billing Overview • UB-04 Claim Form • UB-04 submission will apply facility claim edits to ASC's • See Institutional Provider Manual (IPM) for sample of UB-04 claim form and requirements for ASCs

Billing Overview • UB-04 Claim Form Field Locator Completion Details • FL 14 – REQUIRED • PRIORITY (TYPE) OF ADMISSION OR VISIT • Enter the appropriate code indicating the priority of this admission/visit. • FL 15 – REQUIRED (except for TOB 014x) • POINT OF ORIGIN (PoO) FOR ADMISSION/VISIT • Enter the appropriate code indicating the point of patient origin for this admission/visit. The PoO is where the patient came from before presenting to the health care facility. See Blue Cross newsletter BC-13-18 for additional information. • FL 17 –REQUIRED • PATIENT DISCHARGE STATUS • Enter the appropriate two-digit code indicating the patient's discharge status. Note: This is required on all inpatient, observation, or emergency room care claims. For additional information see BCBSKS Newsletter BC-13-14.

Billing Overview • UB-04 Claim Form Field Locator Completion Details • FL 51 – NOT REQUIRED BY BCBSKS • HEALTH PLAN IDENTIFICATION NUMBER • Enter the number used by the health plan to identify itself. • FL 52 – NOT REQUIRED BY BCBSKS • RELEASE OF INFORMATION • Enter a "Y" or "I" to indicate if the provider has a signed statement on file from the patient or patient's legal representative allowing the provider to release information to the carrier. The member's BCBSKS agreement allows us to obtain this information from providers without the signed statement. • FL 53 – NOT REQUIRED BY BCBSKS • ASSIGNMENT OF BENEFITS • Enter a "Y", "N", or "W" to indicate if the provider has a signed statement on file from the patient or patient's legal representative assigning payment to the provider.

Billing Overview • UB-04 Claim Form Field Locator Completion Details • FL 70 – REQUIRED FOR UNSCHEDULED OUTPATIENT VISIT • PATIENT'S REASON FOR VISIT • Enter the appropriate diagnosis code describing the patient's reason for the visit at the time of the outpatient encounter only for bill types 013X, 085X, 045X, 0516, 0526, or 0762. N/A for Ambulatory Surgery Centers • FL 71 – SITUATIONAL • PROSPECTIVE PAYMENT SYSTEM (PPS) CODE • Enter the PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. N/A for Ambulatory Surgery Centers

Billing Overview • UB-04 Claim Form Field Locator Completion Details • FL 72 – SITUATIONAL • EXTERNAL CAUSE OF MORBIDITY AND PRESENT ON ADMISSION INDICATOR • Enter the cause of injury code or codes when injury, poisoning, or adverse affect is the cause for seeking medical care. N/A for Ambulatory Surgery Centers • FL 74 – REQUIRED FOR INPATIENT PROCEDURE • PRINCIPAL PROCEDURE CODE AND DATE • Enter the principal procedure code and date using a six-digit format (MMDDYY) if the patient has under gone an inpatient procedure.N/A for Ambulatory Surgery

Billing Overview • UB-04 Claim Form • Charges for all ASC services, procedures, supplies, equipment and/or implants provided during an outpatient are billed on one claim using the ASC's NPI billing number. • Payment for outpatient surgeries will be reimbursed at an all inclusive rate, based on the MAP.

Billing Overview • Maximum Allowable Payment (MAP) • MAPs are set at a surgical level payment • All procedures eligible for reimbursement in the ASC are MAP'd • Multiple surgeries are reimbursed based on the highest MAP'd surgical code • The total surgical MAP is allocated proportionally over all lines of the claim • MAP lists are mailed annually with contracts, but an electronic (excel) copy of the MAP list can be requested, as well.

Billing Overview • Limited Patient Waiver (LPW) • Submit claims with GA modifies appended to the CPT/HCPCS code

Billing Overview • Limited Patient Waiver (LPW) • The waiver is retained in the patient's file • By obtaining a signed LPW, the Not Medically Necessary (NMN) or Experimental/Investigational (E/I) charges are denied as the patient's responsibility • Cannot use a blanket waiver • If providers use their own waiver form, as opposed to the BCBSKS form, BCBSKS highly recommends that you have your IR Provider Consultant review the waiver to ensure it contains all required information

Welcome to Availity Type in www.availity.com into the browser window Click on the Login to get started!

Log into Availity… Recommendations: Add this page to you Favorites for quick and easy access

Availity continued… Click on the Blue Cross and Blue Shield payer space.

BlueAccess Click on the BCBSKS Provider Secure Section (Blue Access)

BlueAccess Select your facility name from the drop down menu.

BlueAccess Enter your institution's tax ID number.

BlueAccess Make sure that you select the NPI with (Inst) next to it. DO NOT select the Professional organization!

Accessing the QBRP Portal! Click on QBRP Portal

Quality Based Reimbursement Program

Quality Based Reimbursement Program Click on QBRP Form to report your prerequisites, data, and attestations

Quality Based Reimbursement Program • Program Description • Explains what QBRP is. • Measure Set Descriptions • Detailed guide to each measure. • Recent Publications • Provides links to any publications that BCBSKS has made about QBRP . • Portal Instruction Manual • QBRP Portal User Guide

Program and Measure Set Description

Quality Based Reimbursement Program This feature is not available for ASC facilities.

Quality Based Reimbursement Program • My Scorecard • This function will be available in 2017. • Update Contact Information • This can be used for administrative and demographic changes.

QBRP Scorecards Scorecards are mailed out at the end of each reporting period.

Important Dates • Period 1Period 2 Due no later than November 5, 2016Due no later than May 5, 2017 • Period 1 incentives will be effective January 1, 2017 Period 2 incentives will be effective July 1, 2017 Period 1 incentives are effective Period 2 incentives are effective Period 1 submission due Period 2 submission due

Prerequisites • I attest that this facility will file all claims electronically. • I attest that this facility will accept electronic remittance advices through the ANSI 835 transaction or retrieve remittance advices from the BCBSKS website. • I attest that this facility will obtain eligibility, benefit and claim status information primarily through electronic transactions. These transactions will be accessed through the Availity interface or the ANSI 270/271 transaction to electronically obtain BCBSKS patient eligibility and benefit information. BCBSKS claim status information will be accessed through the Availity interface or the ANSI 276/277 transaction.

2017 QBRP Measures

QM1: Prophylactic Intravenous (IV) Antibiotic Timing (CMS ASC-5) • Numerator: Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infections (SSI) who received the prophylactic antibiotic on time • Denominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection • Incentive: 1.75%

QM2: Falls Within the ASC (CMS ASC-2) • Report the number of ASC admissions experiencing a fall within the confines of the ASC. • Numerator: Falls within the confines of the ASC • Denominator: All ASC admissions • Incentive: 1.75%

QM3: All-Cause Hospital Transfer/Admission (CMS ASC-4) • Report ASC admissions that are transferred or admitted to a hospital upon discharge from the ASC. • Numerator: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. • Denominator: All ASC admissions • Incentive: 1.75%

QM4: Surgical Time Out • I attest that this hospital has implemented and is consistently using a time-out protocol which requires a hard stop by all surgical staff after prep and drape and prior to the start of the procedure. The protocol shall include the following: (a) Identification of the patient by name. (b) The procedure is stated. (c) The marked incision site is visible. (d) Allergies are stated and shared with the team and selected prophylaxis antibiotics ordered and given. (e) The team is asked about any concerns before starting. Concerns are shared with the team and discussed to mitigate risk. • Incentive: 1.00%

Medical Policies • Medical Policies reflect medically necessary criteria used/developed by BCBSKS • The policies are located on the Institutional Provider page on the BCBSKS website • http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies.shtml • Medical Policies do not guarantee benefits • Policies apply to Institutional and Professional providers • All services are subject to medical necessity; please refer to the "by report" codes on your MAP listing that also are reviewed by our Medical Review staff

2017 Contract Changes In 2017, the reimbursement for CPT 19303 will be reduced to better reflect the resources required for this service. Based on additional information submitted by providers, the following procedures in the table below will be added to the ASC maximum allowable payment listing in 2017. Please refer to the separate MAP listing included in the contracting package for the entire 2017 MAP listing for ASCs.

2017 Contract Changes • Overview of Policy and Procedure Changes • Overview of Policy and Procedure Payment Attachment Changes

Questions and Answers If you have additional questions after today's webinar concludes, please contact us at the email or number below: Janne Denton – janne.denton@bcbsks.com (785)291-8813 Connie Winkley – connie.winkley@bcbsks.com (785)291-7236 Misty Tillman - misty.tillman@bcbsks.com (785)291-6593 Thank you for participating in today's webinar!

Presented by Blue Cross and Blue Shield of Kansas