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Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing Jill Abramson, MD MPH February14, 2013.

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Presentation on theme: "Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing Jill Abramson, MD MPH February14, 2013."— Presentation transcript:

1 Partners for Children (PFC) Waiver Services, Procedure Codes, Rates and Billing Jill Abramson, MD MPH February14, 2013

2 PFC Provider Training Overview Care Coordination/CCSNL/Communication Family-Centered Action Plan Services/Billing Federal Assurances/ Health & Welfare Agency Responsibilities/Summary

3 What Happens Before Submitting Claim Services identified on F-CAP Services authorized by CCSNL SAR received by agency Service(s) provided

4 PFC Services, Procedure Codes, Rates and Billing Objectives: Understand PFC services Understand the use of the procedure codes and billing limits Know the rates for each service Understand claims processing procedure

5 PFC Services Care Coordination: Will provide child/family with Care Coordinator to: Assume a majority of the responsibility, otherwise placed on parents, of coordinating all medically necessary care in the community Work with the child/family to develop the Family- Centered Action Plan (F-CAP) Provide ongoing monitoring of health and safety of the child, including home visits

6 PFC Services Regularly communicate with the CCSNL, child, family, treating physician and other providers Accompany child/family to appointments as necessary such as; physician, school or hospital Service Provider: RN, MSW Care Coordination (cont):

7 PFC Services Expressive Therapies: Will allow children to express their understanding and reaction to their illness by utilizing play, art, music and massage therapy to improve the capacity of the body and mind to heal. Service Provider: certified therapist

8 PFC Services Family Training: Allows an RN to instruct caregivers about end of life care, palliative care principles, care needs, medical treatment regimen, use of medical equipment and how to provide in-home medical care to meet the needs of the child. Service Provider: RN

9 PFC Services Respite Care: Provides relief for family members either in the home or in an approved facility. This benefit may be intermittent or regularly scheduled. Service Provider: RN, LVN, HHA

10 PFC Services Family Counseling: Provides child/family with emotional support and grief counseling. Includes visits before and after the death of the child. Service Provider: LCSW, Licensed Psychologist, MFT, ACSW

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12 PFC Procedure Codes and Rates Care Coordination Services: Procedure CodeDescriptionRateLimit(s) G9001 Bill prior to initial F-CAP Coordinated care fee Requires at least 22 hours of initial assessment services $1,000One time fee T2022 May bill first unit in same month as G9001 Monthly case management 4 – 8 hours of case management, per child, per month $ per unit 1 unit per month; 1 U = 4-8 hr. 12 units per year

13 PFC Procedure Codes and Rates Care Coordination Services (cont): Procedure Code DescriptionRateLimit(s) G9012Supplemental hourly care coordination Used after 8 hours of monthly case management has been exceeded Service Provider – RN, MSW $45.43 per unit 1 U = 1 hour Maximum of 60 hours every 90 days.

14 PFC Procedure Codes and Rates Expressive Therapies: Procedure Code DescriptionRateLimit(s) G0176Activity Therapy 45 minutes per session Includes art, music, play and massage therapy Service Provider – approved expressive therapist $35.00 per unit 1 unit = 1 session Up to three units (sessions) per day Up to 60 sessions every 90 days Will change to 4 U per day soon

15 PFC Procedure Codes and Rates Family Training: Procedure Code DescriptionRateLimits S5110 Home care training Service Provider: RN $11.36 per unit (when RN employed by HA/HHA) $8.94 per unit (when provided by INP billing independently) 1 unit = 15 minute Up to 12 units per day Up to 400 units per year

16 PFC Procedure Codes and Rates Respite Care: Procedure CodeDescriptionRateLimits H0045 Provider type: Congregate Living Health Facility Out-of-home respite Provided in an approved facility on a short-term basis. Level of care 1. Skilled nursing services A or B Level of care 2 - Sub acute Level of care 3 – Acute $91.28 per 24 hrs. $ per 24 hrs. $ per 24 hrs. Up to 30 days per year, combined with in-home respite.

17 PFC Procedure Codes and Rates Respite Care (cont): Procedure CodeDescriptionRateLimits T1005 Provider type: RN, LVN, CHHA, (HHA/HA); RN, LVN ( INP) In-home respite Intermittent or regularly scheduled temporary care and supervision provided in the home Ranges from $ $10.14 (based on provider skill level), per 15 minute unit Maximum of 96 units per day, 30 days per year in combination with out-of- home respite

18 PFC Procedure Codes and Rates Family Counseling: *At least one visit must be provided, and the whole 22 units billed, before the childs death. Procedure CodeDescriptionRateLimits X9508 Provider type: LCSW, ACSW, MFT, licensed psychologist Family Counseling (Bereavement), one hour $50.87 per unit (total billable amount $1, (22 units x per unit rate)) 1 Unit = 1 hour 22 units to be billed at one time Limited to a one-time only payment

19 Billing PFC Services PFC services are Fee for Service PFC services must be authorized for the correct dates of service Service Authorization Request (SAR) = auth. Agency requests service on F-CAP, sends to CCSNL for authorization County CCS will share completed authorization with Agency Very different from traditional hospice per diem

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21 Billing PFC Services Billing: – SARs (authorization) Initial SAR to begin Care Coordination Additional SARs for requested PFC services once F-CAP is completed Separate SARs for other non-PFC services covered by the state plan – Check Medi-Cal eligibility prior to providing services

22 Billing PFC Services - Claim Completion UB-04 Field Descriptions: Box #Field NameInstructions 1Unlabeled (used for facility information) Enter the facility name. Enter the address, without a comma between the city and state, and a nine-digit ZIP code, without a hyphen. A telephone number is optional in this field. Note: The nine-digit ZIP code entered in this box must match the billers ZIP code on file for claims to be reimbursed correctly. 4Type of BillEnter the appropriate three-character type of bill code. The type of bill code includes the two-digit facility type code and one-character claim frequency code. This is a required field when billing Medi-Cal. 8bPatient NameEnter the patients last name, first name and middle initial (if known). Avoid nicknames or aliases. 10BirthdateEnter the patients date of birth in an eight-digit MMDDYYYY (Month, Day, Year) format (for example, June 12, 2007 = ). If the recipients full date of birth is not available, enter the year preceded by 0101

23 Billing PFC Services - Claim Completion UB-04 Field Descriptions (cont): Box #Field NameInstructions 11SexUse the capital letter M for male or F for female. Obtain the sex indicator from the Benefits Identification Card (BIC). 42Revenue CodeRevenue codes are not required; however, this field is used when recording Total Charges. Enter 001 on line 23, and enter the total amount on line 23, field DescriptionThis field will help you separate and identify the descriptions of each waiver service. The description must identify the particular service code indicated in the HCPCS/Rate/HIPPS Code field (Box 44). This field is optional. 44HCPCS/RATES/HIPPS Code Enter the applicable waiver HCPCS procedure code and modifier. Note that the descriptor for the code must match the procedure performed and that the modifier must be billed appropriately. All modifiers must be billed immediately following the HCPCS code in the HCPCS/Rate field (Box 44) with no spaces.

24 Billing PFC Services - Claim Completion UB-04 Field Descriptions (cont): Box #Field NameInstructions 45Service DateEnter the date the service was rendered in six-digit, MMDDYY (Month, Day, Year) format, for example, June 12, 2007 = Service UnitsEnter the actual number of times a single procedure or item was provided for the date of service. Medi-Cal only allows two-digits in this field. 47Total ChargesIn full dollar amount, enter the usual and customary fee for the service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar amount and cents, even if the amount is even (for example, if billing for $100, enter not 100). Enter the Total Charge for all services on line 23. Enter code 001 in the Revenue Code field (Box 42) to indicate that this is the total charge line (refer to field number 42).

25 Billing PFC Services - Claim Completion Box #Field NameInstructions 50A-CPayer NameEnter O/P MEDI-CAL to indicate the type of claim and payer. Use capital letters only. When completing Boxes (excluding Box 56) enter all Information related to the payer on the same line in order of Payment. When billing other insurance, the other insurance is entered on Line A of Box 50, with the amount paid by Other Coverage on Line A of Box 54 (Prior Payments). All information related to Medi-Cal billing is entered on Line B of these boxes. Be sure to enter the corresponding prior payments on the correct line. If Medi-Cal is the only payer billed, all information in Boxes (excluding box 56) should be entered on Line A. UB-04 Field Descriptions (cont):

26 Billing PFC Services - Claim Completion UB-04 Field Descriptions (cont): Box #Field NameInstructions 56NPIEnter the National Provider Identifier (NPI). 60A-CInsureds Unique IDEnter the 14-character recipient ID number as it appears on the Benefits Identification Card (BIC) or paper Medi-Cal ID card. 63Treatment Authorization Codes All waiver services must be prior authorized with a CCS Service Authorization Request (SAR) which includes a unique 11-digit SAR number beginning with a prefix 91 or 97. The SAR number must be entered in this box. It is not necessary to attach a copy of the SAR to the claim. Claims without a SAR number will be denied.

27 Claim Completion Sample UB-04 CCS/Medi-Cal claim authorized with a SAR 60. CIN or 14-digit ID # 63. PFC SAR #

28 Billing PFC Services - Claim Completion and Submission For help completing UB04 and submission instructions: Contact Xerox Regional Representative. Xerox Telephone Service Center:

29 Billing Troubleshooting Denied Claims: – Check AEVS, CIN, SAR, correct dates (eligibility, date on SAR corresponds to service), # units – If no clear reason for denial, send to PPC mailbox: Name, CCS#, CIN, service, date of service, CCN, RAD, notes, provider NPI

30 Billing: Troubleshooting Underpaid claims – Verify $ in provider manual vs. $ paid. – If incorrect, send to PPC mailbox: Name, CCS#, CIN, service, date of service, CCN, units paid, $ paid, $ expected

31 Billing: Troubleshooting Claims neither paid nor denied >2 months after submission Send to PPC mailbox: – Name, CCS#, CIN, service, date of service, CCN (if available), whether client has OHC

32 Questions?

33 PFC Provider Training Overview Care Coordination/CCSNL/Communication Family-Centered Action Plan Services/Billing Federal Assurances/ Health & Welfare Agency Responsibilities/Summary

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