Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Education Bulletin January 2010 To: Empire BlueCross BlueShield Participating Medicare Advantage (MA) Physicians and Practitioners, Non-Participating and Medicare Advantage PFFS Physicians and Practitioners CMS Elimination of CPT Consult Codes Effective 01/01/2010 CMS CR6740 final rule on the elimination of consult codes effective 01/01/2010 has been posted on the CMS website and now authorizes the communication of this change to the public as of 12/14/2009. This final rule eliminates the use of all inpatient and office/outpatient consultation codes for all places of service except for Telehealth consultation G-codes. The use of the AMA CPT consultation code ranges and are no longer recognized for Medicare Part B payment for services on or after January 01/01/2010. This change does NOT affect: Physicians and practitioners that participate in Empire s Commercial network(s) when providing services to Commercial Members. Physicians and practitioners that participate in Empire s Medicare Advantage network(s) when providing services to MediBlue members. Empire will continue to recognize and reimburse for consultation codes for Commercial and Mediblue patients. This change DOES affect: Medicare Advantage PFFS Physicians & Practitioners Non-Participating Physicians & Practitioners in Empire s Medicare Advantage network(s) when seeing an Empire Medicare Advantage member. Physicians and practitioners not participating in Empire s Medicare Advantage networks should follow the CMS guidelines when billing Empire. Physicians and practitioners treating Medicare Advantage PFFS patients should also follow the CMS guidelines when billing Empire. The key components of this change in the CMS guidelines are: Physicians & practitioners shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting, all physicians and qualified practitioners, where permitted, who perform an initial evaluation and management may bill the initial hospital care codes or nursing facility care codes As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur in a single day. Modifier -AI, defined as Principal Physician or practitioner of Record, shall be used by the admitting or attending physician or practitioner who oversees the patient s care, as distinct from other physicians or practitioners who may be furnishing specialty care. The principal physician or practitioner of record shall append modifier -AI in addition to the initial visit code. The primary

2 purpose of this modifier is to identify the principal physician or practitioner of record on the initial hospital and nursing home visit codes. Medicare contractors shall take no action if the - AI modifier is billed with codes that fall outside of the correct range and It is not necessary to reject claims that include the -AI modifier on codes other than the initial hospital and nursing home visit codes such as the subsequent care codes or outpatient codes. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians shall bill the available code that most appropriately describes the level of the services provided. Method II Critical Access hospitals may bill using type of bill 85X with revenue code 96X, 97X or 98X, using the appropriate new or established visit code for those physician and non-physician practitioners who have reassigned their billing rights, depending on the relationship status between the physician and patient. RHCs and FQHCs shall discontinue use of consultation codes and and should instead use and In the office or other outpatient setting where an evaluation is performed physicians and qualified non-physician practitioners shall use the CPT codes ( ) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. The following updates affect Medicare Advantage Private Fee for Service providers only Maximum Units of Service Per Day Anthem Blue Cross experienced an error involving the Maximum Units of Service Per Day policy. This error involved 271 procedure codes, whereby the Maximum Units Per Day limits were decreased to match the CMS MUEs (Medically Unlikely Edit). However, the codes involved should not have been decreased to the CMS MUE because of the nature of the service. For example, the CMS MUE limit for subsequent hospital visits ( ) is 1 per day. The Maximum Units limits are based on services provided to the member regardless of provider, therefore the limit for subsequent hospital visits are set to 5 per day. Moving the limit to 1 per day for these services resulted in inappropriate edits for subsequent hospital visits billed by multiple physicians on the same day. Codes that can be billed bilaterally were also affected. These units are now allowed per side. The effected claims are currently being adjusted to pay correctly, no action is required by the provider. The affected codes are: 0176T,0177T,15820,15821,15822,15823,19316,19318,19324,19325,19328,19330,19340,19342,19350, 19371,19366,19370,19371,19380,19396,29450,32850,32851,32852,32853,32854,33496,33507,33510, 33511,33512,33513,33514,33516,33517,33518,33519,33521,33522,33523,33530,33533,33534,33535, 33536,33542,33545,33611,33612,33615,33617,33619,33645,33647,33660,33675,33681,33684,33688, 33692,33694,33697,33702,33710,33720,33724,33730,33732,33735,33737,33768,33770,33771,33774, 33775,33776,33777,33778,33779,33780,33781,33786,33788,33800,33852,33853,33860,33861,33863, 33870,33875,33877,33880,33881,33883,33910,33915,33916,33917,33920,33924,33925,33926,33933, 33935,33945,33975,33976,33977,33978,35103,43310,43340,43341,43400,43401,43415,49525,49550, 49553,49555,49557,64479,64483,89353,89356,90378,99201,99202,99203,99204,99205,99211,99231, 99232,99233,99241,99242,99243,99244,99245,99251,99252,99253,99254,99255,99281,99282,99283, 99284,99285,99291,99307,99308,99309,99310,99324,99325,99326,99327,99328,99334,99335,99336, 99337,99341,99342,99343,99344,99345,99347,99348,99349,99350,A4221,A4253,A4255,A4259,A5500, A5501, A5503,A5504,A5505,A5506,A5508,A5510,B4034,B4035,B4036,B4216,B4220,B4222,B4224, E0986,E1821,E1825,E1830,E2120,E2397,G0239,G0249,K0020,K0609,L0430,L0452,L0462,L0482,L0484, L0486,L0490,L0491,L0492,L0621,L0622,L0623,L0624,L0625,L0626,L0627,L0628,L0629,L0630,L0631, L0632,L0633,L0634,L0636,L0637,L0638,L0639,L0640,L1700,L1710,L1730,L2040,L2050,L2060, L2070,L2080,L2090,L2270,L2627,L2628,L2630,L2640,L2660,L3330,L3332,L3340,L3370,L3651,

3 L3652,L3670,L3671,L3677,L3960,L3961,L3962,L3967,L3971,L3973,L3975,L3976,L3977,L3978, L7362,L7366,L8511,L8515,V5011. Frequency of Dialysis Treatment Billing ESRD Dialysis claims with rev codes are to be billed once a month (or at the conclusion of treatment). Rev codes are specific dialysis type of services. Dialysis is limited to 13 treatments in a 28 to 30 day month or 14 treatments in a 31 day month. Additional treatments require diagnostic medical necessity. CMS regulations require hospital-based and independent renal dialysis facilities to bill monthly unless the member stops dialysis or switches to a different ESRD provider. Claims listed above will not be denied at this time. We are monitoring the ESRD providers that continue to bill incorrectly for possible referral to CMS. Supportive Website for Frequency of Dialysis Treatment Billing: Sec Home Health Claims Submission Reminders When billing subsequent episodes, there should not be a break in service. Final claims are submitted at the end of every 60-day episode (prior to the 60 th calendar day in the event the patient is discharged, dies or transfers to another HHA). Under the Prospective Payment System (PPS), if a Request for Anticipated Payment (RAP) is required, a final claim must be matched up to it within 60 days from the date the RAP pays, or 60 days from the end of the episode, whichever is greater. The following items must match between the RAP and final claim: o CBSA o Treatment Authorization Control Number o To and from dates of service (a to date is only required on the final claim) o Identifier of the billing provider (National Provider Identifier(NPI) after 05/23/2008) o Beneficiary s Health Insurance Claim (HIC) Number (aka, Medicare number) o Admission Date o Admission Hour o HIPPS code (If FROM date is on/after 01/01/2008, only first four HIPPS positions must exactly match). o Date on the 0023 revenue code line Supportive Home Health website: Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross Association, an association of independent Blue Cross plans. The Blue Cross names and symbols are registered marks of the Blue Cross Association.

4 Medicare Advantage Outreach and Education Bulletin January 2010 To: Empire BlueCross BlueShield Participating Medicare Advantage (MA) Physicians and Practitioners, Non-Participating and Medicare Advantage PFFS Physicians and Practitioners CMS Elimination of CPT Consult Codes Effective 01/01/2010 CMS CR6740 final rule on the elimination of consult codes effective 01/01/2010 has been posted on the CMS website and now authorizes the communication of this change to the public as of 12/14/2009. This final rule eliminates the use of all inpatient and office/outpatient consultation codes for all places of service except for Telehealth consultation G-codes. The use of the AMA CPT consultation code ranges and are no longer recognized for Medicare Part B payment for services on or after January 01/01/2010. This change does NOT affect: Physicians and practitioners that participate in Empire s Commercial network(s) when providing services to Commercial Members. Physicians and practitioners that participate in Empire s Medicare Advantage network(s) when providing services to MediBlue members. Empire will continue to recognize and reimburse for consultation codes for Commercial and Mediblue patients. This change DOES affect: Medicare Advantage PFFS Physicians & Practitioners Non-Participating Physicians & Practitioners in Empire s Medicare Advantage network(s) when seeing an Empire Medicare Advantage member. Physicians and practitioners not participating in Empire s Medicare Advantage networks should follow the CMS guidelines when billing Empire. Physicians and practitioners treating Medicare Advantage PFFS patients should also follow the CMS guidelines when billing Empire. The key components of this change in the CMS guidelines are: Physicians & practitioners shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting and the nursing facility setting, all physicians and qualified practitioners, where permitted, who perform an initial evaluation and management may bill the initial hospital care codes or nursing facility care codes As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur in a single day. Modifier -AI, defined as Principal Physician or practitioner of Record, shall be used by the admitting or attending physician or practitioner who oversees the patient s care, as distinct from other physicians or practitioners who may be furnishing specialty care. The principal physician or practitioner of record shall append modifier -AI in addition to the initial visit code. The primary

5 purpose of this modifier is to identify the principal physician or practitioner of record on the initial hospital and nursing home visit codes. Medicare contractors shall take no action if the - AI modifier is billed with codes that fall outside of the correct range and It is not necessary to reject claims that include the -AI modifier on codes other than the initial hospital and nursing home visit codes such as the subsequent care codes or outpatient codes. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. Follow-up visits in the facility setting may be billed as subsequent hospital care visits and subsequent nursing facility care visits as is the current policy. In all cases, physicians shall bill the available code that most appropriately describes the level of the services provided. Method II Critical Access hospitals may bill using type of bill 85X with revenue code 96X, 97X or 98X, using the appropriate new or established visit code for those physician and non-physician practitioners who have reassigned their billing rights, depending on the relationship status between the physician and patient. RHCs and FQHCs shall discontinue use of consultation codes and and should instead use and In the office or other outpatient setting where an evaluation is performed physicians and qualified non-physician practitioners shall use the CPT codes ( ) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. The following updates affect Medicare Advantage Private Fee for Service providers only Maximum Units of Service Per Day Anthem Blue Cross experienced an error involving the Maximum Units of Service Per Day policy. This error involved 271 procedure codes, whereby the Maximum Units Per Day limits were decreased to match the CMS MUEs (Medically Unlikely Edit). However, the codes involved should not have been decreased to the CMS MUE because of the nature of the service. For example, the CMS MUE limit for subsequent hospital visits ( ) is 1 per day. The Maximum Units limits are based on services provided to the member regardless of provider, therefore the limit for subsequent hospital visits are set to 5 per day. Moving the limit to 1 per day for these services resulted in inappropriate edits for subsequent hospital visits billed by multiple physicians on the same day. Codes that can be billed bilaterally were also affected. These units are now allowed per side. The effected claims are currently being adjusted to pay correctly, no action is required by the provider. The affected codes are: 0176T,0177T,15820,15821,15822,15823,19316,19318,19324,19325,19328,19330,19340,19342,19350, 19371,19366,19370,19371,19380,19396,29450,32850,32851,32852,32853,32854,33496,33507,33510, 33511,33512,33513,33514,33516,33517,33518,33519,33521,33522,33523,33530,33533,33534,33535, 33536,33542,33545,33611,33612,33615,33617,33619,33645,33647,33660,33675,33681,33684,33688, 33692,33694,33697,33702,33710,33720,33724,33730,33732,33735,33737,33768,33770,33771,33774, 33775,33776,33777,33778,33779,33780,33781,33786,33788,33800,33852,33853,33860,33861,33863, 33870,33875,33877,33880,33881,33883,33910,33915,33916,33917,33920,33924,33925,33926,33933, 33935,33945,33975,33976,33977,33978,35103,43310,43340,43341,43400,43401,43415,49525,49550, 49553,49555,49557,64479,64483,89353,89356,90378,99201,99202,99203,99204,99205,99211,99231, 99232,99233,99241,99242,99243,99244,99245,99251,99252,99253,99254,99255,99281,99282,99283, 99284,99285,99291,99307,99308,99309,99310,99324,99325,99326,99327,99328,99334,99335,99336, 99337,99341,99342,99343,99344,99345,99347,99348,99349,99350,A4221,A4253,A4255,A4259,A5500, A5501, A5503,A5504,A5505,A5506,A5508,A5510,B4034,B4035,B4036,B4216,B4220,B4222,B4224, E0986,E1821,E1825,E1830,E2120,E2397,G0239,G0249,K0020,K0609,L0430,L0452,L0462,L0482,L0484, L0486,L0490,L0491,L0492,L0621,L0622,L0623,L0624,L0625,L0626,L0627,L0628,L0629,L0630,L0631, L0632,L0633,L0634,L0636,L0637,L0638,L0639,L0640,L1700,L1710,L1730,L2040,L2050,L2060, L2070,L2080,L2090,L2270,L2627,L2628,L2630,L2640,L2660,L3330,L3332,L3340,L3370,L3651,

6 L3652,L3670,L3671,L3677,L3960,L3961,L3962,L3967,L3971,L3973,L3975,L3976,L3977,L3978, L7362,L7366,L8511,L8515,V5011. Frequency of Dialysis Treatment Billing ESRD Dialysis claims with rev codes are to be billed once a month (or at the conclusion of treatment). Rev codes are specific dialysis type of services. Dialysis is limited to 13 treatments in a 28 to 30 day month or 14 treatments in a 31 day month. Additional treatments require diagnostic medical necessity. CMS regulations require hospital-based and independent renal dialysis facilities to bill monthly unless the member stops dialysis or switches to a different ESRD provider. Claims listed above will not be denied at this time. We are monitoring the ESRD providers that continue to bill incorrectly for possible referral to CMS. Supportive Website for Frequency of Dialysis Treatment Billing: Sec Home Health Claims Submission Reminders When billing subsequent episodes, there should not be a break in service. Final claims are submitted at the end of every 60-day episode (prior to the 60 th calendar day in the event the patient is discharged, dies or transfers to another HHA). Under the Prospective Payment System (PPS), if a Request for Anticipated Payment (RAP) is required, a final claim must be matched up to it within 60 days from the date the RAP pays, or 60 days from the end of the episode, whichever is greater. The following items must match between the RAP and final claim: o CBSA o Treatment Authorization Control Number o To and from dates of service (a to date is only required on the final claim) o Identifier of the billing provider (National Provider Identifier(NPI) after 05/23/2008) o Beneficiary s Health Insurance Claim (HIC) Number (aka, Medicare number) o Admission Date o Admission Hour o HIPPS code (If FROM date is on/after 01/01/2008, only first four HIPPS positions must exactly match). o Date on the 0023 revenue code line Supportive Home Health website: Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.