Introduction FQHC Overview Medicare Reporting Part A Encounter Rate Services Part B Services EOB Examples Payment Posting & Calculations Summary

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1 Partnering with CHCs to Help Achieve Their Mission Priority Management Group, Inc. 700 School Street Pawtucket, RI P: F: Introduction FQHC Overview Medicare Reporting Part A Encounter Rate Services Part B Services EOB Examples Payment Posting & Calculations Summary Linda Howrey has an extensive background in healthcare compliance ranging from early days as a billing and coding professional to elevated status as an expert witness on several government actions involving Fraud and Abuse allegations. Linda has worked as a consultant (Physician Practice Service) with Ernst and Young, Hayes Management Consulting and Trusent Solutions. She has traveled extensively throughout the United States working with teaching hospitals and academic practices as well as large and small physician practices. She has developed professional coding and E+M auditing workshops, presented for more than 20 years at national coding/billing workshops, and is a sought after expert in the field of coding and billing. Linda s teaching experience is extensive with work as an adjunct professor at Kaplan University, and an assistant professor at American Intercontinental University and the Massachusetts College of Pharmacy and Health Sciences University. She has written extensively with her some of her most relevant contributions including technical guidance provided for The Professional Medical Assistant: An Integrative, Teamwork-Based Approach, (F.A. Davis), contributing editor for the Representing Physicians publication from the American Health Lawyers Association, contributing author for Health Law & Compliance Update (2010 Edition), and a contributing editor to AHIMA s Journal of AHIMA (August 2008) and past editor of the Physician Practice Coder. At PMGC, Linda will be responsible for new product development, leading Billing Audits, providing training, in person and through Webex, as well as optimizing revenue cycle opportunities. BS, Business Administration from the College of St. Mary (Omaha, NE) EJD, with a Health Law concentration from Concord Law School (Los Angeles, CA). CPC, from the American Academy of Professional Coders (1993) CCS-P, from AHIMA (1997) Trained Mediator from Mediation Works, Inc (Boston, MA) 1

2 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Neither NACHC nor Priority Management Group, Inc. accepts any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service. Encounter Rate Face-to-face with core provider Fixed Rate of Reimbursement vs. FFS So why is coding important? Appropriate capture of breadth & scope of service Compliance Commercial FFS maximization Managed Medicaid with Encounter Rate secondary Data collection for PPS change for Medicare in 2014 data is being collected as of 1/1/11 Cost Based Oversimplified $100,000 to see 1,000 visits PPS (Medicaid) vs. Cost Based (Medicare) PPS Prospective Payment System Sets an FQHC specific baseline based on average cost per visit Medicare s definition of a visit or billable encounter is: A one-on-one face-to-face encounter in an outpatient setting between a patient and a FQHC Core Practitioner. Medical Doctor (MD, DO) Optometrist Note: Some Medicaid programs Podiatrist also include Registered Nurses as Chiropractor Core Providers Physician s Assistant (PA) Certified Midwife (CNM) Nurse Practitioner (NP) Clinical Psychologist (CP) Licensed Clinical Social Worker (LCSW) Certified Diabetic Educator 2

3 Flat Cost-based Encounter Rate (Core Provider = threshold) Unique Medicare Benefits Deductible waived (Part B.yes) Preventive Visits (e.g., 99387/99397) covered Expanded to include Annual Well Visit (AWV) Encounter Rate (Typically 80% of rate below) Rural: $109.90; Urban: $ Co-pay based on FFS charges has charge of $45 co-pay is $9 NOT 20% of encounter rate No Co-pay for AWV and certain preventive services Additional Encounter Rate Scenarios Nursing Facilities & Homebound patients According to the Medicare Benefits Policy Manual Chapter 13 Section 40.1, the following preventive primary services may be covered and billed to the intermediary when provided by FQHCs to Medicare beneficiaries: Medical social services; Nutritional assessment and referral; Preventive health education; Children s eye and ear examinations; Prenatal and post-partum care; Prenatal services; Well child care, including periodic screening; Immunizations, including tetanusdiphtheria booster and influenza vaccine; Voluntary family planning services; For women only: Clinical breast exam; Referral for mammography; and Thyroid function test. Taking patient history; Blood pressure measurement; Weight measurement; Physical examination targeted to risk; Visual acuity screening; Hearing screening; Cholesterol screening; Stool testing for occult blood; Dipstick urinalysis; Risk assessment and initial counseling regarding risks; This is NOT the Welcome to Medicare Exam (IPPE) not the Annual Wellness Visit (AWV). This is the annual exam as described by Medicare Fiscal Intermediaries (FIs) are denying many 993XX services as non-covered service. FIs are recommending a code change to IPPE and AWV. Not the same!! FIs have interpreted targeted to risk to mean that the patient has diagnosed risk factors. Claims with and V70.0 are denying in most instances. Claims with and V70.00 AND a problem diagnosis code (401.9 or etc.) are paying Re-train providers to list all conditions addressed at the visit in addition to the V70.00 Re-train billers to link all diagnosis codes to the 993XX code; ensuring V70.00 is still primary. 3

4 Encounter Rate Ineligible CODE WHAT YOU DID Billing/Charge Entry must know what is billable Nurse Visits, INR, BP Checks, etc. Carve Outs Immunizations (Cost Report) Labs (Billable to Part B) Medicare Wrap Around Medicare Advantage balance billing Medicare As Secondary Payer (ASP) when using incident to billing option Encounter Rate Logic professional core provider Diagnostics -TC Only (not professional (-26)) Historically, Part A: UGS/NGS for ANSI 837I New sites going forward: Part A MAC Part A Submission (EDI) must have EDI Enrollment Form (Trading Partner Agreement) Submitter Action Request form (obtain a submitter ID or links to clearinghouse submitter ID Indicate desire for ERA on this form!! Part B always goes to carrier MAC ALL FORMS LISTED ABOVE 855R for EACH provider Direct Deposit (EFT) for Parts A&B: CMS-588 Recommend clearinghouse vs. direct submission v4010 (Transition to v5010 by Jan 2012) Medicare Part A Intermediary/FI Medicare Part B Carrier/MAC UB-04 (ANSI 837I) Medical: 521 Revenue Code Behavioral Health: 900 code Three Encounter Types 1. Medical a. 80% of Encounter Rate 2. Behavioral Health a. Individual face-to-face b. Encounter Rate Reduction 3. Medical Nutrition Therapy (MNT) or Diabetes Self Management Training (DSMT) CMS 1500 (ANSI 837P) Four Typical Options 1. Office Based Diagnostic Lab a : Urine Dip 2. X-Ray a TC: Chest x-ray 3. Machine Testing a : EKG (TC Only) 4. Hospital Billing a : Initial Hospital Care b. Inpatient Surgery 4

5 Medicare FQHC Benefits Part A Part B All professional services performed in FQHC All professional services performed in SNF/NF Diagnostic labs Technical components of diagnostic tests Hospital services Inpt/Outpt FQHC Revenue codes must be on first line of claim 0521 Medical Visit 0900 Behavioral Health Visit subject to Medicare treatment limitation 0780 Telehealth bill with HCPCS Q DSMT with HCPCS code G MNT with HCPSC code 97802, 97803, G0270 Other FQHC revenue codes: 0522, 0524, 0525, 0527, 0528, = Clinic visit by member to RHC/FQHC 0522 = Home visit by RHC/FQHC practitioner 0524 = Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF 0525 = Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility; 0527 = RHC/FQHC Visiting Nurse Service(s) to a member s home when in a home health shortage area 0528 = Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident) 0519 = Clinic, Other Clinic (only for the FQHC supplemental payment) 5

6 For dates of service on or after January 1, 2011, all except the following revenue codes may be used when billing for services provided in a FQHC: 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or x. NOTE: This information is being captured for data collection and gathering purposes only. Hospital inpatient services Billing Part B work carve out salary portion for core providers Labs for diagnostic purpose The technical component of these preventive services Screening mammography Screening pap smear and screening pelvic exam Prostate cancer screening tests Colorectal cancer screening tests Bone mass measurement Screening for glaucoma Technical component of diagnostic tests ECG 93005; Chest X-ray TC Note: X-ray (reading) or EKG interpretation alone no encounter rate DME crutches, wheelchairs Ambulance Services Prosthetics and Orthotic braces 6

7 Performed Coded Amount OV $100 I&D $75 EKG $50 UA $20 Flu Shot G0008 $15 Flu Vaccine Q2035 $18 Part A Amount Comment $ Sum of 99213, 10060, $ Rolled up $ Professional Component of EKG 0771 G0008 $ Cost Report 0636 Q2035 $ Cost Report Part B Amount Comment $30.00 Technical component of EKG $20.00 Diagnostic Lab Behavioral Health (ICD Range: ) New codes for Exceptions to Reduction of Encounter Rate Initial Evaluation Pharmacologic Management Mental Health or Substance Abuse (MHSA) managed by medical provider as co-morbidity versus stand alone service i.e., Rank non MHSA service ICD ahead of MHSA & avoid use of a 900 (vs. 521) revenue code 7

8 Removal of E&M + Psychotherapy codes (90805, 90807) Removal of (pharmacologic management) Providers use appropriate E&M Inclusion of add-on codes for psychiatry Services performed in addition to primary service or procedure Interactive complexity minutes Insight Oriented minutes minutes Psychotherapy Outpatient Inpatient Interactive Insight Oriented minutes minutes minutes minutes minutes minutes minutes With E & M Without E & M Interactive minutes minutes Psychotherapy only Interactive Complexity minutes minutes minutes 8

9 Psychotherapy + E & M minutes minutes minutes E & M Interactive Complexity Behavioral Health Reduction (Phase Out by 2014) Historic Example: 62.5% of Charge 20% co-pay of this plus difference $100 charge; Eligible amount is $ % co-pay is $12.50 Patient owes $ $37.50 balance or total of $50 Planned Phase Out** Jan 2010 thru Dec 2011: Limitation percentage = 68.75% Jan 2012 thru Dec 2012: Limitation percentage = 75% Jan 2013 thru Dec 2013: Limitation percentage = 81.25% Jan 2014 and onward: Limitation percentage = Medical **Source: MCPM IOM Chapter 9, Section 60 Original Medicare outpatient mental health treatment limitation CPT Charge Encounter Rate 62.50% Medicare 80% Patient Balance $ $ $78.89 $63.11 $ Medicare outpatient mental health treatment limitation CPT Charge Encounter Rate 62.50% Medicare 80% Patient Balance $ $ $86.78 $69.42 $ Medicare outpatient mental health treatment limitation CPT Charge Encounter Rate 62.50% Medicare 80% Patient Balance $ $ $94.67 $75.73 $

10 Part A Remit Sample Paid Part A Remit Sample Paid 10

11 Calculations Part A A. Charge Amount: $72.00 B. Coinsurance (20% of charge): $14.40 C. Encounter Rate (per diem): $ D. Payment Amount (20% of encounter rate): $87.05 E. Adjustment Amount: -$29.45 Adjustment Amount = (Charge Amount * 80%)-Payment Amount Adjustment Amount = ($72.00 *0.80) - $87.05 Adjustment Amount = -$29.45 Adjustments can be posted as positive or negative. May be paid more than amount charged. Calculations Part A A. Charge Amount: $ B. Coinsurance (20% of charge): $36.00 C. Encounter Rate (per diem): $ D. Payment Amount (20% of encounter rate): $87.05 E. Adjustment Amount: $56.95 Adjustment Amount = (Charge Amount * 80%)-Payment Amount Adjustment Amount = ($ *0.80) - $87.05 Adjustment Amount = $56.95 Adjustments can be posted as positive or negative. May be paid more than amount charged. Part B Remit Sample Paid 11

12 Part B Remit Sample Denied Calculations Part B A. Charge Amount: $ B. Allowed Amount: $ C. Coinsurance (20% of allowed amount): $22.75 D. Payment Amount (80% of Allowed): $91.00 E. Adjustment Amount (Charge-Allowed): $43.48 Never a negative adjustment on fee-for-service (FFS). Never paid more than charge. Is a process, not just a quick fix. Must have a communication plan and process Teach a man to fish.. The team involves: Management Information Systems Patients (balances, updated insurance) Clinic Staff (system, coding, general billing Accounting/Finance Third Party Payer Relations Credentialing 12

13 Management Information System Vendor relations liaison Internal staff training (front desk/data extraction) Support work with vendor System updates (new version, annual coding, etc.) Q&A Patients (balances, updated insurance) Clinic Staff (system, coding, general billing) Coding (education/auditing/resource) Tracking & Storing Encounter Forms (Charge Tickets) Bank Deposits Interact with Accounting/Finance Third Party Payer Relations Credentialing Insurance ID # is incorrect Demographics Error CPT/HCPCS Invalid Diagnosis Codes Invalid Physician Name/Referring physician name error Admissions and Discharge dates required Physician not on file Provider number invalid Subscriber policy number is expired What Actually Gets Paid Core Provider visit versus nurse/ma visit Most Common Denials Eligibility verification Inaccurate demographics What They Can Fix Coded encounter forms (at least one ICD and one CPT) Clearly legible and linked Why Patients Call I was told I did not owe any money. I was told my insurance paid for this. Encounter Rate by Clinic (by Provider) Charges versus Payments (by Clinic and Provider) Units of Services (HCPCS with understandable descriptors 13

14 Claim submitted AR/Billing Claim Denied Clearinghouse Denial Appealed Providers Charge Entry Paid Third Party Payor Returned Item Analysis CPT Date(s) Diagnosis Fee Schedule Insurance Provider Demographic Reason for Return Jul Aug Sep Oct Nov Dec Total % CPT not indicated on encounter % Invalid CPT % Missing tooth/surface % Modifier missing 0 0% Was E&M service performed? 1 1 1% Missing date of injury 2 2 1% Missing date of service 5 5 3% Invalid diagnosis code reported % Missing diagnosis % ICD-9 code missing 4th/5th digit 2 2 1% Sliding Fee expired 4 4 3% Fee not in system for procedure 3 3 2% Invalid Insurance ID 0 0% Invalid/missing patient DOB % Treating provider not identified 0 0% Billing/supervising provider not indicated % Patient not registered 5 5 3% Name does not match account # 2 2 1% Total % NGS FQHC Training Summaries ut/p/c4/04_sb8k8xllm9msszpy8xbz9cp0os3gdr2bnrz dtewmdx0sda09hs2a3d3cdyxntq_2cbedfaodbjy0!/ CMS FQHC / RHC Manual (IOM Chpt.13) pdf FQHC Yearly Payment Limits ment/fqhcmaxlim.asp 14

15 CMS Understanding the Remittance Advice ll_ pdf NGS Medicare Revenue Coding Card b969d8743e7e46ee7c6fe/294_0810_ub_04_ot her_codes.pdf?mod=ajperes&cacheid= b969d8743e7e46ee7c6fe Claims Processing Manual Benefit Policy Manual Educate all billing staff Stay up to date on all changes Watch payments and denials Commit to Educate (Top down) 15