IHCP Updates
HP Provider Relations
May 2012
Agenda
– Objectives
– Primary diagnosis for atypical providers
– Health Insurance Portability and
Accountability Act (HIPAA) version 5010
implementation update
– Coverage of implantable cardioverter
defibrillator
– Electronic Health Records (EHR)
– International Classification of Diseases,
Tenth Revision (ICD-10) implementation
– Taxonomy Codes
– Top call center calls
– Claim denials
– Helpful tools
– Questions
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IHCP Updates
May 2012
Objectives
– Learn about the changes for reporting the primary diagnosis for
atypical providers
– Review the HIPAA 5010 implementation
– Understand the coverage of implantable cardioverter defibrillator
devices
– Describe the EHR incentive program
– Provide an update about ICD-10 implementation
– Review taxonomy codes
– Review the top call center inquiries
– Explain how to resolve claim denials
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IHCP Updates
May 2012
Learn
Primary Diagnosis Code for Atypical Providers
Primary Diagnosis Code
Requirement for claim submission
– With the implementation of HIPAA version
5010, the transaction requirement for a
primary diagnosis code was changed
from situational to required for 837 claim
transactions.
– Effective April 1, 2012, this billing
requirement will also apply to both
Indiana Health Coverage Programs
(IHCP) paper and Web interChange claim
submissions.
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IHCP Updates
May 2012
Primary Diagnosis Code
Requirement for claim submission
– This change for reporting the primary diagnosis affects providers that
are currently exempt from submitting a diagnosis code specific to
transportation, waiver, or durable medical equipment (DME) services.
• Transportation
and waiver providers should bill diagnosis code 7999 as the
primary diagnosis code for claim submissions in which the actual diagnosis is
not known.
• For
DME providers, the primary diagnosis code will need to be obtained from
the physician who ordered the DME supplies or equipment.
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IHCP Updates
May 2012
Primary Diagnosis Code
Requirement for claim submission
– If a claim is submitted through Web interChange without a primary
diagnosis code indicated, the error message "Primary diagnosis is
required” will display.
– Paper claims missing the primary diagnosis code will be denied for
edit 258 – Primary diagnosis code missing.
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IHCP Updates
May 2012
Inform
HIPAA 5010 Implementation Update
HIPAA Claim Update
HIPAA 5010 claim process
– HIPAA qualifiers
•
837 I electronic billing qualifier is ME for milligram as a unit of measure when billing a
procedure code requiring a National Drug Code (NDC).
•
Paper claims CMS-1500/UB-04 can use the ME or MG qualifier to represent a
milligram as a unit of measure when billing a procedure code requiring a National Drug
Code (NDC).
– Patient status is required for all institutional claim types (UB-04).
•
Including outpatient claims
– Implementation is scheduled for June 27, 2012.
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IHCP Updates
May 2012
Understand
Implantable Devices
Implantable Cardioverter Defibrillator
BT 201203 and BR201209
– Effective March 1, 2012, the IHCP began reimbursing the cost of
implantable cardioverter defibrillator devices separately from
reimbursement for the implantation procedure when the implantation is
performed in an outpatient surgical setting.
– This change in coverage and reimbursement policy is retroactive for
dates of service (DOS) on or after January 1, 2009.
– Outpatient facilities bill the device on the CMS-1500 claim form or the
837P transaction
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IHCP Updates
May 2012
Implantable Cardioverter Defibrillator
BT201203 and BR201209
– For DOS January 1, 2009, through June 30, 2011, you must submit a
retail invoice or a manufacturer’s cost invoice with your claim, along
with a copy of the front page of bulletin BT201203.
– For DOS July 1, 2011, through February 29, 2012, you must submit
both a cost invoice and documentation of the manufacturer’s
suggested retail price (MSRP) with your claim, along with a copy of
the front page of BT201203.
– For DOS March 1, 2012, and after, you must submit both a cost
invoice and documentation of MSRP with your claim.
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IHCP Updates
May 2012
Describe
EHR Incentive Program
EHR Incentive Program
– The American Recovery and Reinvestment Act of 2009 provides for
incentive payments to eligible professionals (EP) and eligible hospitals
(EH) who are meaningful users of certified EHR technology.
– EPs include the following:
•
Doctor of medicine or osteopathy
•
Dentist
•
Certified nurse midwife
•
Nurse practitioner (advanced practice nurse)
•
Physician assistant (PA) when practicing at a Federally Qualified Health Center
(FQHC) or rural health clinic (RHC) that is led by a PA
– EHs include the following:
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•
Acute care hospital
•
Children’s hospital
•
Critical access hospital
IHCP Updates
May 2012
EHR Incentive Program
Meaningful use of EHR
– The Centers for Medicare & Medicaid Services (CMS) has determined
that meaningful use focuses on establishing the functionalities in
certified EHR technology that allow for the following:
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•
Continuous quality improvement
•
Ease of information exchange
•
Electronically capturing health information in a structured format
•
Using that information to track key clinical conditions and communicating that
information for care coordination purposes
•
Implementing clinical decision support tools to facilitate disease and medication
management using EHRs to engage patients and families
•
Reporting clinical quality measures and public health information
IHCP Updates
May 2012
EHR Incentive Program
EHR Regrestration
– EPs and EHs register for the incentive program through a two-step
process:
1.
2.
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Providers must register using the CMS Registration and Attestation system and
select Indiana as their state.

A registration number will be created on the CMS website

Use the registration number when registering in the Web interChange
Providers register their EHR system using the Provider Profile feature of Web
interChange.
IHCP Updates
May 2012
EHR Incentive Program
Eligible Professional
– According to federal rule, EPs must register for EHR incentive
payments no later than calendar year 2016.
– EPs must meet patient volume criteria as follows:
•
EPs, other than pediatricians, must have a minimum 30 percent patient volume
attributable to Medicaid-funded services; for pediatricians, the patient volume minimum
requirement is 20 percent.
•
EPs must practice predominantly in an FQHC or RHC and have a minimum 30 percent
patient volume attributable to needy individuals.
– Hospital-based providers are not eligible for the EHR incentive
program.
•
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EPs are considered to be hospital-based when 90 percent of their services are
furnished in a hospital inpatient or emergency room setting.
IHCP Updates
May 2012
EHR Incentive Program
Eligible Professional
– An EP may not receive EHR incentive
payments from both Medicare and
Medicaid programs in the same year.
– If an EP qualifies for EHR incentive
payments from both Medicare and
Medicaid programs, the EP elects to
receive payments from only one
program.
– After the EP qualifies for the EHR
incentive payment under one program,
an EP can switch between the
Medicare and Medicaid programs once
prior to 2015.
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IHCP Updates
May 2012
Update
ICD-10
ICD-10
Implementation October 1, 2013
– On January 16, 2009, the Department of Health and Human Services
(HHS) released a final rule mandating HIPAA-covered entities to
implement ICD-10 for medical coding by October 1, 2013.
– The ICD-10 codes must be used on all HIPAA transactions including
outpatient and professional claims with DOS and inpatient claims with
dates of discharge (DOD) on or after October 1, 2013.
– The ICD-10 implementation does not affect Current Procedural
Terminology (CPT®2) coding.
– To accommodate ICD-10, the new transaction standard HIPAA 5010
must be operational.
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IHCP Updates
May 2012
ICD-10
CMS Mandate
– Providers will not be able to continue to report ICD-9 codes for
services provided on or after October 1, 2013.
– After October 1, 2012, there will be only limited code updates to both
ICD-9 and ICD-10 code sets to capture new technologies and new
diseases.
– After October 1, 2013, there will be only limited code updates to ICD10 code sets to capture new technologies and new diseases.
•
There will be no updates to ICD-9 on or after October 1, 2013, as the code set will no
longer be a HIPAA standard.
– On October 1, 2014, regular updates to the ICD-10 code sets will
begin.
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IHCP Updates
May 2012
ICD-10
Frequently Asked Questions (FAQs)
– What is the current implementation timeframe?
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•
The HHS and CMS have provided no definitive strategy or timeline for a delay in ICD10 implementation. As such, Indiana’s plans for migration to ICD-10 remains unaltered.
Further information will be forthcoming once definitive guidance is received regarding
the ICD-10 implementation dates for both the International Classification of Diseases,
Tenth Edition, Clinical Modification and the International Classification of Diseases,
Tenth Edition, Procedure Coding System code sets.
•
Hewlett-Packard (HP) has completed the assessment for the Medicaid Management
Information System and is on target for the October 1, 2013, implementation of ICD10.
IHCP Updates
May 2012
ICD-10
Frequently Asked Questions (FAQs)
– Will there be vendor testing? When?
•
Yes, there will be vendor testing that will include managed care entities. Vendor testing
is scheduled to begin January 1, 2013.
– Will providers and vendors be able to use the ICD-9 codes after the
October 1, 2013, implementation?
•
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No, you must use ICD-10 codes for DOS or DOD on or after the October 1, 2013,
implementation date. There is no grace period.
IHCP Updates
May 2012
ICD-10
Provider Readiness Surveys
– The third provider survey will be released May 8, 2012, and will close
May 24, 2012.
– Survey results will help us help you by tracking your progress and
capturing your issues.
– HP and the Family and Social Services Administration have committed
to surveying contracted vendors and IHCP providers every 90 days
through August 2013.
– The purpose of continually surveying contracted vendors and IHCP
providers is to understand where they are in preparation for the
change to ICD-10 and to track progress.
– Information about these surveys is available in the IHCP Newsletters
available on indianamedicaid.com.
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IHCP Updates
May 2012
ICD-10
Advice to IHCP providers
– Now is the time to begin the ICD-10 planning process, if you have not
already.
– If you have not been contacted by your software vendor and/or
clearinghouse about ICD-10 readiness, be proactive and contact them.
– The IHCP has posted ICD-10 information pages at indianamedicaid.com
which include the following:
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•
ICD-10 Information page with links to relevant websites
•
ICD-10 FAQs page with answers to ICD-10 questions posed by providers, vendors, and
other stakeholders
•
ICD-10 Decisions page with explanations of decisions that have been made and issues for
your consideration. Providers, vendors, and stakeholders are encouraged to weigh in on
these issues during the open (posted) discussion period.
•
ICD-10 Training page, which is new to the website and contains a list of ICD-10 training
resources from state agencies and associations which will be updated frequently.
IHCP Updates
May 2012
Understand
The Importance of Taxonomy Usage
Importance of Taxonomy Code(s)
Best Practice
– Taxonomy codes are national codes providers use to indicate their
specialties when submitting claims.
– Reporting the correct National Provider Identifier (NPI) and taxonomy
combination ensures that claims—both paper and electronic 837
transactions—are processed under the correct service location and
provider type.
– Submitting the proper billing provider ZIP Code + 4 and taxonomy
code that are on file with the Indiana Health Coverage Programs
(IHCP) identifies your billing provider office location.
•
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A provider may have multiple service locations or provider types that use the same
NPI.
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Importance of Taxonomy Code(s)
Best Practice
– When an erroneous NPI and taxonomy combination is entered on the
claim, it can cause claims to deny, or to report to the wrong service
location or provider type.
– Providers are encouraged to check with their vendors and
clearinghouses to ensure the correct taxonomy is being submitted on
their claims.
– To find out what taxonomy is linked to your NPI for your service
locations, go to the PROVIDER PROFILE on Web interChange and
choose the Specialty tab for each of your locations.
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Explore
Top Call Center Inquiries
Top Call Center Inquiries
• Manual pricing … what is and is not acceptable documentation?
• BR201206 explains what constitutes acceptable documentation of MSRP and how
claims are reimbursed if the MSRP is not available for a manually priced medical
supply or DME procedure code.
• How do you determine who the accounts receivable (A/R) is for on a
Remittance Advice (RA)?
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•
A/R control numbers identify system-generated A/Rs on the RA along with the original
internal control number (ICN) for reference.
•
Nonclaim-specific financial transactions affect a provider’s payment and are unrelated
to a particular claim.
IHCP Updates
May 2012
Top Call Center Inquiries
• Why do claims deny for edit 6652 – Multiple surgeries must be billed on same
claim?
•
A surgical procedure code for the same physician for the same DOS has been
previously paid.
•
To request payment for additional surgical procedures, replace the original paid ICN
via Web interChange so the appropriate multiple surgery reduction can be applied.
• Request the adjustment using the paper Adjustment Request Form when the DOS is greater
than 365 days old.
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IHCP Updates
May 2012
Top Call Center Inquiries
• How do you bill claims using Web InterChange?
•
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Step-by-step billing guidelines are located under the Help and Reference Materials links on the
Web interChange at https://interchange.indianamedicaid.com/Administrative/logon.aspx.
IHCP Updates
May 2012
Top Call Center Inquiries
– How do you find NDC codes for the J codes?
•
Information on NDCs can be found at
http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm.
•
CMS maintains a list of rebating labelers that can be found at the following Web site:
http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp.
– Why do you receive a check with no RA?
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•
Effective September 1, 2009, RA documents are available on Web interChange at
https://interchange.indianamedicaid.com/Administrative/logon.aspx under the
Check/RA Inquiry tab.
•
RAs are no longer printed or mailed to providers.
•
RAs are removed in 28 days
•
A 15 cents per page fee is assessed for duplicate RA copies
IHCP Updates
May 2012
Help
Top Claim Denials
Top 5 Claim Denials
– EOB 558 – Coinsurance and deductible amount is missing indicating
that this is not a crossover claim.
•
Coinsurance and deductible amounts must be included on all crossover claims.
– EOB 593 – At least one detail submitted contains Medicare COB data,
resulting in a review of all detail COB data.
•
When submitting Medicare crossover claims, ensure that all Medicare coordination of
benefits information is on the claim for all details. This applies to CMS-1500 claims.
– EOB 5001 – This is a duplicate of another claim.
•
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Review claims to see if any billed services were previously paid. Verify previous claim
payments and denials using Web interChange to avoid erroneous rebilling of paid
claims.
IHCP Updates
May 2012
Top 5 Claim Denials
– EOB 4021 – Procedure code is not covered for the dates of service for
the program billed.
•
Verify that the procedure code is covered for the DOS via the Fee Schedule at
indianamedicaid.com.
– EOB 2510 – Member is eligible for Medicare B/D.
•
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Claim must be billed to Medicare before billing the IHCP.
IHCP Updates
May 2012
Find Help
Resources Available
Helpful Tools
– IHCP website at indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or
paper)
– IHCP Fee Schedule
– Customer Assistance
•
1-800-577-1278 toll free or (317) 655-3240 in the
Indianapolis local area
– Written Correspondence
•
P.O. Box 7263
Indianapolis, IN 46207-7263
– Provider field consultant contacts at
provider.indianamedicaid.com/contactus/provider-relations-field-consultants.aspx
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IHCP Updates
May 2012
Q&A