Presentation on theme: "February 4, 2014 What Successful Rehab Providers need to know about Georgia Medicaid Presentation to: GAMES/GRTC Winter Meeting Presented by: Courtney."— Presentation transcript:
February 4, 2014 What Successful Rehab Providers need to know about Georgia Medicaid Presentation to: GAMES/GRTC Winter Meeting Presented by: Courtney Haynes, DME/O&P Program Specialist Linda Wiant, Director of Pharmacy
Mission We will provide Georgians with access to affordable, quality health care through effective planning, purchasing and oversight. We are dedicated to A Healthy Georgia.
3 Topics for Discussion Welcome Recent Changes NCCI Edits Quote Invoices for Manually Priced Items PT/OT Evaluation Post-assessment PT/OT Evaluation K0108 vs. K0739 E0240- NU/U1 Complex Rehab Equipment POS 31/32 Audit Preparedness- (If it isn’t documented it wasn’t done) Helpful Resources Q&A Closing
4 Welcome! I am Courtney Haynes, The DME and O&P Program Specialist/Compliance Auditor For Georgia Medicaid
5 Recent Changes for Rehab Equipment E0240- Billing Guidance added for modifiers NU and U1. Note: Refer to the DME SMAP for pricing of the shower/bath chair. Refer to Appendix D for manual pricing applied to modifier U1 for other rehab toilet aids (excluding noncovered items). Physical Therapist Post-assessment for PMDs- This Requirement has been removed Effective 01/01/2014. For PMDs delivered on or before 12/31/2013 this requirement is valid and the assessment should be on file. For PMDs delivered on or after 01/01/2014 this requirement no longer exists (this information has been removed from Chapter 1102 #7 and the Q&A Section- #8 has been revised to reflect this information ). You will find a revised manual on MMIS within the next week containing the revised information for the changes to the Physical Therapist post-assessment.
6 NCCI EDITS (PTP/MUE) The National Correct Coding Initiative (NCCI) contains two types of edits: 1.NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Technology (CPT) codes that should not be reported together for a variety of reasons. The purpose of this is to prevent improper payments when incorrect code combinations are reported. 2.Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. HCPCS codes do not allow the use of CPT modifiers
8 NCCI Continued –NCCI edits are in effect. You will begin seeing denials for claims from 01/01/2013 for PTP and MUEs. You should become familiar with these edits to avoid unnecessary denials. program -information/by-topics/data-and-systems/national-correct-coding- initiative.htmlhttp://www.medicaid.gov/medicaid-CHIP- program -information/by-topics/data-and-systems/national-correct-coding- initiative.html –These are front end edits that are Federally mandated. These edits cannot be appealed unless the line has an indicator of “1”, however, if CMS or the NCCI contractor makes revisions to the NCCI tables DCH will reprocess claims accordingly. –Indicator- “0” cannot appeal,- 2 nd line is mutually exclusive of primary code –Indicator- “1” Line two may be approved in rare circumstances (RT/LT etc) –Indicator- “9” line has been end dated/ deleted
9 Quotes for Manually Priced Items – HOT TOPIC- –Submit the Actual Quote from the Manufacturer DO NOT ALTER THIS DOCUMENT. –There must be a quote number that can be traced to the paid invoice. –The patient for which the quote was created must be identified. –Providers may attach an additional document with the unaltered quote that includes any comment/suggestion they may have. We are aware that some manufacturers try to code items that may or may not be accurate. –If you disagree with the manufacturers code you should provide the code that more accurately describes the item provided and provide the line number/part number and any other information that is necessary for review. –You can cross reference you item on the DME PDAC website if needed. –NOTE- K0108 is limited to the list of codes in the table provided so do not Add items on any attachment with this code unless you have referenced the table. –Copies of generic forms printed offline, retail order sheets not sent in and returned with a quote number linked to a specific beneficiary, or copies of catalogue pages will not be accepted.
10 PT/OT Evaluation –The DME Provider can create a template to provide to the PT to ensure that current Policy Guidelines are met –The DME provider can work with the PT/OT to ensure the appropriate equipment is provided based on the results of the seating evaluation –The DME provider CANNOT complete any portion of the Physical Therapists Clinical Evaluation. This is a clinical evaluation that is reimbursed to the physical therapist, and this PT/OT should specialize in this type of rehab equipment. –DCH has identified issues with DME Providers completing this evaluation in its entirety and having the document signed by a licensed PT/OT. This is strictly prohibited by both parties.
11 PT/OT Post-assessment This is no longer a requirement effective 01/01/2014. Claims with a DOS on or before 12/31/2013 must have this documentation in the medical record to be in compliance with DCH Policy.
12 K0108 -vs- K0739-U2 K0108 is used to report certain miscellaneous components for a wheelchair during the initial purchase of the items. -See APPENDIX E Wheelchair Accessory Supplies/Services (K0108)— Categorized List For Invoice Pricing for items that are covered under K0108. For Repairs/Parts after the initial purchase of the wheelchair that are not covered under warranty and not described by another code report A repair is a correction or replacement of the original part(s) of a purchased item. The labor component for repairs is coded K0739 U1 ( Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component). K0739 U2 is reported in conjunction with K0739 U1 when repairs are for custom or specialty parts that do not have a HCPCS code. If modifier U2 is used to report custom repairs/parts, then an itemized list must be submitted and the total price must be the submitted charge. **DO NOT report K0108 for parts that are being replaced** All modifications/repairs listed on the certificate of medical necessity must also be on the original Prior Authorization form. If modifications/repairs are being requested for a wheelchair, a recommendation from a physical or occupational therapist, actively involved in the member’s care, must accompany the medical necessity statement. The therapist may be associated with a school, hospital, clinic or developmental center, but cannot be a vendor or be employed by a vendor. This does not apply to consumable items (batteries, tires, items under $200.00) that are routinely replaced or items that did not require a PT/OT evaluation for the initial order.
13 E0240 – Shower/Bath Chairs or Other Rehab Toilet Aids Shower chairs are coded as follows: E0240-NU represents a shower/bath chair, with or without wheels, any size only. This code is listed in the DME-SMAP with standard pricing applied. No PA is required. E0240-U1 is applicable to other rehab toilet aids that are covered by Medicaid. This code MUST not be used for items that are noncovered by Medicaid (i.e. Bath lifts for patients over 21 etc.) see 906. Of this manual for the list of noncovered items (this includes items not specifically listed not listed as covered in the policy manual or DME-SMAP). Physician must document specific physical limitations. An OT/PT evaluation/recommendation is required. Suppliers must be CRTS. Providers must submit t a quote meeting the guidelines for manually priced items that contains the price and the manufacturer’s model number for the items on the PA request.
14 COMPLEX REHAB EQUIPMENT -SNFs DCH understands that there are times when patients who require custom/complex rehab equipment will be enrolled in a SNF/NF and will cover equipment in the event this occurs, however, this should be rare, and in most cases the equipment would be a replacement and not a new issue. This is limited to Power Mobility Devices for members less than 21 years of age. -Patients typically do not develop the need for this equipment during a SNF enrollment period -Since equipment is normally issued as a purchase and is issued for a long standing diagnoses that lead up to the need for such equipment, most patients have this type of equipment before the enrollment in to a skilled nursing facility. GMCF will review cases submitted for patients in this situation on a case by case basis.
15 Specificity of Diagnoses for Complex Rehab Equipment The diagnoses submitted for a patient requiring custom/complex rehab equipment must be coded to the highest level of specificity to prevent delays in the prior approval process. A general diagnosis may not support the need for such equipment especially if there is a more specific diagnosis for the patient’s condition Example: Patient has Infantile Cerebral Palsy with paralysis affecting both sides of the body ( CONGENITAL DIPLEGIA; DIPLEGIC INFANTILE CEREBRAL PALSY) Provider submits: CEREBRAL PALSY NEC; OTHER SPECIFIED CEREBRAL PALSY (This does not support the equipment requested and delays your request by the need for additional supporting documentation and the correct diagnosis code).
16 Time limits for Documentation - Providers should receive the F2F within 45 days from the date it is completed in most cases- -Equipment should be delivered within 120 days from the date the PA is approved under normal circumstances. If this time limit needs to be extended the provider must request this extension from GMCF DME that is not considered Complex Rehab Equipment should be received by the provided within 30 days as identified in the policy manual
17 Documentation Checklists -Create Checklists (example) Physician’s Order CMN PT/OT Evaluation Home Assessment Detailed Product Description F2F Evaluation Notes/Dates Quotes Invoices (Quote converted to purchase) Proof of Delivery READ THE MANUAL- REVIEW THE UPDATES – THEY ARE ITEMIZED AT THE BEGINNING OF THE MANUAL SO YOU DO NOT HAVE TO GUESS WHAT HAS BEEN UPDATED!!!
18 Submit Timely Claims/Adjustments -Submit claims within six months of the date of service. -Adjust claims within 90 days of paid date. -Attach new RA to auto crossover claims from Medicare. If Medicare was not rebilled you cannot adjust the claim. See the Medicaid Policy and Procedures Manual, Part I, Chapter 200 for detailed information on Timely Submission.
19 Surviving An Audit Be Audit Ready- It starts internally- 1)Perform Quantitative Analysis- Do I have ALL the required documentation needed to get a Prior Approval ?? 2)Perform Qualitative Analysis- Is ALL my documentation complete? All signatures and dates are in place and all components required to be in compliance with GA Medicaid Policies and Procedures are documented? 3)Did you follow policy guidelines (diagnosis/age/limitations/restrictions/max units/ reasonable useful lifetime, prior authorization)? 4)You submitted unaltered quotes with quote numbers that are linked to purchased Invoices in your records? Is the patient clearly identified on the quote? 5) Did you submit the authorized dollars and authorized units for payment of manually priced items? If not did you receive an overpayment? YOU MUST BE PREPARED- IF YOU GET AUDITED YOUR #1 GOAL IS TO ENSURE YOUR DOCUMENTATION SUPPORTS THE LEVEL OF SERVICES PROVIDED AND ITEMS PROVIDED.
20 Emerging Technology nstructions.html If there is a new type of equipment that is not described by an existing HCPCS code the Manufacturer must apply for a HCPCS code for consideration to be made for coverage. This will promote coverage at a national level and CMS will issue coverage guidance and appropriate reimbursement fees. The application form and process can be found on the CMS website at the link listed above. Any new type of equipment that does not fit the criteria of an existing HCPCS code is considered emerging technology and the manufacturer must apply for a HCPCS code and obtain FDA approval etc. Miscellaneous codes are almost always used by GA Medicaid as options/accessories/additions to base equipment that falls within a current HCPCS code. Emerging technology would be considered base equipment and therefore does not qualify for the use of a miscellaneous code.
22 Provider Resources- Policy Information
23 Provider Resources- Websites For additional questions concerning policy information, contact the Provider Services Contact Center (PSCC) at The PSCC can also be reached by initiating a “Contact Us” inquiry on the Web Portal. WHEN IN DOUBT – INQUIRE! To search for key words in the provider manual select “Control F” and a “find/search” tool will pop up which allows you to type key words this will keep you from searching through 200 pages of information in the manual!
24 Provider Resources- Websites DCH Resources – GAMMIS Website for Provider Manuals/ Schedules of Maximum Allowable Payments https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20 Manuals/tabId/54/Default.aspx – DCH ICD-10 FAQs & Fact Sheet <<<
25 Provider Resources- Phone Numbers RESOURCEPHONE NUMBER EDI SERVICES PROVIDER CONTACT MEMBER CONTACT CENTER FRAUD and ABUSE
26 Resources for Coders/ Health IT
27 Thank You! We welcome your questions and comments related to Policy Issues/Concerns: Who to contact: GAMES - Teresa-GAMES Representative- Teresa will collectively send your Questions/Comments the appropriate staff at DCH: Linda Wiant, Director of Pharmacy or Courtney Haynes, DME/O&P Program Specialist/Compliance Auditor Please contact HP with questions regarding claims, Prior Authorizations, Mass Adjustments etc. If necessary, HP will contact DCH for policy inquiries.
28 Questions & Comments
29 ICD-10 is Real 239 days until ICD-10 is here!