Agenda 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 Questions & Contact Information
NEWS-editing we are working on will affect your Out-Patient Hospital claims
News-future changes! 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? Here is what Medicaid Policy states: – 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.” – Projected correction date to the system /26/2013 *
News 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. Compound Drugs have an issue with NDC's after 5010 implementation- denying as duplicates. Projected /15/2013 CHAMPS manage claims-trying to change a PRO# but system keeps saving the original data only. Fixed /28/2012 Release Effective 06/22/2012 system started paying only up to charges billed instead of up to the APC rate. Fixed /28/2012 Release Effective 06/22/2012 system is not deducting Value Code 66 for the spend-down/deductible. Projected to be corrected in the future
News – Per MDCH-Bulletin Number MSA effective for DOS on/after 1/1/11 (following CMS rules) All non- diagnostic 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 /15/2013) ) now delayed due to budget constraints*
News Enhancement to create additional logic to deny service lines on IPH and OPH claims with professional charges. (Projected /26/2013 ) now delayed due to budget constraints* – 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 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- 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 Logic enhancement as a result of ICD-10 to redesign so that all diagnosis codes on the claim will compare to the procedure code – 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! 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 /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 /15/2013 ) now delayed due to budget constraints* 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 PPS to obtain this information if patient was in a facility other then their own. Projected (was /26/2013 ) ) now delayed due to budget constraints*
News CHAMPS Direct Data Entry issue with the occurrence span codes/dates Fixed /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 /02/2012 – Screens let user enter more then 10 characters – Claims fail to load-need to restrict DDE to 10 or less characters
News Logic regarding other insurance needs to be further modified Projected /15/2013 – Have claim rejection for other insurance when the only other “coverage type” =RX
News Logic regarding PACER requirements needs to be further modified. Projected (was /26/2013) but now pushed back to /28/2013* – 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 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 G0166 is listed on the WRAP AROUND CODES list database as of October 2011, with an R1 indicator reflecting its MDCH non- covered 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 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 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: To see FEE SCHEDULES for therapy codes go to: pyServiceshttp://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/Thera pyServices need to use MPPR rate file (Multiple Procedure Payment Reduction)
Out-Patient Hospital Coding Updates 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.
Eligibility change 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 Michigan National Correct Coding Initiative Update- Effective 10/01/2012 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 cut- back). Current MUE values can be found on the CMS website: Topics/Data-and-Systems/National-Correct-Coding-Initiative.html
MSA Policy regarding enrollment of CSHCS/MA beneficiaries into MHP –Effective 10/01/2012 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 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 Exclusions: 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
MSA Disproportionate Share Hospital Process (DSH)-Effective 11/01/2012 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 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 Medicaid Liability- issued 11/01/2012 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 re- billing 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 2 nd opinion – Obtain PA
MSA Medicaid Provider Screening/Enrollment and Program Integrity -Issued 11/01/2012 and effective immediately 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 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= – Fingerprinting/criminal background checks – Unannounced site visits – Verifications of SSN, NPI, OIG exclusion status and etc.
MSA 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 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 Elective Delivery Prior to 39 Weeks Completed Gestation- Effective 01/01/2013 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 – 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 (Policy Division) or fax to
MSA DRG Grouper Update- Effective 01/01/2013 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 OPPS Reduction Factor Effective 01/01/2013 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 Claim Predictive Modeling-Effective 01/01/2013 “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 – 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 ICD-10 Update-Issued 12/01/2012 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 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 (click the Medicaid Provider Training Sessions button in ‘Hot Topics’).
MSA Post-Payment Review Hospital Audit Contract-Issued 12/28/2012 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 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 HCPCS Code Updates- Issued 12/28/2012 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 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 All of our policy may be accessed on our web-site: >>Policy and Forms – 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! >>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. 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 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 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 RA 01/24/2013 PC 04= OPH secondary claims overpaid more then the Medicare Co-Insurance (TBD TCNs) The claim notes will show: 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 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 Top 3 edits to make claims suspend are: – 1. Time limit – 2. Procedure code is not supported by the primary diagnosis – 3. No PACER on the claim
Suspended Claims TIME LIMIT= claims processing uses a specific set of filters to look for activity – 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 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 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 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 ? CALL our hotline staff at 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 You may also address any questions in writing to our staff that answers at: WRITTEN inquiries Provider Research & Analysis PO BOX Lansing, MI 48909
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