Reducing Adolescent Substance Abuse Initiative (RASAI) Learning Community

Transcription

1 Howard Zucker, Acting Commissioner Arlene González-Sánchez, M.S., L.M.S.W. Commissioner Ann Marie T. Sullivan, M.D., Commissioner Reducing Adolescent Substance Abuse Initiative (RASAI) Learning Community Andrew M. Cuomo, Governor 1

2 Presenters Mark Tremblay, M.A., M.P.A. NYS Department of Health - Office of Health Insurance Programs Gwen Diamond NYS Office of Mental Health - Reimbursement Policy and Implementation Katherine Cusano, Broome County Deputy Commissioner of Mental Health Christopher Baron Lourdes Hospital - Executive Director Revenue Cycle Rita Guido Computer Sciences Corporation (CSC) - Outreach Supervisor 2

3 Provider Types Eligible to Bill for Office-based SBIRT Services Provider Type Physicians (services may be performed by another provider type under the supervision of the physician) Required OASAS Approved Training/Certification 4 hours, unless certified by the American Society of Addiction Medicine (ASAM), the American Board of Ambulatory Medicine (ABAM), the American Academy of Addiction Psychiatry (AAAP) or the American Academy Osteopathic Association (AOA) Nurse Practitioners 4 hours, unless qualified as a Certified Addictions Registered Nurse (CARN) Nurse Midwives Psychologists 4 hours 4 hours 3 NOTE: Article 31 clinics cannot submit practitioner claims for SBIRT. Only institutional claims can be submitted for SBIRT

4 Providers Eligible to Deliver SBIRT Services Under a Licensed Provider/Facility Physician Assistants Provider Type Required Training/ Certification 4 hours Registered Nurses Licensed Practical Nurses Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) Licensed Mental Health Counselors Licensed Marriage and Family Therapist Certified School Counselor Certified Rehabilitation Counselor 4 hours, unless qualified as a CARN 4 hours 4 hours 4 hours 4 hours 4 hours 4 hours OASAS-credentialed professionals including CASACs, (CPPs) and Credentialed Problem Gambling Counselors Health Educators and unlicensed individuals (may only provide SBIRT services under the supervision of a licensed health care professional, following consistent protocols) 4 hours 12 hours 4 NOTE: Article 31 clinics cannot submit practitioner claims for SBIRT. Only institutional claims can be submitted for SBIRT

5 SBIRT Billing Guidelines Practitioner Offices, Hospitals and Clinics 5

6 Insurance Codes and Types of Insurance The type of insurance the patient has, and the length of time spent in service delivery determines the codes used. This will also determine any fee billed to the insurance company.

7 SBIRT Billing Codes Payer Code Description Medicaid H0049 Alcohol and/or drug screening Medicaid H0050 Alcohol and/or drug service, brief intervention, per 15 min 7

8 Medicaid FFS Billing CPT H0049 (alcohol and/or drug screening) is used for substance use screening. Diagnosis code ICD-9 code V82.9 (unspecified condition) is REQUIRED on claims with this procedure code. CPT H0050 (alcohol and/or drug service, brief intervention) is used for substance abuse brief intervention services. Diagnosis code ICD-9 V65.42 (counseling and substance abuse) is REQUIRED on claims with this procedure code. When Medicaid is secondary Providers must code the correct HCPCS codes when submitting claims to Medicaid. If Medicare or third-party payors require a different code, it must be replaced with H0049 or H0050 before submitting to Medicaid. 8

9 Medicaid FFS Billing cont. Frequency Limits Medicaid will cover two screenings (H0049) and six brief interventions (H0050) per year NCCI Edits Some procedure code combinations will consolidate due to the Federal National Correct Coding Initiative. Article 31 clinics are exempt from NCCI edits For more information see: Coding-Initiative.html 9

10 Billing SBIRT in an Article 31 Clinic Providers will bill use the 837i claim form (do not submit a separate practitioner claim) SBIRT claims will use the appropriate OMH clinic rate code (e.g., 1504, 1516) and appropriate HCPCS code: H0049 and/or H0050. Both codes have an APG weight of.2803 SBIRT rates for OMH licensed clinics: Rate with QI Rate without QI Hospital Rate (Art.31 Clinic) Upstate Article 31 & DTCs Downstate Article 31 & DTCs County Article 31 Upstate Article 31 & DTCs Downstate Article 31 & DTCs County Article 31 Upstate Hospital Downstate Hospital $ $ $ $ $ $ $39.03 $

11 Billing SBIRT in Part & Clinics Pre-Admission Screen H0049 (Medicaid) Brief Intervention H0050 (Medicaid) Post Admission Brief Treatment H0004 A brief treatment may be billed on the same day as other categories, including, but not limited to individual or group counseling services Providers should code H0004 and NOT H0050 for postadmission Brief Treatment services 11

12 APG Payments for SBIRT in Part and Programs Medicaid APG Rate Per Service Upon Full Implementation of APG Payments Clinic Upstate Clinic Downstate Opioid Upstate Opioid Downstate Screening $41.37 $48.41 $38.13 $44.62 Brief Intervention/ Brief Treatment $41.37 $48.41 $38.13 $44.62 Screening is not intended to be provided to all patients or where it is known that the patient is appropriate for admission (e.g. a court order); has an assessment from another program; or presents with circumstances that indicate that a substance use disorder (SUD) problem may be present. Additionally, screening may not be provided in a group setting. 12

13 Medicaid Managed Care SBIRT services are covered benefits under Medicaid Managed Care and Family Health Plus (FHPlus) MCOs are required to pay government rate for at least 1 st 2 years Plans are required to cover the same frequency limits as FFS w/out prior authorization, but may permit additional screenings/brief intervention visits Reimbursement rates for plan members receiving SBIRT services from in network providers will be established in provider agreements. Out-of-network providers will be reimbursed at negotiated rates, except for out-of-network emergency departments which will be reimbursed according to the Medicaid FFS methodology FHPlus co-payments are not applicable to SBIRT. 13

14 Requirements for SBIRT Documentation Screening tool completed CRAFFT Score on the CRAFFT Copy of the completed screening tool must be retained in the record. Documentation must denote start/stop time or total face-to-face time with the patient, because the SBIRT codes are time-based codes Although the completed screenings may be in another section of the chart, there needs to be representation on the progress note that the screening still took place.

15 Modifiers Used with Diagnostic Codes: Two digit, two character or alphanumeric characters, appended to the end of a Current Procedural Technology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code Modifies the code description without changing the core meaning of the Current Procedural Technology and/or Healthcare Common Procedure Coding System description Provides additional information regarding the services or procedures provided Tells the clinical story more completely Integral part of the Current Procedural Technology and Healthcare Common Procedure Coding System coding system Are designed to provide payers with additional information needed to process or adjudicate a claim

16 Modifiers cont. When two separate and distinct patient encounters are provided by a single provider on the same day, a modifier (e.g., 25 Significant, Separately Identifiable Evaluation and Management Service or 59 Distinct Procedure Service) should be appended to the additional procedure/service to indicate that the second code is separate and/or distinct. This is especially important when billing for mental hygiene type services. For instance, NCCI prohibits billing both (family psychotherapy) and SBIRT (i.e., H0049 or H0050) for the same session, but will allow payment for both codes if modifier 59 is appended to the second procedure (applicable in Article 31 hospital). However, please note that modifiers may only be appended to HCPCS/CPT codes if clinical circumstances justify use of a modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. 16

17 Real Life Experiences with SBIRT Billing Chris Baron - Lourdes Hospital Katherine Cusano - Broome County Mental Health 17

18 Computer Sciences Corporation (CSC) Responsibilities Processing Medicaid claims Provider Manuals Remittance statements and checks Electronic Fund Transfer Billing inquiries & guidelines Provider training Medicaid Eligibility Verification System (MEVS) Issues paper claim forms (excluding UB-04) Electronic Transmitter Identification Numbers (ETIN) epaces (Electronic Provider Assisted Claim Entry System) Provider Enrollment Maintenance (Fee-for-Service) Contact CSC / emedny Call Center (800) Website 18

19 Computer Sciences Corporation (CSC) emedny Call Center Support units for Practitioners, Institutions, Professional, Pharmacy, MOAS, PTAR and MEIPASS Provides assistance with questions regarding: - claims - billing - electronic and paper remittance - form orders - prior approval - new enrollment into the New York State Medicaid program - epaces enrollment - Electronic Funds Transfer (EFT) - ETIN applications - provider maintenance forms - Explanation of eligibility responses Hours of Operation: non-pharmacy billing or claims, or provider enrollment: Monday through Friday: 7:30 a.m. - 6:00 p.m., Eastern Time (excluding holidays) eligibility, DVS, and pharmacy claims: Monday through Friday: 7:00 a.m. - 10:00 p.m., Eastern Time (excluding holidays) Weekends and Holidays: 8:30 a.m. - 5:30 p.m., Eastern Time 19

20 Computer Sciences Corporation (CSC) Provider Outreach Regional Representatives located in 8 regions Capital District, North Country/Mohawk Valley, South/Central NY, Finger Lakes, Western NY, Hudson Valley, NYC and Long Island CSC Regional Representatives are available to offer provider billing training on a variety of topics through numerous methods including: Individual meetings with providers to train and troubleshoot issues Group training seminars and webinars Request a meeting with a regional representative at or register to attend a seminar or webinar on the emedny website Training page at 20

21 Medicaid Billing Questions CSC Billing/Claiming Questions: NYS DOH - Medicaid Policy Questions: APG Mailbox [email protected] NYS OMH Article 31s Billing Questions NYS OASAS - Billing Questions (518) or [email protected] 21

22 Questions? 22