Michigan Medicaid
REIMBURSEMENT UPDATES
WINTER 2012/2013
Presenter-Catherine Caswell
1
*Revised 01/16/2013
Agenda
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Hospital – edit changes for OPH/IPH
Coding Updates
Policy Clarifications
New policy Review
Proposed policy review
CHAMPS Payment Schedule Posted
Mass Claim Adjustment Schedule
Suspended Claims Activity
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Questions & Contact Information
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NEWS-editing we are working on
will affect your Out-Patient
Hospital claims
News-future changes!
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Did you know that Michigan Medicaid policy states that per APC Policy
***A single OPH episode of care is to be billed on one claim in order to
group/price edit the OPH visit under the APC methodology?
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Here is what Medicaid Policy states:
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CHAPTER: Billing & Reimbursement for Institutional Providers
Section: 7.1.E Date of Service
“All services for a single outpatient encounter must be reported on one
claim, except for Medicare’s allowable repetitively billed services and
hospital-owned ambulance services. MDCH aligns closely with
Medicare's guidelines for monthly repetitive billing.”
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Projected correction date to the system 4.7 04/26/2013 *
News
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MOMS and/or ESO Benefit Plan claims appear to be paying voluntary
sterilizations. This is a non-covered service. Projected to be corrected in future.
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Compound Drugs have an issue with NDC's after 5010 implementationdenying as duplicates. Projected 4.6 02/15/2013
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CHAMPS manage claims-trying to change a PRO# but system keeps
saving the original data only. Fixed 4.4 09/28/2012 Release
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Effective 06/22/2012 system started paying only up to charges billed
instead of up to the APC rate. Fixed 4.4 09/28/2012 Release
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Effective 06/22/2012 system is not deducting Value Code 66 for the
spend-down/deductible . Projected to be corrected in the future
News
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Per MDCH-Bulletin Number MSA 10-60-effective for
DOS on/after 1/1/11 (following CMS rules) All nondiagnostic services rendered in the 3 day window prior
to the Inpatient hospital admission may not be billed
separately and must be bundled into the DRG Stay.
Hospitals may document the "unrelated" OPH services
by appending condition code 51 to the OPH claim.
Need new edit developed to suspend/deny OPH claims
billed w/o condition code 51 within 3 days of an IPH
claim. Projected (was 4.6 02/15/2013) ) now delayed due to budget
constraints*
News
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Enhancement to create additional logic to deny
service lines on IPH and OPH claims with
professional charges. (Projected 4.7 04/26/2013 ) now delayed due to
budget constraints*
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Currently we do mass sweeps quarterly and void
out miss-paid claims.
Providers have asked for this enhancement as
Medicare Crossover claims from CCA facilities bill
this way
Will reject revenue codes that should be used to
reflect professional fees (96X, 97X, 98X)
News
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Service lines billing drug codes throwing an erroneous error as
not rebate-able (providers remittance advice would show
adjustment reason code 211-NDC not eligible for rebate, are not
covered and remittance remark code M119)
– Problem identified 09/12/2012
– Error has to do with emergency logic to the cross-over claims
sent without a service line date of service-
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Work around is for provider to adjust and ADD those
service line dates to their claims.
Projected correction=4.6 release 02/15/2013
News
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Logic enhancement as a result of ICD-10 to
redesign so that all diagnosis codes on the
claim will compare to the procedure code
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Currently suspend several claims to manually
review all subsequent DX codes
Future (not assigned to a release)
NEWS-editing we are working on
will affect your In-Patient Hospital
claims
News-future changes to look
forward to!
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Needs working bypass for admit source = 5 (transferred from SNF)
within our Patient Pay Logic. Per policy when patient is living in a
Skilled Nursing Facility and is transferred to an In-Patient Hospital
setting we should normally bypass deducting the PPA from the first
month service however currently we are immediately taking the
PPA Projected (was 4.6-02/15/2013 ) now delayed due to budget constraints*
Co-Pay Deducted ($50.00) when transfer in's, per policy system
should not deduct a copayment. Provider may see CARC 3.
Projected (was 4.6-02/15/2013 ) now delayed due to budget constraints*
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Enhancement to information appearing in the Claim Limit List –will
show readmit within 15 days the date span involved and the NPI
etc. Currently providers must call or email PPS to obtain this
information if patient was in a facility other then their own.
Projected (was 4.7-04/26/2013 ) ) now delayed due to budget constraints*
News
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CHAMPS Direct Data Entry issue with the occurrence span
codes/dates Fixed 4.5 12/02/2012
– Screens let user enter up to 12 entries
– Claims fail to load as CHAMPS logic only allows for 4 of
these fields-need to expand to allow for correct number of
these fields (black hole effect)
CHAMPS Direct Data Entry issue with the other payer “amount
paid” field Fixed 4.5 12/02/2012
– Screens let user enter more then 10 characters
– Claims fail to load-need to restrict DDE to 10 or less
characters
News
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Logic regarding other insurance needs to be
further modified Projected 4.6 02/15/2013
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Have claim rejection for other insurance when the
only other “coverage type” =RX
News
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Logic regarding PACER requirements needs
to be further modified. Projected (was 4.7 04/26/2013) but
now pushed back to 4.8 06/28/2013*
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Claims with admit source transfer (=4 or 6)
regardless if admit type is urgent/emergent
Updates
Coding-Out-Patient Hospital
Out-Patient Hospital Coding
Updates
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094X Revenue Code was included in Plan First Benefit
Plan(PFBP) and is not now. Resolved-determined not an
appropriate revenue code to bill for PFBP Issue resolved as of 08/20/2012
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G0166 is listed on the WRAP AROUND CODES list database as
of October 2011, with an R1 indicator reflecting its MDCH noncovered item. (On the CMS Addendum B list this code is status
indicator=T.) However we are trying to obtain clarification if
this code should be listed as MDCH non-covered prior to
October 2011 as current claims processing we are noticing
claims are rejecting as non-covered in that prior date range.
Problem identified 09/17/2012
Out-Patient Hospital Coding
Updates
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Individual and group counseling codes for diabetes training and
education. Receiving inquiries regarding G0108 and G0109 as these
are the payable codes under Medicaid for providers that are certified
to provide this service. These codes should be listed on the wrap
around codes list as on Addendum B the status indicator is set to an
A. We are working with policy regarding correction of this issue.
(Claims billed correctly are paying correctly –this is a documentation
issue only and has been ongoing issue from legacy.)
Dialysis providers inquiry if Q2047 is payable by MA? On Addendum
B=Status Indicator of A but is not on the wrap around codes list. We
verified that code is paying-referred issue to policy to further
determine if we should or should not be paying this code and if the
Wrap Around Codes list needs to be updated. (Identified and reported
01/03/2013)
Out-Patient Hospital Coding
Updates
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We are receiving multiple inquiries regarding therapy reimbursement.
There is posted on our provider specific information website a data
base for therapy codes that seems to imply that this is what we cover,
frequency, modifier requirements etc. Therapy is paid from CMS
guidelines and here are some web sites you may wish to use to
explain our reimbursement further:
To see if the specific therapy code REQUIRES a modifier (sometimes/always)
see:
http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html
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To see FEE SCHEDULES for therapy codes go to:
http://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/Thera
pyServices need to use MPPR rate file (Multiple Procedure Payment Reduction)
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Out-Patient Hospital Coding
Updates
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We identify OPH therapy claims by APC Status = AT on the line.
The multiple procedure payment reduction will be applied for a therapy
procedure when more than one unit or more than one procedure is
provided to the same patient on the same date of service.
Full payment is made for the unit or procedure with the highest payment.
For subsequent units and procedures furnished to the same patient on the
same day, the 25% reduction is used (25% is the rate for services
furnished in an institutional setting).
When using the fee schedule data base you will need to be sure to use
your CARRIER/LOCALITY to get the correct amounts.
Use “fee amount” and then apply the appropriate Michigan Medicaid
Reduction Factor.
Or if / when appropriate select the 25% reduction column and then apply
the Michigan Medicaid Reduction Factor.
Policy Clarification/HospitalProposed Medicaid Changes
Eligibility change
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New Benefit Plan ID: MME-MC
– Medicaid-Medicare Dually Eligible – Managed
Care
Starting 12/14/2012 providers will notice for
beneficiaries dually covered by Medicaid and
Medicare that are enrolled in a Medicaid Health Plan
will have this special Benefit Plan ID designation in
CHAMPS.
There are no changes to the benefit coverage's.
AND this benefit plan designation will show for
enrollment dates of service 10/01/2012 and ongoing.
MSA-12-40- -Michigan National
Correct Coding Initiative UpdateEffective 10/01/2012
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Policy issued in August 2012 states that in further accordance with the
Section 6507 of the Affordable Care Act of 2010 in requiring that State
Medicaid programs use National Correct Coding Initiative(NCCI)
policies and edits to process claims. The purpose of the Medicaid
NCCI is to prevent improper payments when incorrect code
combinations or units are reported.
CMS has reviewed and reduced Medically Unlikely Edits (MUE’s) for
bilateral surgical procedures. Providers will be required to bill with
quantity of 1 and use of modifier 50. Billing otherwise (with a quantity
of 2 or with modifiers of LT or RT etc. on multiple lines) will be
considered non-compliant billing. Claims will be rejected (not cutback).
Current MUE values can be found on the CMS website:
http://www.medicaid.gov/Medicaid-CHIP-Program-nformation/ByTopics/Data-and-Systems/National-Correct-Coding-Initiative.html
MSA-12-46- Policy regarding enrollment of
CSHCS/MA beneficiaries into MHP –Effective
10/01/2012
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Effective 10/01/2012 beneficiaries dually
enrolled in CSHCS and Medicaid will
transition from an excluded population to a
mandatory population for purposes of MHP
enrollment.
Effective 10/01/2012 these beneficiaries will
no longer be retroactively dis-enrolled from a
MHP. (CSHCS split-billing exception is
rescinded)
MSA-12-46
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Providers are responsible for verifying a beneficiary’s
eligibility and enrollment status prior to rendering
service. The CHAMPS Eligibility Inquiry transaction
indicates a Benefit Plan ID of CSHCS-MC for a
CSHCS/MA beneficiary enrolled in an MHP.
Providers must bill the appropriate payer for all
services rendered.
CSHCS/MA beneficiaries enrolled in an MHP,
including beneficiaries age 21 and over, are exempt
from MHP copayment requirements for all Medicaid
covered services.
MSA-12-46
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Exclusions:
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CSHCS/MA beneficiaries without full Medicaid coverage (e.g.,
Medicaid Deductible, Emergency Services Only, Qualified
Medicare beneficiaries, Special Low Income Medicare
beneficiaries, Additional Low Income Medicare beneficiaries,
etc.)
CSHCS/MA beneficiaries excluded for other reasons such as
medical exception, incarceration, or enrollment in commercial
health maintenance organizations (HMOs) or preferred provider
organizations (PPOs)
CSHCS/MA beneficiaries who meet any of the excluded criteria
described in the Medicaid Provider Manual, Beneficiary
Eligibility Chapter
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MSA 12-49 Disproportionate Share
Hospital Process (DSH)-Effective
11/01/2012
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What is DSH? Monies from CMS that allows payment adjustments for hospitals
that serve a disproportionate share of low income patients with special needs.
Beginning with Medicaid State Plan years 2011 and thereafter, the state is
required to recover DSH payments made to a hospital in excess of its audited
DSH ceiling. (States must verify their methodology for computing the
calculations of hospital-specific DSH limits/payments to hospitals and annually
report an independent certified audit of its DSH program as a condition for
receiving Federal payments.)
Unless otherwise noted, the MDCH will modify its existing DSH process to
mitigate DSH audit related recoveries. The new process will expand current
DSH process to recalculate ceiling and payment amounts the year following the
original calculation. This will allow hospitals to provide input into the DSH
calculations by providing an opportunity to review ceiling and payment
amounts, decline DSH funds, and reduce their DSH ceiling. This will establish
a process to allocate audit related recovered DSH funds to remaining DSH
eligible hospitals with capacity to accept DSH funds.
MSA 12-49
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Purpose of the new process will expand MDCH’s
current DSH process to recalculate ceiling and
payment amounts the year following the original
calculation. The new process will allow input and
opportunity to the involved providers. In addition this
policy establishes a process to allocate audit-related
recovered DSH funds to remaining DSH-eligible
hospitals with capacity to accept additional funding.
MSA 12-51 Medicaid Liabilityissued 11/01/2012
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Bulletin clarifies existing policy regarding Medicaid Liability when
patient has other coverage(s) through commercial or Medicare.
The MDCH will not pay for services denied by OI due to
noncompliance with OI plans requirements. The provider and the
beneficiary/responsible party have the responsibility for complying with
OI plans requirements. In instances where MDCH has denied payment
or made a post-payment recovery due to noncompliance it is the
provider’s responsibility to remediate with the primary payer prior to rebilling MDCH.
Examples of noncompliance is failure to:
– Obtain a referral for the PCP
– Be seen by a participating provider
– Be seen in a participating place of service
– Obtain 2nd opinion
– Obtain PA
MSA 12-55-Medicaid Provider
Screening/Enrollment and Program Integrity
-Issued 11/01/2012 and effective immediately
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As required by the Affordable Care Act the
MDCH is implementing new Medicaid
provider screening and enrollment
requirements and new measures related to
Medicaid fraud and abuse for the Medicaid
FFS programs.
MSA 12-55
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Providers will be categorized based on at
least 3 levels of risk. (This risk categorization
is established by the CMS) High/Med/Low
Screening activities include=
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Fingerprinting/criminal background checks
Unannounced site visits
Verifications of SSN, NPI, OIG exclusion status
and etc.
MSA 12-55
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For hospitals probably the biggest issue will be that
the ordering/referring/attending providers must be
Medicaid enrolled. (prior to this the provider did not
have to be enrolled in the CHAMPS-)
Initially the system will show information only edits
to notify providers that the claim does not meet this
standard criteria
***Look for N253=Missing/incomplete/invalid
attending provider primary identifier.
MSA 12-55
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Revalidation of Enrollment- All providers will
be required to revalidate their Medicaid
enrollment information a minimum of once
every five years (or more often if requested
by MDCH)
Providers must notify MDCH within 35 days
of any change to their enrollment information.
MSA 12-59-Elective Delivery Prior
to 39 Weeks Completed GestationEffective 01/01/2013
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Need to ensure that each Medicaid enrolled
birthing hospital utilizes elective delivery
evidence-based guidelines (EBGs)
Each Medicaid enrolled birthing hospital is
required to submit MSA-1755 by 03/01/2013
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This form certifies the hospital utilizes elective delivery
EBG’s for Medicaid beneficiaries and must be signed by the
Chief Executive Officer and the Chief Medical Officer of the
facility
Send to POB 30479 (Policy Division) or fax to 517 335 5136
MSA 12-61-DRG Grouper UpdateEffective 01/01/2013
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DRG Grouper Version 30 will be used for In-Patient Hospital
claims effective 01/01/2013
Hospital prices for medical/surgical hospitals reimbursed by
DRG and Rehabilitation per diem rates have also been updated
Budget Neutral
Effective with admissions that occur on/after 01/01/2013
reimbursement will be based on rates/grouper version in effect
no the patient’s date of discharge.
Effective with this change the coding on the claim should be
valid codes based on the date of discharge. In addition the
patient age at the time of admission will continue to determine
instances when system is grouping differentiated by age. (some
alternate weight assignments)
MSA 12-62-OPPS Reduction
Factor Effective 01/01/2013
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Announces reduction factor for
reimbursements made for Outpatient
Prospective Payment System claims incurred
on dates of service beginning with
01/01/2013
Budget-neutral
54.3% (2012 DOS=55.3%)
MSA 12-65- Claim Predictive
Modeling-Effective 01/01/2013
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“Claim Predictive Modeling.” This new process will utilize
statistical analysis models to identify and flag Medicaid
claims in which there are billing irregularities. Any claim
that has been flagged for review will suspend. The review
may include a review of medical records and/or past
claims. Providers must submit the requested records in a
timely manner to avoid denials for lack of documentation.
(Will be similar to the Fraud Prevention System screening
implemented by CMS)
Look for CARC 133/RARC N10
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CARC 133=The disposition of the claim/service is pending further
review
RARC N10=Payment based on the finding of a review
organization/professional consult/manual adjudication/medical or
dental advisor.
MSA 12-67- ICD-10 Update-Issued
12/01/2012
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ICD-10 implementation = 10/01/2014
Medical Services Administration is continuing
to promote awareness among provider
community:
ICD-10 implementation education as part of the core Medicaid educational training
sessions and one-on-one provider consultations.
Informative ICD-10 webcasts, such as ICD-10 Implementation: "Get Ready", which is
available on the MDCH website at www.michigan.gov/5010icd10. Additional webcasts will
be available in the future, including ICD-10 Clinical Documentation.
State-wide ICD-10 implementation sessions. Providers should check the MDCH website
regularly at
www.michigan.gov/medicaidproviders
(click the Medicaid Provider Training Sessions button in ‘Hot Topics’).
MSA 12-69-Post-Payment Review
Hospital Audit Contract-Issued
12/28/2012
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This is announcing that the department’s contract with the
MPRO will be expiring and to expect a possible new contactor
to be announced via an L-Letter once the post-payment review
hospital audit contract has been granted.
L-12-46-the numbered letter was sent out and announces the
contract was awarded to HMS. (Medicaid Recovery Audit
Contract or RAC)
IMPORTANT NOTE: MPRO will continue
to provide the service of issuing the Prior
Authorization Certification Evaluation
Review or PACER.
MSA 12-70-HCPCS Code UpdatesIssued 12/28/2012
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This bulletin details for providers the
procedure codes being adopted by MDCH
for dates of service on and after
01/01/2013.
Any new procedure code not listed will
not be covered.
For OPPS there is a list of new codes to
be added to the Wrap Around Codes list.
MSA 12-70
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The “Wrap Around Codes”(WAC) lists codes that MDCH will
cover differently then OPPS. Example: The status indicator on
the addendum B may show a code is payable but on the WAC list
it will show the code is not covered.
New quarterly WAC list has not yet been posted on our web-site
(to the provider specific information pages.)
Remember that for some period of time we will still be using the
APC software of the last quarter to process claims and this may
cause some claim rejects. As a courtesy we always resurrect
these claims once the next quarters software is loaded. Example:
A procedure code that has only become effective as of 01/01/2013
–the may make the claim set A8 as the software will not recognize
new codes.
Notices of Proposed Policy
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All of our policy may be accessed on our
web-site:
www.Michigan.Gov/MedicaidProviders
>>Policy and Forms
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From this page you find the Medicaid Provider
Manual, Approved Policy Bulletins dating back to
2001, and Michigan Medicaid Proposed Policy
Proposed Policy-how to be heard!
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>>Proposed Medicaid Changes
– These documents inform interested parties of proposed
changes in Michigan Medicaid policy. Proposed new
policy and changes to existing policy must undergo a
30-day public comment period before it becomes final.
– The page will explain the Comment Due Date, the
project number and subject. Within the project number
paper is the contact information to use for your
comment.
Proposed Policy-cont.
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Also out for comment is Notice#1241-MHP Post-Stabilization
Authorization Determinations
This will be issued to the Medicaid Health Plans and Hospitals to
clarify responsibilities prior to any treatment and after stabilization.
This post-stabilization authorization determination refers to the process
in which inpatient hospital admission or admission to observation
status is authorized by the MHP after the beneficiary has been
stabilized.
Hospitals are required to make and document all of these requests via
phone to the MHP prior to providing any treatment after stabilization.
The MHP is required to response within in one hour of receipt of the
call. The MHP contract requires the MHPs to provide 24/7 availability
for requests. Hospitals may not wait until the next business day after
stabilization to call for authorization.
CHAMPS PAYMENT SCHEDULE
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The fiscal year 2013 schedule is now posted
to our website.
Any claims submitted within 12 hours prior to
a deadline may be subject to delay in the
event of excessive system traffic!
Includes Electronic & DEG Batch 837 cut-off
times/dates
Includes Direct Data Entry cut-off times/dates
CHAMPS-Changes for Providers
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Beginning in mid-December when providers use the
inquiry screens they can pull up all of the claims that
are both “In Process” and “Suspended”. These are
essentially the same thing-an edit has triggered the
claim to be manually reviewed.
When in the CHAMPS you will notice a “LINKS” box
in the upper right far corner with new optional
connections to other websites such as a link to our
MDCH-Medicaid Hot Topics page!
Emergency Release and MASS
Claim Adjustments-Hospital
MASS Claim Adjustments
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RA 01/24/2013 PC 04= OPH secondary claims overpaid more then the
Medicare Co-Insurance (TBD TCNs) The claim notes will show: 75520268
overpayments to adj.
RA 01/12/2013 PC 02=Additional batches of Oct. APC Updates-OPH to be
Adjusted (2689 TCN’s)
RA 12/27/2012 PC 52= Duplicate suspending claims-script deny(1,395 TCNs)
RA 12/20/2012 PC 51= OPH claims incorrectly limiting to charges to Adjust
(5,191 TCNs)
Ra 11/29/2012 PC 48= MIP Indicator Fixes (3786 TCNs)
Ra 11/29/2012 PC 48=TPL VOIDS-no OI reported but patient over age 65
(TBD TCNs)
RA 10/18/2012 PC 42=OPH crossovers with professional fees/revenue codes
(1,000+TCN’s)-these are VOIDS (from CAH provider type)
Ra 09/27/2012 PC 39=TPL VOIDS-no OI reported but patient over age 65
(8,782 TCNs)
Suspended Claims Activity
Suspended Claims
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Claims processing is happy to inform
providers that they are caught up!
Because of this be sure to send your
documentation 5-10 days prior to sending in
your claims. EZ LINK documentation filing is
a manual process.
Suspended Claims
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Top 3 edits to make claims suspend are:
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1. Time limit
2. Procedure code is not supported by the
primary diagnosis
3. No PACER on the claim
Suspended Claims
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TIME LIMIT= claims processing uses a
specific set of filters to look for activity
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Beneficiary ID#
NPI
Date of Service
It is the providers responsibility to keep track of all
TCN’s involved and to supply them when necessary
to satisfy time limit requirements
Suspended Claims
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HCPCS compared to the Primary Diagnosis Code=
CARC 11 with N10=Procedure code not allowed for
primary DX.
Claims processing will manually review all diagnosis
codes listed on the claim to verify if there is a proper
support code. Documentation may actually be
required if claim is not properly coded.
Several high dollar drug codes have recently been
added to this editing group. (>70 codes)
Some additional x-ray codes have also been added.
(>40 codes)
Suspended Claims
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PACER not on the claim
– Claims processing will look for claim notes/remarks
– Claims processing may look for Occurrence Span Code 71 with the
from/through dates of a prior In-Patient Hospital Stay
Transferring hospital should report appropriate patient discharge status code
(02)
Receiving hospital must report appropriate Point of Origin for Admission (Form
Locator #15)
– And PACER number in the PRO Number Field
– And Occurrence Span Code 71 with dates
Call Provider Support 800 292 2550 for billing information when your
remittance advice denies claim with remark code N47-(Claim conflicts with
another inpatient stay) and ask for other facility name and their from through
dates. Investigate if PACER was or should be obtained etc.
Questions ?
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CALL our hotline staff at 800-292-2550 Mon-Fri
8-5.
You will always need to provide identifying
information such as your name, your contact
phone number(if we have to call you back)
providers name, NPI and tax ID#. We prefer
that you call prepared with your TCN# and all
accompanying remittance advice with your
questions.
Contact us
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E-MAIL
You may also address any questions in writing to our
staff that answers e-mail at:
ProviderSupport@Michigan.gov
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WRITTEN inquiries
Provider Research & Analysis
PO BOX 30731
Lansing, MI 48909
THANK YOU
FOR PARTICIPATING IN THE MICHIGAN
MEDICAID PROGRAM
WINTER 2012/2013 REIMBURSEMENT UPDATES