1 Preface Summary of Changes Table of Contents Service Contacts October 2014 Replaces: May 2014 S /14
2 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing business with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. The guides are referenced in your provider agreement, and include information that applies to all benefit plans in Iowa and South Dakota unless specified within the text. Explanation of Terminology Wellmark Throughout the guides, the term Wellmark indicates Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. Member Individuals with health coverage through Wellmark are referred to as members. Provider Guide Updates Wellmark s Provider guides are continually updated to bring you the most current information. The following items identify when the guide or section was last changed. The date of the most current update can be found next to the linked guide name on Wellmark.com > Provider > Communications and Resources > Provider Guides. The most current date is printed on the front cover and inside pages. The date of the version replaced is also printed on the front cover. A Summary of Changes page lists all the substantial changes made in the most current updates. The page(s) affected and a brief explanation of the change is linked from the Summary of Changes page to the change within the document. Changed text and most links appear in blue type. Printed Copies of Wellmark s Provider Guides We invite you to print Wellmark s Provider guides from the website. Guide updates are periodically listed in the BlueInk newsletter. You will always find the current version at Wellmark.com > Provider > Communications and Resources > Provider Guides. Current Procedural Terminology (CPT) is copyright 2014 by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Blue Cross, Blue Shield, the Cross and Shield symbols, Blue Access, Blue Advantage, BlueCard, Blue Choice, Blue Connections, Classic Blue, Blue Select, and Senior Blue are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark Blue PPO SM, Wellmark Blue HMO SM, Wellmark Blue POS SM, Blue Traditions SM, SimplyBlue SM, EnhancedBlue SM, CompleteBlue SM, PremierBlue SM, and myblue HSA SM are service marks of the Blue Cross and Blue Shield Association. Wellmark is a registered mark and Alliance Select SM is a service mark of Wellmark, Inc. Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association.
3 Inpatient Services- Guide to Billing Facility Services Summary of Changes- May and October 2014 Summaries below link to the actual changes in the text. The most recent changes appear in blue. Throughout: (May) Changed Billing Guides to Provider Guides. Page 8: (October) Added the section Post Pay Audits. Service Contacts page: (October) Removed local phone numbers. Service Contacts page: (October) Removed phone numbers listed for Iowa Bankers, UI Care, UI GradCare, and UI Select; and Ford Retirees.
4 Inpatient Services Section 1 of Guide to Billing Facility Services Table of Contents I. Covered Benefits... 1 Discharge Summary... 1 II. Precertification/Notification Procedures... 2 Precertification/Notification... 2 Skilled Nursing Facility, Acute Rehabilitation Facility, Acute Care (FEP only), Long-Term Acute Care Facility, and Swing-Bed Admissions... 2 III. Reimbursement for Covered Services... 3 Billing on the UB Sample Inpatient Claim... 4 Rehabilitation Services... 7 Anesthesia Services... 7 Dental Procedures... 8 Nursing Facility Revenue Codes... 8 Noncovered Services... 8 IV. Post-Pay Audits... 8 DRG Validation Audits... 8 Audit Outcomes... 8 V. Contact Wellmark... 9
5 Scope Use of terms Information in this guide applies to networks and products offered or administered by Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. As individual benefit plans vary, always verify eligibility and benefits using our secure Web tools on Wellmark.com. This section contains information about inpatient services provided to Wellmark members in Iowa and South Dakota. All contracting providers must comply with the requirements identified below as a term of their provider contracts. Unless otherwise noted, in this section the term facility refers to hospitals, skilled nursing facilities, and freestanding substance abuse facilities. Verify eligibility on the Web or by phone Standard SNF benefit limit First-time access to our secure online tools Note: FEP members under age 65 do not have SNF benefits Send discharge summary to PCP Inpatient benefits may vary, depending on the patient s benefit contract. Typically, a member has benefits for inpatient services that may require a deductible and/or coinsurance. To check a patient s benefits, use the secure online tools available on our website. You may also call Wellmark s Iowa Provider Service at ; or Wellmark Blue Cross and Blue Shield of South Dakota s Provider/Customer Service at Wellmark s standard inpatient skilled nursing facility (SNF) benefit is limited to 90 days per member per benefit period. This does not affect members covered by individual contracts or most Medicare Supplement plans. Some large employer groups may also choose benefits that differ from the standard. To determine a member s coverage, log in to Wellmark.com and select Check Member Information. To gain first-time access to our secure online tools, apply by selecting the Register now quick link on our website s Provider page. Federal Employee Program (FEP) employees under age 65 do not have a skilled nursing benefit. However, there may be exceptions when medically necessary, as determined by Case Management. Discharge Summary Hospital discharge summaries contain important information about a patient s history, condition, and discharge plan of treatment. Please make sure this information becomes part of the patient s permanent medical record by sending a copy of the discharge summary to the patient s Primary Care Practitioner (PCP).
6 Precertification/Notification Precertification requires the patient's physician or the facility to precertify with/notify Wellmark prior to providing specific services. A complete list of services subject to precertification/notification is available at Health Management section Skilled nursing facilities (SNF), rehabilitation, acute care (FEP only), longterm acute care, and swing-bed For details on Wellmark s preservice review requirements, go to the Health Management section of the Wellmark Provider Guide at Wellmark.com > Provider > Communications and Resources > Provider Guides. Skilled Nursing Facility, Acute Rehabilitation Facility, Acute Care (FEP only), Long-Term Acute Care Facility, and Swing-Bed Admissions Wellmark requires precertification before a patient receives services at a skilled nursing facility (SNF), an acute rehabilitation facility or a longterm acute care facility, or is admitted to a swing-bed. Precertification is required for FEP (Federal Employee Program) members for all inpatient planned admissions, and notification within two working days of an emergent admission. Contracting facilities are responsible for obtaining precertification. This allows Care Coordination staff to verify that the services are being performed in the most medically appropriate setting. Skilled nursing per diem at a free-standing SNF includes: Room and board Pharmacy Supplies Therapies Non-emergent transport services Labs if performed by the facility Radiology if performed by the facility DME [HME] services if provided by the facility Patients that receive laboratory, radiology, or DME [HME] services from an outside agency or hospital may have those services submitted separately by that provider. DME providers must be separately credentialed by Wellmark. This list is not intended to be an all-inclusive list of services, but to provide a guideline for providers. Services delivered by the free-standing skilled nursing facility and billed on the institutional claim are considered included in the per diem payment.
7 Overview of how services are paid Refer to the Provider Guide Observation bed services Wellmark reimburses covered inpatient services based on the provider contract and payment rate in effect at the time the patient was admitted. This also applies to interim billing situations. Wellmark does not use the rate in effect when you submit the claim to us or when we process the claim. Billing on the UB-04 To bill Wellmark, follow the guidelines in the Claims Filing section of the Wellmark Provider Guide at Wellmark.com > Provider > Communications and Resources > Provider Guides. The use of an observation bed allows the physician to observe and evaluate a patient to determine the need for inpatient care. An observation bed may be used when the patient is presenting symptoms or conditions that are potentially life-threatening or emergent, or do not meet the criteria for acute care. Observation bed services are generally provided for less than a 24-hour period, but may on rare occasion be extended to 48 hours. The observation bed period begins when the physician makes the decision to place the patient in an observation bed. Observation bed status is not appropriate when used for: Elective or non-emergent preoperative care Outpatient surgery with postoperative medical complications that meet Wellmark s criteria for acute level of care Outpatient surgery Members undergoing outpatient diagnostic treatment who require normal recovery Patients who meet medical necessity guidelines for Intensive Care Unit/Critical Care Unit Inpatient admission If the health status of a member admitted to an observation bed changes so that an inpatient admission is necessary, the observation bed charges and associated ancillary charges should be billed as part of the overall inpatient stay. The admission date is the date the physician orders the admission of the patient to inpatient acute care. See sample claim. If a procedure is performed more than one day prior to the admission date, please see Billing an Outpatient Procedure that Results in a Subsequent Admission in the Outpatient Services section of the Guide to Billing Facility Services.
8 Sample Inpatient Claim Patient was placed in an observation bed on 7/18/YYYY. On 7/19/YYYY the patient was admitted as an inpatient. The patient was discharged on 7/21/YYYY. Jane Doe 0719YYYY 0721YYYY 0762 Observation Bed $$$ 0120 Room-Board $$$ 0270 Med./Surg Supplies $$$ 0300 Lab $$$ 0320 DX X-Ray $$$ 0001 $$$
9 Transportation services Private room charge/isolation room charges Hospital-based ambulance services to transport the patient from the scene of an accident or a home should not be included with an inpatient claim since it is not part of the hospital s per case payment rate. These services should be reported on a separate claim. If ambulance services are required to transport an inpatient from the hospital to a freestanding service, such as MRI, the charge for the ambulance is included in the case payment and should not be billed separately. Currently Wellmark allows a private room charge only for isolation of infectious conditions, reverse isolation, radiation implant therapy and eclamptic OB patients. Wellmark considers isolation medically necessary when: the patient s health or recovery might otherwise be compromised other patients may be affected by the patient s symptoms or treatment, or by the spread of infection Submit revenue code 0164 to identify patient care for services provided in isolation or in a sterile environment. A written statement by the doctor ordering a private room is not the controlling factor in establishing medical necessity for isolation. The question is whether isolation is necessary for the health of the patient or of other patients. Do not bill for an isolation rate if it does not meet the medical necessity criteria discussed above. Leave days Outpatient services as inpatient Mother/child claims Bill leave days with revenue code 0180 in loop 2400 SV201 on electronic claims or in form locator (FL) 42 on the UB04. This code indicates a patient went home from the hospital for a brief period of time. Wellmark does not cover leave days; however, leave days must be reported for the accommodations units to match the Statement Covers Period field (loop 2300 DTP03 where DTP01 = 434 on the electronic claim or FL 6 on the UB04). Bill outpatient services performed at your facility within 1 (one) calendar day of an admission on the inpatient claim when the services are related to the admission. These services are considered related to the inpatient admission if they are provided in connection with the principal diagnosis that necessitates the admission. Bill all obstetrical claims on two separate claim forms, one for the mother and one for the baby. Use the infant s full name on the claim. Remember that many new mothers qualify for a home health visit within three (3) days of discharge. When the mother s stay does not exceed the normal length of stay for vaginal delivery (2 days) or Cesarean delivery (4 days), the physician should order a home health visit to review mother s and baby s health in the home.
10 Discharge from acute care to skilled Submit two bills for skilled level services When an acute care patient progresses to a skilled level of care while remaining in an acute bed, it is important to first discharge the patient from acute care. Bill the skilled claim separately using your NPI. Facilities billing for skilled level services must submit two separate bills. 1. Discharge the patient from acute care with the correct patient status listed in status loop 2300 CL103 for electronic claims or in form locator (FL) 17 on the UB-04 claim form. Bill any acute services on this claim. Use the facility s acute care NPI. 2. File a second claim for the skilled level services and reflect the NPI in loop 2010AA NM109 for electronic claims or in FL 56 on the UB-04 claim form. Remember that the Type of Bill (loop 2300 CLM05 or FL 4) on a swing-bed claim should include a 1 as the first digit, 8 as the second, and an appropriate third digit. Use this Type of Bill even if the patient remains in an acute bed but receives skilled care. For a list of Type of Bill digits, consult the Claims Filing section of the Wellmark Provider Guide. Discharge/transfer code per diems Hospitals will receive the APR-DRG (All Patient Refined Diagnostic Related Groups) specific transfer per diem instead of a case payment for most claims submitted with patient discharge status codes 02, 05, 43, 65, 66, 82, 85, 88, 93, and 94. Wellmark s payment methodology is based on the definitions of the codes. PATIENT DISCHARGE STATUS CODE DEFINITION Discharged/transferred to another short-term general hospital Discharged/transferred to a designated cancer center or children s hospital Discharged/transferred to a Federal Health Care facility Discharged /transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital Discharged/transferred to a critical access hospital (CAH) Discharged /transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission Discharged/transferred to a designated cancer center or children s hospital with a planned acute care hospital inpatient readmission Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission Discharged/transferred to a psychiatric distinct part unit of a hospital with a planned acute hospital inpatient readmission Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission
11 Rehabilitation services use special NPI Acute care services Rehabilitation services Payment reduction for failure to precertify Billing employed or contracted CRNA services Bill actual minutes Rehabilitation Services Hospitals with a Medicare certified rehabilitation unit are assigned a separate NPI. Use this provider number with Type of Bill 0111 when billing inpatient services provided in this unit. These services must be submitted on a separate claim from acute care services the patient may have received in the hospital setting. First bill the acute care services and indicate the patient s discharge from this setting in loop 2300 CL03 on an electronic claim, or by entering 62 (Acute Claim) in the Patient Status field (FL 17 on a paper claim form). Next, bill the inpatient rehabilitation services, using the date the patient entered the Medicare certified unit as the new admit date. The Admit date is found in loop 2300 DTP01 = 435 DTP02 = D8 then DTP03 =CCYYMMDD or if DTP02 = DT, DTP03 = CCYYMMDDHHMM. On a paper claim, enter the date in FL 12. (Example: Patient is discharged from acute care on 01/15/07 and admitted on 01/15/07 to the Medicare certified rehabilitation unit.) If the admitting facility or service provider has a provider contract with Wellmark, the facility or service provider is responsible for obtaining precertification for acute rehabilitation services. Please refer to the Health Management section of the Wellmark Provider Guide for details on precertification requirements and payment reduction for failure to precertify. Anesthesia Services Bill hospital employed and/or contracted certified registered nurse anesthetist (CRNA) professional services on a CMS Wellmark s facility reimbursement allows for the technical services provided, but does not include settlement for professional services. Bill the actual time spent administering anesthesia services electronically in loop 2400 SV104 where SV103 = MJ (minutes), or in the Units of Service field (24G) on the CMS Submit actual minutes only do not add base units to the time Use CPT* codes to report anesthesiology services; do not use surgical CPT codes. Use modifier QY (medical direction of one CRNA by an anesthesiologist), AD (medical supervision by a physician; more than four concurrent anesthesia procedures), QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), or QX (CRNA service: with medical direction by a physician) when an anesthesiologist is directing the CRNA service and there is no employer/employee relationship. For more specific information on how to bill anesthesiology services, please refer to the Anesthesia Services section of the Wellmark Provider Guide.
12 Removal of impacted teeth Bill appropriate revenue codes Hospital-acquired conditions Dental Procedures Many Wellmark contracts exclude inpatient hospital services for surgical removal of teeth, except when the patient has a non-dental, physical condition that makes hospitalization medically necessary to safeguard the patient s health. To check dental benefits, contact Provider Service at (Iowa) or (South Dakota). Nursing Facility Revenue Codes Do not bill for any services not performed in your facility. For example, a nursing facility would not bill for diagnostic or surgical services normally provided in an acute care setting. Noncovered Services Inpatient services related to hospital-acquired conditions (HAC) will be provider liability. For a complete list of CMS HAC diagnosis codes, please visit the CMS website at <http://www.cms.gov/medicare/medicare-fee-for- Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html>. Wellmark pays for inpatient services on a per case basis and percentage of charge, depending on the hospital. Wellmark has contracted with Inpatient Claim Review Services ( ICRS ) to perform post pay audits for inpatient services. Audits for inpatient case payment hospitals DRG Validation Audits Post-pay audits for inpatient case payment hospitals are called DRG (Diagnosis-related group) validation audits. DRG validation audits are a complete evaluation of DRG coding. The diagnosis and procedures are checked for correct coding and assignment to the proper DRG category and severity of illness indicator. The diagnosis and procedure are also checked for proper sequencing and for the primary or secondary diagnosis. Complications are evaluated for validity and proper coding. The current DRG and severity of illness assignment is assessed to determine if it is correct. Audit Outcomes For DRG validation audits, the hospital is notified in writing of any findings. The hospital is given the opportunity to confirm or appeal the findings before a claim adjustment is initiated. For more information on post-pay audits, refer to the Frequently Asked Questions document found on Wellmark.com > Provider > Claims and Payment > Inpatient Facility Claims (UB-04).
13 Questions? With questions about topics in the Inpatient Services section of the Guide to Billing Facility Services, Iowa providers should call Wellmark s Provider Service Center at ; South Dakota providers should call our Provider Service Center at
14 Wellmark Blue Cross and Blue Shield of Iowa Wellmark Health Plan of Iowa, Inc. Des Moines, IA Wellmark Blue Cross and Blue Shield of Iowa* Wellmark Health Plan of Iowa, Inc.* Provider Service Federal Employee Program* Admission Notification, Precertification, and Case Management Network Engagement Contracting Opportunities: Pregnancy Program* Disease Management Program* Network Administration* Provides information about: network participation, provider number, address change, application status, credentialing/recredentialing status, and taxpayer identification number change or BlueCard Program* Out-of-state members claim status or payment information: Out-of-state members eligibility information: EC (Electronic Commerce) Solutions* Electronic claims and reports information: Pharmacy Department Wellmark Blue Cross and Blue Shield of South Dakota Sioux Falls, SD Wellmark Blue Cross and Blue Shield of South Dakota* Provider/Customer Service Federal Employee Program* Admission Notification, Precertification, and Case Management Network Engagement Contracting Opportunities: Pregnancy Program* Disease Management Program* Network Administration* Provides information about: network participation, provider number, address change, application status, credentialing/recredentialing status, and taxpayer identification number change BlueCard Program Out-of-state members claim status or payment information: Out-of-state members eligibility information: EC (Electronic Commerce) Solutions* Electronic claims and reports information: Pharmacy Department *You will find links to these areas from our website at Wellmark.com > Contact Us (top right of page). Select For Iowa Providers or For South Dakota Providers.
Preface Summary of Changes Table of Contents Service Contacts November 2014 Replaces: September 2014 S-5787 11/14 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers
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