CONNECTIONS TESTING FOR ICD-10

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1 TESTING FOR ICD-10 In conjunction with the Centers for Medicare and Medicaid Services (CMS), Providence Health Plan (PHP) and all major payers will convert from International Classification of Diseases, Ninth Revision (ICD-9), to International Classification of Diseases, Tenth Revision (ICD- 10), on October 1, All PHP applications will be ready for end-to-end (i.e., start to finish) formal testing by the summer of PHP will be testing with the clearinghouses and trading partners with which it does business and with all providers who submit claims to those clearinghouses and trading partners starting this summer. Specifically, PHP will be processing electronically submitted claims (known as Electronic Data Interchange or EDI 837) sent from the clearinghouses and will be providing Electronic Remittance Advice (ERA) 835 to those same clearinghouses. PHP will be implementing beta testing the first half of the year with select providers. For additional information on the transition to ICD-10, visit the CMS websites: index.html?redirect=/icd10/ ProviderResources.html March-April 2014 In This Issue Testing for ICD-10 Payment Policy Updates Always Use Current Codes (REPEAT) Modifiers 33 and PT (REPEAT) Dosimetry Calculations and Treatment Devices Documentation Required for Appeals Pharmacist-Managed ACC Correction to Previous Connections Article CPT Codes and No Longer Recognized by PHP PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery 1

2 PAYMENT POLICY UPDATES PHP completed its annual review of payment policies, and the updated policies have been published on ProvLink. The following policies have changes: Payment Policy 09.0 (Anesthesia): Added a statement saying claims billed with modifier AD will pend for medical review. Added instructions for reporting injections given for postoperative pain control. Payment Policy 13.0 (Bundled or Adjunct Services): Added codes (telephone consultation services), which also have a bundled status on the Medicare Physician Fee Schedule. Added HCPCS codes G9001-G9140, which are designated as Coordinated Care or Demonstration Project, codes and should not be used by providers not involved in a Medicare demonstration project. Payment Policy 51.0 (Modifier -47): Anesthesia provided by the surgeon is not paid separately by PHP. The wording previously said no additional payment would be made for anesthesia provided by the surgeon and the modifier was considered informational only. Wording was changed to show that surgery codes billed with modifier -47 will be denied. To report provision of anesthesia by the surgeon, one surgery code may be reported with modifier -47 and one without modifier -47, and only the code without the modifier will be paid. Payment Policy 52.0 (Medical Visits): Added wording to clarify that providers of the same specialty within the same group practice may not report multiple E&M services on the same day. This is not a change in policy but a clarification of current policy. Payment Policy 53.0 (E-Visits): Changed policy to show only providers who may report E&M services may bill E-visits. Payment Policy 67.0 (Telehealth Services): Transitional care management codes (99495 and 99496) added to the policy. Payment Policy 87.0 (Wellness Visits for Medicare Advantage): Added instructions for billing Wellness Plus Visit (code S0250). Payment Policy 90.0 (Chemotherapy Administration): Code Q2050 added to the policy. Payment Policy 91.0 (Pharmacist Managed Anticoagulation Clinic): This policy was published October 1, See related article in this issue. 2

3 ALWAYS USE CURRENT CODES Providers may use only the most current code sets for billing PHP. PHP Payment Policy 19.0 (Service Code Policy) states, Providence Health Plan will use the most current published service codes for coverage issues and pricing. These service codes are published in the Current Procedural Terminology (CPT), International Classification of Diseases (ICD), HCPCS (National Level II codes) and Diagnostic Related Groupings (DRG) books. Systematic implementation of approved service codes and rates is effective January 1. Per HIPAA guidelines, the most current code sets must be used for billing services. As it does every year, PHP began accepting the current codes on the first of January. The 2014 CPT codes may be used for dates of service on or after January 1, Codes that are new this year will be retrofitted for contracts that use the previous year s relative value schedule for setting payment rates. MODIFIERS 33 AND PT Modifier 33 is used to identify a service that was originally intended to be preventive, but the focus changed to an illness-related visit or procedure due to abnormal findings during the preventive service. Modifier 33 was developed to identify services that should be paid as preventive according to government mandates for payment of preventive services. Modifier PT is used to identify a colorectal cancer screening test that was converted to diagnostic test or other procedure due to abnormal findings on the screening exam. PHP accepts either modifier 33 or modifier PT to identify colorectal cancer screening tests that are converted to a diagnostic test or other procedure. Modifier 33 should not be used on codes that are specifically identified as preventive. For example, modifier 33 would not be appended to CPT code 99395, as this code is already identified as a preventive service. However, if the patient presents for an annual exam, and during the course of performing the annual exam the physician finds a medical problem that needs to be addressed, the physician may elect to report CPT code instead of CPT code In this case, the provider would append modifier 33 to CPT code to identify the original intent of the visit as a preventive service. The preventive and problemfocused services would both be performed and billed with one code, i.e., All claims billed with modifier 33 or modifier PT will be pended by PHP for manual review. Chart notes may be requested to verify the nature of the service. 3

4 DOSIMETRY CALCULATIONS AND TREATMENT DEVICES CPT code is used to report, Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose. PHP allows payment for one unit of CPT code for each treatment port (each gantry angle for IMRT) per course of therapy, with additional calculations allowed if medically indicated, to a maximum of ten units total (combined for all ports or gantry angles) per course of therapy. Code may only be reported when the plan is verified. The documentation must show the date of verification and must be signed by the provider who performed the verification. The date of service is the date the plan is verified. PHP allows payment for one set of treatment devices (CPT code 77332, 77333, or 77334) for each port (each gantry angle for IMRT), with additional units allowed if medically indicated, to a maximum of ten units total (combined for all ports or gantry angles) per course of therapy. A pair of devices for opposing ports (e.g., left and right lateral, AP and PA) constructed from a single film is considered one port for billing purposes. The date of service is the plan print date. PHP allows up to six units of and six units of 77332, 77333, or to be paid without review. When more than six units of or more than six units of 77332, 77333, or are needed during the course of therapy, the provider may submit an appeal with chart notes supporting all the units billed. When dosimetry calculations and/or treatment devices are billed across multiple dates of service, chart notes will be required for all dates of service. If medically indicated and supported by the documentation, PHP may allow up to ten units of code and up to ten units total of 77332, 77333, or per course of therapy. Documentation must show the actual dose calculations (as outlined in the CPT code description) approved and signed by the provider to support reporting code Documentation must show a description of the treatment devices (as outlined in the CPT code description) to support reporting codes 77332, 77333, and/ or For additional information, please refer to PHP edit review for Multiple Units of 77300, , and 77338, which is available on ProvLink. 4

5 DOCUMENTATION REQUIRED FOR APPEALS Providers are required to submit the final, signed draft of any medical records sent to PHP for review. If the provider s signature is missing from the note, or if the signature is illegible, the documentation will not be considered for review. A refund may be requested for services already paid. An electronic signature is acceptable if it is added to statements such as authenticated by or reviewed by. It must be clear to the reviewer that this is an electronically generated statement. A typed name alone is not valid and would need to have a handwritten signature authenticating the entry. Providers are advised to review PHP Payment Policy 58.0 (Documentation Guidelines for Medical Services), which is available on ProvLink, for complete information on what documentation is required to support services billed to PHP. To avoid delays when submitting records to appeal denied services, submit signed records for ALL services billed on that date. It is not sufficient to send documentation supporting only the denied code. If documentation is not submitted for all services billed on claim, the appeal may be returned to the provider requesting additional notes. Include documentation to support all lab tests, x-rays, surgical or diagnostic procedures, and E&M services billed. PHARMACIST-MANAGED ANTICOAGULATION CLINICS PHP allows payment for face-to-face visits and/or telephone visits provided by a pharmacist in a medical clinic or an outpatient hospital setting where the pharmacist regulates anticoagulation therapy using physician-approved protocols as authorized by ORS collaborative drug therapy rules and in accordance with the Oregon State Board of Pharmacy. PHP Payment Policy 91.0 (Pharmacist-Managed Anticoagulation Clinics) was published on ProvLink on October 1, 2013 to give billing and coding information for these services. Please refer to the payment policy for additional information. 5

6 CORRECTION TO ARTICLE ABOUT PAYMENT POLICY 03.0 An article in the January/February 2014 issue of Connections about updates to PHP Payment Policy 03.0 (Assistant for Surgery) stated in error that an assistantat-surgery had to bill the same charge for surgery as the surgeon. The same code must be reported, but it is not necessary for both providers to bill the same amount. PHP Payment Policy 03.0 (Assistant for Surgery) reads: The assistant surgeon must report the same code reported by the surgeon with the addition of the appropriate modifier (80, 81, or AS). Reimbursement is based on the assistant surgeon s contract and is a percentage of the allowed amount for the surgery as listed below. Please review PHP Policy 03.0 (Assistant for Surgery) on ProvLink for additional information. CODES AND NO LONGER RECOGNIZED BY PHP Effective June 1, 2014, PHP will not recognize CPT codes or but will require providers to use HCPCS codes G0461 and G0462 to report immunohistochemistry tests. Claims billed with codes and will receive a denial notice advising providers to Rebill HCPCS/CPT with appropriate HCPCS/CPT. Providers receiving this denial notice may send a corrected claim reporting G0461 and G0462 instead of and The CPT Editorial Panel revised the existing immunohistochemistry code, CPT code 88342, and created a new add-on code 88343, for Prior to 2014, coding requirements allowed CPT code to be billed once per specimen for each antibody, but the revised CPT codes and descriptors allow reporting of multiple units for each slide and each block per antibody (88342 for the first antibody and for subsequent antibodies). CMS felt that this coding would encourage overutilization by allowing multiple blocks and slides to be billed. To avoid this incentive, CMS created HCPCS codes G0461 (Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain) and G0462 (each additional single or multiplex antibody stain) to ensure that the services are reported once for each antibody per specimen. PHP will be following CMS guidelines for codes G0461 and G0462 for all lines of business. 6

7 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 a29 b01 b02 d01 d02 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on codes billed without an appropriate parent code Co or team surgeons not appropriate for code Charges are included in global OB payment Postoperative visit included in global surgery payment New patient visit frequency exceeded per CPT guidelines Pharmacy codes currently invalid Lifetime maximum for procedure exceeded Bundled/global services, services are never paid separately Chemo admin code not allowed with this drug Clinical daily maximum exceeded for this service Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service Procedure is incidental to another procedure Procedure is mutually exclusive to another procedure Postoperative care is included in global surgical payment Preoperative care is included in global surgical payment Assistant surgeon not allowed for this procedure Invalid gender for procedure Age does not fit within range described by procedure Rebundle edit occurred with a claim in history Duplicate unilateral or bilateral procedure Daily maximum for this procedure has been exceeded Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum Mutually exclusive edit with claim in history Incidental edit with claim in history CCI edit, procedure is incidental to another procedure CCI, current claim denied as incidental to claim in history CCI edit, procedure mutually exclusive to another procedure CCI, current claim denied as mutually exclusive to claim in history 7

8 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). A review of the coding applications will be initiated. Service may be allowed and the claim reprocessed. Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you. Appeal If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld. Edit Reviews When there is a high volume of inquiries or appeals about a specific edit combination, PHP Medical Directors will review the edit combination. If the decision is made to reverse the edit, PHP will implement within 7 days. If the decision is made to uphold the edit, we will publish the information in Newsletter. If an edit combination is upheld, we will ask that you not continue to submit individual claims for review unless there is a clear and distinct exception clearly documented. 8

9 PAYMENT RULES Payment Rules are located on ProvLink. Please review these, as they may explain many of the payment applications that affect your claims payment. It is our policy to notify providers via Connections newsletter prior to implementing new payment rules. ELECTRONIC CONTRACT DELIVERY Providence Health Plan offers secure electronic contract delivery. If you have not already done so, please provide your Providence Health Plan Provider Relations Representative with an address for the person in your organization who should receive contract negotiation and contract update information. Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and to your Providence Health Plan Provider Relations Representative. 9

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