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1 #352 March 2013 THORConnect.org Table of Contents Coding and Billing Psychiatric and Substance Abuse Services Institutional... 1 Psychiatric Services... 1 Inpatient... 2 Residential Treatment Centers (RTC)... 2 Partial Hospitalization... 2 Intensive Outpatient Program (IOP)... 3 Substance Abuse Services... 3 Inpatient... 3 Residential Treatment Centers (RTC)... 3 Partial Hospitalization... 4 Intensive Outpatient Program (IOP)... 4 Medical Policy Medical Policies Available Online... 4 BlueCard New Imaging Management Program for The Boeing Company Members... 5 News Preauthorization can be obtained by submitted information Glad You Asked... 5 Coding and Billing Psychiatric and Substance Abuse Services Institutional There was a typographical error in the Substance Abuse IOP article published in the December News issue 349. Facility-based substance abuse IOP should be billed with Revenue Code The code was incorrectly listed as Many different levels of psychiatric and substance abuse services are provided by facilities with various types of licensure. These services are billed on the UB-04 using the facility s National Provider Identifier (NPI). Each level of care requires specific billing and coding information, which determines appropriate reimbursement. The billing guidelines for these various levels are listed below. All inpatient, residential treatment and partial hospitalization services require preauthorization. on THOR or by calling Psychiatric Services Psychiatric Services Type of Provider Type Bill Title font is: Wiesbaden Swing LT Std Revenue Code Level HCPCS Inpatient N/A N/A Private 0124 Semiprivate Residential 86X 1001 N/A T2048 Treatment Center (RTC) - Adolescents Only Partial Half Day S9480 Hospitalization Full Day S Specialty Program S9485 Intensive Outpatient Program (IOP) N/A H2020

2 Inpatient Inpatient services are reimbursed an all-inclusive per diem that includes all medically necessary services used in a hospital treatment program such as room and board, lab, x-ray, all therapies including ECT, and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. These services should be billed using traditional revenue codes. Services by psychiatrists and psychologists inherent to the treatment program, such as group therapy, should not be billed separately on the CMS Psychiatrists and psychologists may bill separately on the CMS for services outside of the treatment program diagnoses and hospital Evaluation and Management (E&M) services. Residential Treatment Centers (RTC) RTC services are reimbursed on a uniform per diem basis and per diem payments are based on the lesser of charge or the per diem rate. The per diem rate includes all medically necessary services used in the RTC program, such as room and board, lab, all therapies and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. Services by psychologists and psychiatrist inherent to the treatment program, such as group therapy, should not be billed separately on the CMS Psychiatrists and psychologists may bill separately on the CMS for services outside of the treatment program lthcare diagnoses and News hospital E&M services. Group or family counseling cannot be billed in addition to the RTC stay. Partial Hospitalization Partial hospitalization services are reimbursed the lesser of charges or an all-inclusive per diem payment that includes all medically necessary services used in the program. This includes all services and disciplines normally used in the program, such as all therapies, social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. Psychiatrists and psychologists may bill separately on the CMS-1500 for services outside of the treatment program that are medically appropriate and necessary, such as psychological testing, individual therapy for psychiatric diagnoses and hospital E&M services. Group or family counseling cannot be billed in addition to the partial hospitalization stay. Blue Cross Blue Shield of North Dakota (BCBSND) recognizes three levels of psychiatric partial hospitalization treatment. These levels are defined by: The number of active treatment program hours per day The days of offered treatment per week The number of licensed professionals (disciplines) treating the patient The following grid delineates the program hours per day as well as days per week offered and disciplines involved. Each of these levels is further separated into child (ages 0 through 12 years), Adolescent (ages 13 through 17 years) and Adult (ages 18 years and older). Partial Hospitalization - Psychiatric Half Day Full Day Specialty Program Active treatment program hours Days per week program is offered Licensed professionals treating patient 3 hours per day 5 or 4 or hours per day 5 or 7 or hours per day 5 or (number of disciplines) 3 or 3 or HCPCS Code S9480 S S9485 As approved on program basis by BCBSND Clinical Directors Specialty Programs provide services above and beyond those of standard partial hospitalization programs in an effort to achieve improved outcomes for specific disorders. To be reimbursed as a Specialty Program, the Program must be approved by BCBSND for that level of care, and the patient must meet medical necessity requirements for that level of care during the preauthorization process. Specialty applicant programs are evaluated using the following criteria: Evidence that staff involved in the Specialty Program have a significantly higher level of expertise in treating the disorder than the standard partial hospitalization program. This evidence may include post-graduate courses or extensive workshops in the disorder or in a treatment protocol, staff publications in scholarly journals, certification of specialty training, etc. Evidence that the nature of patients being treated in the Specialty Program require treatment given by a higher level of expertise than the standard program, and require 7 or hours of active treatment per visit. To be granted this status, the facility must provide documentation to support their request. Determination of Specialty Program status will be made by BCBSND s Medical Director of Behavioral Health. 2 #352 March 2013 THORConnect.org

3 Intensive Outpatient Program (IOP) Psychiatric IOP is a facility-based level of care and is defined as a structured, short-term treatment modality intensive than outpatient treatment but less intensive than partial hospitalization provided by an appropriately credentialed health care facility. It is a multi-disciplinary program of at least three (3) treatment hours per day at least three (3) times per week with an individualized treatment plan and length. Psychiatric IOP does not have a pre-determined program length. Psychiatric IOP does not require pre-authorization. Psychiatric IOP is paid on the lesser of charge or a per diem rate. Psychotherapy services (individual, family and group) and pharmacologic management services completed by any provider type are considered to be included in the facility per diem payment. For reimbursement purposes, the facility must be licensed and credentialed for partial hospitalization services before being eligible to be credentialed for IOP. Participating facilities that are currently credentialed for partial hospitalization services must still be credentialed by Blue Cross Blue Shield of North Dakota (BCBSND) before being eligible to be reimbursed for psychiatric IOP services. The IOP Program must be reviewed and approved at the Program level. Substance Abuse Services Substance Abuse Services Provider Type Type of Bill Revenue Code Inpatient Private 0124 Semiprivate Residential Treatment Center (RTC) - Adolescent Residential Treatment Center (RTC) - Adult Partial Hospitalization Intensive Outpatient Program (IOP) ASAM Level III.7 III.7-D IV HCPCS N/A IV-D 086X 1002 III.1 H X 1002 III.5 H X 1002 III.1 H X 1002 III.3 H X 1002 III.5 H II.5 S II.1 H2035 BCBSND has restructured substance abuse services in order to support the continuum of care model warranted by the American Society of Addiction Medicine (ASAM). The differing levels of care for substance abuse are identified by the numeric ASAM level of care. Inpatient Inpatient services are reimbursed an all-inclusive per diem that includes all medically necessary services used in a hospital treatment program such as room and board, lab, x-ray, all therapies including ECT, and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. These services should be billed using traditional revenue codes. Services by psychiatrists and psychologists inherent to the treatment program, such as group therapy, should not be billed separately on the CMS Psychiatrists and psychologists may bill separately on the CMS for services outside of the treatment program diagnoses and hospital Evaluation and Management (E&M) services. Residential Treatment Centers (RTC) Substance Abuse Residential Treatment Centers will continue to be reimbursed on a uniform per diem basis and payment will be based on the lesser of charge or the per diem amount. Substance abuse RTCs levels of care continue to be identified based on ASAM definitions and criteria. The per diem rate includes all medically necessary services used in the RTC program, such as room and board, lab, all therapies and services of social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. Services by psychologists and psychiatrist inherent to the treatment program, such as group therapy, should not be billed separately on the CMS News Psychiatrists and psychologists may bill separately on the CMS-1500 for services outside of the treatment program diagnoses and hospital E&M services. Group or family counseling cannot be billed in addition to the RTC stay. The per diem for ASAM Level III.5 services will be a diminishing per diem rate methodology for care rendered at the same facility. A diminishing per diem rate methodology has different per diem amounts based on the length of stay of the episode of care. A minimum of 30 days between admissions will be required before starting a new reimbursement episode. Days 1 through 21 Services will be reimbursed at the full per diem amount. Days 22 through 29 Services will be reimbursed at 75% of the full per diem amount. Days 30 through end of stay Services will be reimbursed at 50% of the full per diem amount. #352 March 2013 THORConnect.org 3

4 The per diem for ASAM III.1 will continue to be reimbursed on a uniform per diem basis and payment based on the lesser of charge or the per diem amount. This amount has been reduced substantially from the prior year to appropriately reflect the services provided. Partial Hospitalization Partial hospitalization is identified as ASAM II.5 for adolescents and adults. Reimbursement for ASAM II.5 corresponds to the Full Day description noted on the partial hospitalization fee schedule. Partial hospitalization services are reimbursed the lesser of charges or an allinclusive per diem payment that includes all medically necessary services used in the program. This includes all services and disciplines normally used in the program, such as all therapies, social workers, licensed addiction counselors, psychiatric nurses, occupational therapists, dieticians, etc. a and psychologists may bill separately on the CMS-1500 for services outside of the treatment program that are medically appropriate and necessary, such as psychological testing, individual therapy for psychiatric diagnoses and hospital E&M services. Group or family counseling cannot be billed in addition to the partial hospitalization stay. Intensive Outpatient Program (IOP) Substance Abuse IOP facility-based programs will be reimbursed a per diem rate effective January 1, This per diem rate will apply to a structured ASAM Level II.1 facility-based program in which the provider also offers ASAM II.5 services in order to facilitate individualized, coordinated delivery of service intensity as intended by ASAM. IOP is intensive than outpatient but less lthcare intensive than News partial hospitalization, these services must be billed on the UB-04. Payment will be based on the lesser of charge or the per diem amount. If these services are an integral part of another program, they cannot be identified separately. If an independent practitioner with the appropriate licensure provides IOP, the services are submitted on the CMS-1500 using H2035 which is then reimbursed based on an hourly rate rather than the facility rate. Medical Policy Medical Policies Available Online Blue Cross Blue Shield of North Dakota regularly develops and revises medical policies in response to rapidly changing medical technology. Our commitment is to update the provider community as medical policies are adopted and/or revised. Benefit determinations are made based on the medical policy in effect at the time of service. The following medical policies were reviewed by the Internal Medical Policy Committee on January 15, Medical policies are available online at New Medical Policies Xtandi Effective March 1, 2013 Synribo Effective March 1, 2013 Urinary Tumor Markers for Bladder Cancer effective March 1, 2013 Genetic Testing for Inherited Thrombophilia effective March 1, 2013 Psychiatric Intensive Outpatient Program Eating Disorder Intensive Outpatient Program Draft Policies Available for provider comment. See policy for comment period. Epidermal Growth Factor Receptor Mutation Analysis Revised medical policies See policy for effective date Weight Loss Prescription Medications Percutaneous Annuloplasty Votrient Zytiga PATH Gene Expression Profiling for Breast Cancer Medical Indications for Coontraceptives PET Scan Genetic Testing for Colorectal Cancer Bariatric Surgery Retired: Low Osmolar Contrast Media medical criteria listed in BCBSND Bulletins 200, #352 March 2013 THORConnect.org

5 BlueCard New Imaging Management Program for The Boeing Company Members Effective January 1, 2013, The Boeing Company, in partnership with Blue Cross and Blue Shield of Illinois and AIM Specialty HealthSM is expanding its Radiology Quality Initiative (RQI) program to 15 additional states. This makes AIM effective for all Boeing employees. RQI is a prospective clinical review program for outpatient advanced diagnostic imaging services. Participating members can be identified by the alpha prefixes ( BHP, BYR, BEM, BCU ) that appear on their BlueCross BlueShield member ID cards. The diagnostic imaging studies covered under this program include the following: Computed Tomography (CT/ CTA) Magnetic Resonance Imaging (MRI/MRA) Nuclear Cardiology Positron Emission Tomography (PET) Imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and free standing surgery centers), urgent care centers, or 23-hour observations are excluded from this requirement. For most situations, the above information will suffice. For complex cases, information may be necessary, including results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history). If you have any questions or require any additional information, please contact the number on the back of the member s ID card. Source: Blue Cross Blue Shield Association Glad You Asked Question: When a patient comes into our facility and rents an HME item, we submit the claim with a place of service 11- office or 17- walk in retail health clinic. How do we bill the subsequent rental when the patient is using the item at home but the item was initially picked up in the office? Answer: If the patient is continuing to use an item at home that was picked up in the office, the subsequent rental claims should be billed with place of service 11 or 17. Place of service 12- home should be used if supplies or equipment are shipped to the patient s home. How the Process Works Similar to your existing imaging management program, all providers are required to contact AIM for an order number before scheduling one of the outpatient advanced diagnostic imaging procedures listed above for a Boeing member. Imaging providers are strongly encouraged to verify that an order number has been obtained before scheduling and performing diagnostic imaging exams. You may contact AIM to request or verify an order number one of two ways: online through AIM s ProviderPortal SM at or via telephone at (866) If you are already registered for AIM s ProviderPortal, you do not need to register again. News Required Information for Imaging Requests The checklist below is a guideline to help ensure you have all the information necessary when submitting a request for an imaging exam: Member s identification number, name, date of birth, and health plan Ordering physician information (name, location) Imaging provider information (name, location) Imaging exam(s) being requested (body part, right, left, or bilateral) Patient diagnosis (suspected or confirmed) Clinical symptoms/indications (intensity/duration) #352 March 2013 THORConnect.org 5

6 PRSRT STD U.S. POSTAGE PAID Fargo, North Dakota Permit No th Ave S, Fargo, ND RETURN SERVICE REQUESTED Routing Box Date received: Please route to: m Office manager m Physician m Nurse m Billing manager m Billing agency m Receptionist m Other: News is published as a service to health care providers. Please send all written inquiries to: Provider Service Blue Cross Blue Shield of North Dakota th Avenue S. Fargo, ND Provider Service a.m. 4:30 p.m. CST 8 a.m. 4:30 p.m. CST Monday, Tuesday, Thursday, Friday Wednesday FEP a.m. 4:30 p.m. CST Monday through Friday Case Management Fax: a.m. 4:30 p.m. CST Monday through Friday The Healthcare Online Resource Welcome to THOR (The Healthcare Online Resource) THOR is a self-service website that allows providers, payers and other professionals secure access 24/7 to information regarding claims, patients and a wide range of electronic services to help do business faster, accurately and at less cost. Register online at THOR provides secure access to the following functions and : Submit professional claims online and receive payment information within seconds. View claim status and submit claim adjustments. Correct claims electronically in a real-time environment. Verify eligibility, benefits and coverage information. Check deductible and out-of-pocket status. Create, update and view referrals and admission notifications. Submit and receive a response for a Contraceptive Medication Request. Receive your weekly remittances electronically. E-Services offered: Bulletin Board, Chiropractic Fee Schedule, Claim Inquiry, Claim Adjustment, Claim Correction, Contraceptive Medication Request, Electronic Payment Listing, Membership, Injectables/Other Pharmacy Fee Schedule, Physician Payment Schedule, Preauthorization and Referral, Provider Data Exchange, Real Time Claims Submission, Reference Lab List and Provider Directory. Call Application Support Services at THOR (8467) or for a demonstration or training on any of the THOR applications (4891) 2-13

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