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1 professional billing module

2 Professional CMS-1500 Billing Module Coding Requirements...2 Evaluation and Management Services...2 Diagnosis...2 Procedures...2 Basic Rules...3 Before You Begin...3 Modifiers...3 Reimbursement and Co-payment...4 How to Complete the CMS

3 Coding Requirements (HCPCS, ICD-9-CM, E & M) EqualityCare Coding Guidelines When coding for EqualityCare you should be aware that CPT-4 codes and modifiers including their respective definitions were developed by the American Medical Association for providers to describe their services numerically for claim submission to insurers. These codes serve insurers as guidelines for claim adjudication but are not legally binding. EqualityCare has established specific guidelines, which must be followed for reimbursement. EqualityCare requires the use of uniform procedure and diagnosis coding on all claims. Evaluation and Management Services: EqualityCare follows the CPT-4 conventions regarding level of services for evaluation and management services. Diagnosis: Procedures: ICD-9 numeric diagnosis codes must be used. The code must include the fourth and fifth digit as appropriate. CPT (Physician's Current Procedural Terminology) and Healthcare Common Procedure Coding System (HCPCS) assigned by Centers for Medicare and Medicaid Services must be used. NOTE: Procedure codes which are described as "unlisted procedures" must be submitted on paper to ACS, Provider Relations with a report attached to the claim for manual review. These codes should only be used for a new or unusual service. Provider may also bill electronically and mark the attachment box that indicates a paper attachment is forthcoming. 2

4 Basic Rules The CMS-1500 is the same claim form as the HCFA The Health Care Financing Administration (HCFA) has changed its name to The Centers for Medicare and Medicaid Services. ACS will honor both forms. Use one claim for each client. Be sure the information on the form is legible. Before You Begin Is the client eligible for EqualityCare on the date of service? Do you have a copy of the client's proof of eligibility? Does EqualityCare cover the service? Did you obtain prior authorization, if applicable? Have you checked to make sure the client does not have other insurance? If you do not have all of this information, review the instructions in Chapter Six of the General Manual, "Verifying Client Eligibility." If the response to all of the above questions is favorable, you can begin to fill out the claim form following the instructions in this module. Modifiers EqualityCare will accept any modifiers billed but only allows the modifiers listed below. EqualityCare limits the use of modifiers to specific ranges of procedure codes as follows: CODE RANGE TYPE OF SERVICE ACCEPTED MODIFIER ANESTHESIA NO MODIFIERS SURGERY 22, 50, 51, 62, 80, AS RADIOLOGY MRI: 22, 52 (NO FEE INCREASE WILL APPLY) TC, LAB QW 26 ONLY FOR MEDICINE 26, TC (no modifiers allowed for 90700) EVALUATION/MANAGEMENT NO MODIFIERS A0001 Z9999 HCPCS RR, 32 3

5 Reimbursement and Co-Payment Reimbursement EqualityCare reimbursement for covered services is based on a variety of payment methodologies depending on the service provided. EqualityCare fee schedule By report pricing Billed charges Invoice charges Negotiated rates Per diem RBRVS ASC Grouping A schedule of EqualityCare fees by procedure is available online at or upon written request to: ACS, Inc. P.O. Box 667 Cheyenne, WY $2.00 Office Visits (The $2.00 co-payment only applies to these office visit codes when the place of service code is 11.) Home Visits Eye Examinations 92002, 92004, 92012, Medical psychotherapy (The $2.00 co-payment only applies to these medical psychotherapy codes when the place of service code is 11.) $2.00 Rural Health Clinic encounters Federally Qualified Health Center encounters ECEPTIONS Co-payment requirements do not apply to: -Recipients under age 21 -Nursing Facility Residents -LTC Waiver recipients (Pharmacy only) -Pregnant Women -Family planning services -Emergency services -Hospice services -Medicare Crossovers -Assisted Living Facility Waiver Service (Pharmacy only) 4

6 EHIBIT 1 CMS-1500 Claim Form 1 1a a-d 10a-c 11 a-d 10d a a 24b 24c 24d 24e 24f 24g 24i 24j 24h 24k

7 Instructions for Completing the CMS-1500 Claim Item Title Req'd Action 1 Insurance Type Put an "" in the "Medicaid" box. 1a Insured's EqualityCare ID Number Enter the client's ten-digit EqualityCare ID number that appears on the EqualityCare Identification card. 2 Patient's Name Enter the client's last name, first name, and middle initial as it appears on the EqualityCare ID Card. 3 Patient's Date of Birth/Sex 4 Insured's Name (When applicable) If the client is covered by other insurance, enter the name of the insured. 5 Patient's Address 6 Patient's Relationship to Insured (When applicable) If the client is covered by other insurance, mark the appropriate box to show relationship. 7 Insured's Address (When applicable) Enter the address of the insured. 8 Patient Status 9a-d Other Health Insurance Coverage (When applicable) Enter the name of the insurance company and other requested information if the client has other insurance. Enter the word "none" or "not applicable" if there is no other insurance coverage. 10a-c Is Patient's Condition Related to? (When applicable) Enter an "" in any part(s) that apply and give corresponding information in Item 9a-d. 10d Reserved for Local Use 11a-d Insured's Group Number (When applicable) If there is another policy covering the client, enter the name of the insurance company and other requested information. 6

8 Claim Item Title Req'd Action 12 Patient's or Authorized Person's Signature 13 Payment Authorization Signature 14 Date of current illness, injury or pregnancy 15 Date of Same or Similar Illness 16 Date Patient Unable to Work 17 Name of Referring Physician Enter the date of illness, injury or pregnancy. (When applicable) Required when the referring physician does not have a UPIN number. 17a ID Number of Referring Physician (When applicable) Enter the UPIN number for the referring physician for consultations, and independent laboratory or independent radiologist services. If the provider does not have a UPIN, enter provider's name in Item For Services Related to Hospitalization 19 Reserved for Local Use 20 Was Laboratory Work Performed Outside Your Office? 21 Diagnosis or Nature of Illness or Injury You cannot bill for laboratory work performed by another provider. Enter the ICD-9-CM diagnosis code exactly as it appears in the Codebook. Number one (1) will be identified as the primary diagnosis code. Use the most specific diagnosis code from the ICD-9- CM Code Book. If there is a fourth and/or fifth digit, it is a required part of the code. 7

9 Claim Item Title Req'd Action 22 EqualityCare Resubmission 23 Prior Authorization (When applicable) Enter the ten-digit Prior Authorization number from the approval letter if this claim has been prior authorized. Claims for these services are subject to service limits and the twelve-month filing limit. 24 Claim Line Detail A Dates of Service Enter the beginning date of service (From Date) in month, day, and year format, such as 06/21/93 for June 21, If the same procedure is provided on consecutive days, also enter the last date of service (To Date). NOTE: If services are performed on a single date, a "To Date" is not necessary. B Place of Service Enter the two-digit Place of Service (POS) for each procedure performed. C T.O.S. D Procedures, Services or Supplies: HCPCS codes and modifiers Enter the correct procedure code for the service being billed. For certain types of service, a two-digit modifier must be entered after the procedure code. For a list a valid modifiers see "Coding Requirements" on page 3 of this module. E Diagnosis Code Enter the ICD-9-CM code that corresponds to the primary diagnosis or the item number (1-4) from field 21. Enter only one code per line. This is the primary condition you are testing. NOTE: Use the diagnosis code exactly as it appears in the ICD-9-CM Code Book. Use the most specific diagnosis code from the ICD-9-CM Code Book. If there is a fourth and/or fifth digit it is a required part of the code. 8

10 Claim Item Title Req'd Action F Charges Enter your usual and customary charge for the procedure performed. When billing for multiple visits on one line, enter total charges for all units. G Days or Units Enter the units of service rendered for each detail line. A unit of service is the number of times a procedure is performed, except for anesthesia. Anesthesiologists, please see note below. NOTE: When only one procedure is performed, a "1" must appear in this field. When the same procedure is performed on consecutive days, enter the number of days when using a From-To date in item 24A. (Antepartum visits are an exception to the from/through span.) Anesthesiologists: Enter the anesthesia time in total minutes. For example: One hour and fifteen minutes should be entered as "75". Do not convert time to units. H EPSDT/Family Planning (When applicable) Enter an "F" if the services on this claim line are for family planning. Enter an "E" if the client was referred for services on this claim line as a result of a Health Check screening exam. I EMG J COB K Reserved for Local Use (When applicable) When the provider number in item 33 is a group number, enter the individual performing practitioner's nine-digit EqualityCare provider number. 25 Federal Tax ID Number 26 Patient's Account Number No entry required Optional 27 Accept Assignment Check "Yes." Assignment is required. 9

11 Claim Item Title Req'd Action 28 Total Charge Add together all charges in Column 24F and enter the total amount in this field. 29 Amount Paid (When applicable) Enter the amount paid by other health insurance coverage. Do not enter prior EqualityCare payments or the $2.00 co-payment here. This field is reserved for third party coverage only. 30 Balance Due No entry required 31 Signature of Physician or Supplier and Date 32 Name and Address for Facility Where Services Rendered 33 Provider's Name, Address, Zip Code, Telephone Number & EqualityCare Provider Number Sign and date the claim. A personal signature, a facsimile signature, typed signature, initials, computer generated name, or an authorized signature, and date must appear in this field. Providers are responsible for all claims billed using their EqualityCare provider number whether the provider, the provider s employee, subcontractor, vendor or business agent submits the claim. (When applicable) If services were rendered in other than home or office, enter the complete name and address of the hospital, clinic, laboratory, or any facility where services were rendered. Otherwise, no entry required. Enter your provider name, address, zip code, and telephone number. The provider number entered in Item 33 is the one to which EqualityCare payment is to be made. Enter your nine-digit EqualityCare Provider Number by the "GRP number". If this provider number identifies a group provider, you must enter the individual performing provider number in Item 24K for each line billed. 10

12 Place of Services Place Of Place Of Service Name Place Of Service Description Service 11 Office Location, Other than a Hospital, Skilled Nursing Facility, Military treatment Facility, Community Health Center, State or Local Public Health Clinic, or Intermediate Care Facility, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. 12 Home Location, other than a Hospital or other Facility, where the patient receives care in a private session. 21 Inpatient Hospital A facility, other than Psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of a Hospital, which provides diagnostic, therapeutic (both surgical and non surgical), and rehabilitation services to sick or injured persons who do not require Hospitalization or institutionalization. 23 Emergency Room A portion of a Hospital where emergency diagnosis Hospital 24 Ambulatory Surgical Center and treatment of illness or injury is provided. A free standing facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis. 31 Skilled Nursing Facility A facility, which primarily provides inpatient skilled, nursing care and related services to patients who require medical, nursing, or rehabilitation services but does not provide the level of care of treatment available on a hospital. 32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. 33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a longterm basis, which does not include a medical component 11

13 Place Of Place Of Service Name Place Of Service Description Service 41 Ambulance Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the 42 Ambulance Air or Water 53 Community Mental Health Center 61 Intermediate Care Facility/Mentally Retarded 62 Comprehensive Outpatient Rehabilitation Facility 65 End-Stage Renal Disease Treatment Facility 71 State or Local Public Health sick or injured. An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. A facility that provides the following services: Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC s mental health services are who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; A facility which primarily provides health related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF A facility that provides comprehensive rehabilitation services to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. A facility other that a hospital, which provides dialysis treatment, maintenance, and /or training to patients or caregivers on an ambulatory or home-care basis. A facility maintained by either State or local health department that provides ambulatory primary medical care under the general direction of a physician. 72 Rural Health Clinic A certified facility, which is located in a rural medically, underserved area that provides ambulatory primary medical care under the general direction of a physician. 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician s office. 99 Other Place of Service Other place of service not listed above. 12

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