1 OBGYN Orientation & Billing Guide 2014
2 Welcome to Magnolia Health! We thank you for being part of or considering Magnolia s network of participating providers, hospitals, and other healthcare professionals. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. Magnolia works to accomplish this goal by partnering with the providers who oversee the healthcare of Magnolia members. The intent of this presentation is strictly for provider billing guidance and to assist and educate on MH policy in regards to billing. Our responsibility is to render current coding information and advise accordingly. It is always the responsibility of the provider to determine member eligibility and also determine and submit the appropriate codes, modifiers and charges for the services performed for MH members
3 Agenda Overview Eligibility Verification Obstetrics Maternity Services Radiology - Ultrasounds Observation Anesthesia - Epidurals Case Management - High Risk Mental Health Additional Services provided by Magnolia Health Gynecology Pap Smears Mammography Hysterectomy Family Planning Contacts Sterilization Abortion
4 OB/GYN Overview Obstetrics OB is short for obstetrics or for an obstetrician, a physician who delivers babies Gynecology GYN is short for gynecology or for a gynecologist, a physician who specializes in treating diseases of the female reproductive organs. The gynecology come from the Greek gyno, gynaikos meaning woman + logia meaning study, so gynecology literally is the study of women. These days gynecology is focused largely on disorders of the female reproductive organs. Obstetrician/Gynecologist (OB/GYN) An Obstetrician/Gynecologist (OB/GYN) is therefore a physician who both delivers babies and treats diseases of the female reproductive organs.
5 Verify Eligibility It is highly recommended to verify member eligibility on the date services are rendered due to changes that occur throughout the month, using one of the following methods: Log on to the Medicaid Envision website at: Log on to the secure provider portal at Call our automated member eligibility interactive voice response (IVR) system at Call Magnolia Provider Services at (MEMBER ID CARDS ARE NOT A GUARANTEE OF ELIGIBILITY AND/OR PAYMENT)
6 Eligibility Important Information for Pregnancy Only Members In keeping with the compliance of the Affordable Care Act (ACA), Magnolia Pregnancy Only members will now receive full benefits effective January 1, Prior to this change, Pregnancy Only members did not receive dental, vision or behavioral health benefits.
7 Obstetrics - Maternity Services Antepartum services is the care of a pregnant woman during the time in the maternity cycle that begins with conception and ends with labor. Antepartum The Delivery is the care involved in the actual birth and continues for two (2) months following the month of the birth of the newborn. Delivery Postpartum services are services that is inclusive of both hospital and office visits following vaginal and cesarean section deliveries. Eligible pregnant women continue to be eligible for postpartum medical assistance for a sixty (60) day period beginning on the last day of her pregnancy and for any remaining days in the month in which the sixtieth (60th) day falls. Postpartum
8 Billing Maternity Services Antepartum Providers should utilize CPT E&M codes , 59425, and (antepartum visits) through range for antepartum visits 1 or 2 or for antepartum visits for antepartum visits 7 or more * Bill only one code per visit with TH modifier. Delivery 59410, 59515, 59614, and are used for deliveries and postpartum care. Postpartum care is inclusive of both hospital and office visits following Vaginal and C-section deliveries 59409, 59514, 59612, and are used for deliver ONLY. These codes should only be by physician who ONLY completes the delivery, and provides no other services. * TH Modifier must be reported with each delivery code. Postpartum can be used for postpartum hospital and office visit Should only be used by physician who did NOT deliver and is billing for inpatient and office postpartum visits ONLY Cannot be utilized by physicians in the same group as the delivery physician *TH Modifier must be reported for postpartum visits.
9 Maternity Services 17 Alpha- Hydroxyprogesterone 17 Alpha-Hydroxyprogesterone Magnolia covers 17 Alpha-Hydroxyprogesterone (17-P) when medically indicated. Additional information can be found on our website Medical Indications Include: History of previous singleton spontaneous pre-term birth before 37 weeks gestation. Current singleton pregnancy. Initiate treatment between 16 and 20 weeks gestation. 17P is not payable for other risk factors for pre-term delivery, such as multiple gestations, short cervical length, or positive tests for cervicovaginal fetal fibronectin. For the generic 17-P compound no prior authorization is required. How to Bill for 17-P Use Code J3490. This must have modifier TH attached. The Max unit per visit is 1. The primary diagnosis for this service line must be V23.41
10 Maternity Services - Radiology Maternal Fetal Ultrasound Routine Ultrasonography (ultrasounds) are not covered during pregnancy. Our Radiology slide will contain additional details regarding medically necessary ultrasounds.
11 Maternity Services - Radiology cont d Medicaid covers medically necessary ultrasounds when all of the following criteria are met: See Title 23 Part 222 Rule 1.3 The ultrasound is consistent with the beneficiary s signs, symptoms, and/or condition, Diagnosis cannot be made through clinical evaluation of the beneficiary s signs and symptoms, and the results of the ultrasound can reasonably be expected to influence the beneficiary s treatment plan.
12 Maternity Services Observation Care Will be paid a per hour rate for a minimum of 8 and maximum of 23 hours. Only the hours between 8 and 23 will pay. The first 7 hours are bundled and hours over 23 will be denied. Observation Care Must be included on a single line even the hours that take place after midnight. Physician observation codes will not be paid if billed on the hospital claim.
13 Maternity Services Observation Care Observation hours between 8hrs and 23hrs would require an authorization to be considered for benefit Observation hours less than 8hrs would be required to be billed as an ER visit or a clinic visit to be considered for benefit Observation hours greater than 23hrs is considered Inpatient services and would be handled by The Division of Medicaid and require authorization
14 Maternity Services - Anesthesia Maternity Anesthesia Billed by Anesthesiologists and CRNAs The reimbursement for CPT codes 01961, 01967, 01968, and is the provider s charge or the fee on file, whichever is lower. As requested by anesthesiologists, these codes have a flat fee and are not paid based on the anesthesia base rate plus time units. Providers must note that CPT Codes and are add-codes and must be billed with CPT NOTE: TH modifier is NOT required on Maternity Anesthesia codes.
15 Maternity Multiple Birth Deliveries w/ Billing Procedure Medicaid covers multiple birth deliveries, same delivery setting, when two (2) or more infants from one (1) pregnancy are delivered vaginally in the same delivery setting. One (1) vaginal delivery fee at one hundred percent (100%) of the Medicaid allowable rate, and one (1) additional vaginal delivery fee will be reimbursed at fifty percent (50%) of the Medicaid allowable rate. Medicaid covers multiple birth deliveries, same delivery setting, when two (2) or more infants from one (1) pregnancy are delivered by cesarean section in the same operative setting. One (1) cesarean section delivery fee at one hundred percent (100%) of the Medicaid allowable rate, and one (1) additional cesarean section delivery fee will be reimbursed at fifty percent (50%) of the Medicaid allowable rate. How to bill this type of delivery? How to bill this type of delivery? Bill the appropriate CPT code, one unit, on one line and one additional appropriate CPT code with modifier -51, one unit, on a second line of the CMS For example, bill CPT code 59409, one unit, on one line, and CPT code , one unit, on a second line. Bill the appropriate CPT code, one unit, on one line and one additional appropriate CPT code with modifier -51, one unit, on a second line of the CMS For example, bill CPT code 59514, one unit, on one line, and CPT code , one unit, on a second line.
16 Maternity Multiple Birth Deliveries w/ Billing Procedures cont d Medicaid covers multiple birth deliveries, same delivery setting, when at least one (1) infant of a multiple pregnancy is delivered vaginally followed by one (1) or more infants delivered by cesarean section. The cesarean section fee at one hundred percent (100%) of the Medicaid allowable rate, and one (1) vaginal delivery fee will be reimbursed at fifty percent (50%) of the Medicaid allowable rate. Medicaid covers multiple birth deliveries, separate delivery settings, with delayed interval deliveries each at one hundred percent (100%) of the Medicaid allowable rate for the appropriate procedure. In the case of multiple births of three (3) or more infants where one (1) infant is delivered during one setting followed by two (2) or more infants delivered later in a separate setting, Medicaid covers the second (2nd) delivery of the multiple birth in accordance with the same setting policy outlined in Rule 1.2.A of Part 222: Maternity Services. How to bill this type of delivery? How to bill this type of delivery? Bill the appropriate CPT code, one unit, on one line and one additional appropriate CPT code with modifier -51, one unit, on a second line of the CMS For example, bill CPT code 59514, one unit, on one line and CPT code , one unit, on a second line of the CMS In the case of multiple births of three or more infants where one infant is delivered during one setting followed by two or more infants delivered later in a separate setting, the multiple birth, same setting policy will apply to the second delivery. For example, if one infant is delivered vaginally and two additional infants are delivered hours later by Cesarean section, the first delivery will be paid at 100% of the Medicaid allowable rate for a vaginal delivery and should be billed on one CMS-1500 claim form. The second delivery will be paid at 100% of one Cesarean section delivery fee and 50% of one additional Cesarean section delivery fee at the Medicaid allowable rate and should be billed according to the multiple births, same setting policy.
17 Maternity Case Management Care Management We understand some members have special needs. In those cases, Magnolia offers our members care management services to assist our members with special healthcare needs. If you have special healthcare needs or you have a disability, care management may be able to help you. Our case managers are registered nurses or social workers. This service is for members who have complex medical conditions such as an high risk pregnancy. These members often see several providers. They may need medical supplies or help at home.
18 Maternity Services Mental Health Cenpatico Behavioral Health hours a day, 7 days a week Depression Screening Program 13% of new mothers experience postpartum depression after childbirth Fax screening to Cenpatico
19 Maternity Additional Services from Magnolia Health Start Smart for your Baby Awarded URAC Best Practice Platinum Award for improved outcomes tied to Notification of Pregnancy. This special program is for pregnant women. CentAccount Card - The CentAccount rewards program lets you earn money onto your own CentAccount card simply by doing things that help you stay healthy! * Start Smart Completion of Prenatal Care Visits * Start Smart Completion of Postpartum Care Visits
20 Gynecology Pap Smears Mammography Hysterectomy
21 Gynecology Pap Smears Cervical Cancer Screenings Measure evaluates the percentage of women ages 21 to 64 who were screened for cervical cancer using either of the following criteria: 1) Cervical cytology performed every year for women ages 21-64; 2) Cervical cytology/human papillomavirus (HPV) co-testing performed every year (must occur within 4 days of each other). Cervical Cytology Codes (ages 21-64): CPT Codes: , 88147, 88148, 88150, , , 88174, HCPCS codes: G0123, G0124, G0141, G0143-G0145,G0147, G0148, P3000, P3001, Q0091 Cervical Cytology plus one HPV code: (For Ages 30-64) CPT codes: 87620, 87621, 87622
22 Gynecology Mammography CPT codes UB Revenue Breast Cancer Screenings HCPCS G0202, G0204, G0206 ICD-9-CM
23 Gynecology - Hysterectomy The Division of Medicaid defines a hysterectomy as the surgical removal of the uterus. Title 23 Part 202 Rule 5.6 The Division of Medicaid covers a hysterectomy when deemed medically necessary in an inpatient or outpatient hospital setting in accordance with current standards of medical practice for beneficiaries when: The beneficiary has been informed, both orally and in writing, that a hysterectomy will make the beneficiary permanently incapable of reproducing, and The beneficiary and the physician who performs the hysterectomy have completed and signed the appropriate section(s) of the Hysterectomy Acknowledgement Form, prior to the surgery, except as otherwise provided for in Miss. Admin. Code Title 23, Part 202, Rule 5.6.D.
24 Family Planning Family planning services are services provided to eligible beneficiaries who voluntarily choose to prevent pregnancy, plan the number of pregnancies, or plan the spacing between pregnancies. Family planning services are provided, with limitations, in the following general categories: Visits Contraceptive drugs Contraceptive devices Voluntary sterilization Laboratory procedures
25 Family Planning Covered Services Contraceptive Drugs Insertion and removal of contraceptive implants are covered. Contraceptive injections administered in the provider s office are covered. Prescription contraceptives are available through the pharmacy program. Contraceptive Devices Insertion and removal of contraceptive intrauterine devices are covered. Insertion and removal of contraceptive implants are covered. Diaphragm or cervical cap fitting with instruction is covered. Vaginal rings are covered. Laboratory Procedures Laboratory procedures that must be conducted during initial and annual visits include the following: Complete blood count, urinalysis, PAP smear, STD/HIV test and pregnancy test
26 Family Planning - Sterilization The Division of Medicaid covers sterilization procedures in an inpatient and outpatient hospital setting. See Title 23 Part 202 Rule 5.3: Sterilization Tubal ligation procedures, including tubal ligation by hysteroscopy, are covered if they meet Medicaid criteria for sterilization. The informed consent form for Sterilization must be accurately filled out and signed. Please note: Once this form is filled out and signed please send this form to our claims processing center: Magnolia Health Plan P.O. Box 3090 Farmington, MO
27 Abortions Abortions are covered in accordance with DOM Contract and DOM Administrative Code Title 23: Medicaid Part 202 Hospital Services Rule 5.4-coverage will be allowed only in the following circumstances: when the abortion is medically necessary to prevent the death of the mother, or when the abortion is being sought to terminate a pregnancy resulting from an alleged act of rape or incest. Please note: The physician is required to maintain sufficient documentation in the medical record that supports the medical necessity for the abortion for one of the reasons outlined above. This service does not require authorization by the Plan. However, the Mississippi Medicaid Abortion Necessity Form is required to be completed and must be submitted with the claim.
28 Abortions Please note: The physician is required to maintain sufficient documentation in the medical record that supports the medical necessity for the abortion for one of the reasons outlined above. This service does not require authorization by the Plan. However, the Mississippi Medicaid Abortion Necessity Form is required to be completed and must be submitted with the claim.
29 Secure Web Portal Health Record
30 Provider Relation Contacts NORTH TERRITORY - ASHLEY ARMSTRONG CENTRAL TERRITORY - CHINWE NICHOLS SOUTH TERRITORY - TINA LAWRENCE DIRECTOR, PROVIDER RELATIONS - WALTER PAWLAK
31 Provider Services Available M-F, 8-5, CST First Line of Communication Authorization status and questions Provider Services Call Center Eligibility status and questions Payment Inquiries Claim status and questions
33 Thank you!