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Presentation preparation guide Request copy of coding tool guide and nursing contact hours information one week prior to viewing presentation. **Contact.

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Presentation on theme: "Presentation preparation guide Request copy of coding tool guide and nursing contact hours information one week prior to viewing presentation. **Contact."— Presentation transcript:

1 Presentation preparation guide Request copy of coding tool guide and nursing contact hours information one week prior to viewing presentation. **Contact the North Dakota Family Planning Program office for these documents at: Phone Print presentation handout. 1

2 Coding and Documentation from an auditor’s perspective Family Planning Program Fall Meeting – October 21,

3 ND MEDICAID Fee Schedule ND Medicaid fee schedule was updated to reflect a 6% inflationary increase to providers effective July 1, 2009 and an additional 6% inflationary increase to providers will go into effect July 1, 2010 as appropriated by the ND Legislature. NOTE: The fee schedule increases do not include contraceptive drugs or other drugs/medications. 3

4 ND Family Planning Program Medication/Supplies ND Medicaid evaluates and/or adjusts drug fees on January 1 of each year. J8499 (Prescription drug, oral, … NOS) This code must be submitted with a descriptor. If no descriptor is submitted the claim will be denied. J3490 (Unclassified drugs) This code must be submitted with a descriptor. If no descriptor is submitted the claim will be denied. See North Dakota Family Planning Program Medication/Supply List (updated 09/09) 4

5 New, Deleted, and Revised ICD-9-CM Diagnosis Codes Effective October 1, 2009 CMS website identifies ICD-9-CM Diagnosis Code changes that go into effect on October 1 st of each year and are valid through September 30 th of the following year. mmarytables.asp#TopOfPage See the handout for the list of ICD-9-CM codes most pertinent to Family Planning Clinics. This list is not a complete list of ICD- 9-CM codes and should not be the providers exclusive list of ICD-9-CM (diagnosis) codes 5

6 Medicaid Coding Guidelines Web address: edicalserv/medicaid/cpt.html edicalserv/medicaid/cpt.html 6

7 Web addresses to remember: NPI information - – Medical Services Provider Information Medical Services Provider Information NPI Companion Guides National Provider Identifier (NPI) Information Register your NPI with ND Medicaid Medicaid Provider information - (read and [click] Accept) 7

8 Medicaid Provider (website) Information – cont. Medicaid Provider Information Last updated August 24, 2009 Billing Manuals Cost Reports Durable Medical Equipment Providers Fee Schedules HIPAA / Electronic Data Interchange (EDI) Medicaid Coding Guidelines Medication Prior Authorization Program National Provider Identifer (NPI) Information ND Medicaid Local Codes to National Standard Codes Crosswalk ND Relative Weight Grouper (2006 version) (41kb) ND Relative Weight Grouper (2006 version) Online Forms Pharmacy Providers Provider Appeals [Form SFN 00168] (158 kb pdf) Provider Appeals Provider Appeals - Information only (17.4 kb pdf) Provider Appeals - Information only Provider Enrollment Provider Manuals Swing Bed Rates (9 kb pdf) Swing Bed Rates Tamper Resistant Prescription Pads 8

9 Medicaid Provider (website) Information – cont. Newsletters August Issue 65 ( 199 kb) August Issue 65 October Issue 64 (111 kb pdf) [One insert added to the end of the PDF file.] October Issue 64 March Issue 63 (289 kb pdf) [no inserts] March Issue 63 September Issue 62 - ( 114 kb pdf) [One insert added to the end of the pdf file.] September Issue 62 April Issue 61 (138 kb pdf) [no inserts] April Issue 61 December Issue 60 (75 kb pdf) [no inserts] December Issue 60 August Issue 59 (100kb pdf) [no inserts] August Issue 59 April 2006-Issue 58 (622 kb pdf) [The two inserts have been added to the end of the pdf file.] April 2006-Issue 58 March 2005-Issue 57 (714 kb pdf) March 2005 Insert #1-Adjustment Examples (54.8 kb pdf) March 2005 Insert #2-ND Healthcare Review (27.6 kb pdf) March 2005 Insert #3-Out of State Requirements (69.8 kb pdf) March 2005 Insert #4-Recipient Liability (63.1 kb pdf) March 2005-Issue 57March 2005 Insert #1-Adjustment ExamplesMarch 2005 Insert #2-ND Healthcare ReviewMarch 2005 Insert #3-Out of State RequirementsMarch 2005 Insert #4-Recipient Liability September 2004 (166kb pdf) September 2004 Insert (23kb pdf) September 2004September 2004 Insert January 2004 (59kb pdf) January 2004 July 2003 (28kb pdf) July

10 Medicaid Provider (website) Information – cont. Medicaid Provider Address Change Information Is your address changing? To prevent delays in receiving Medicaid payments and policy updates, please notify us as soon as possible in one of the following ways: MAIL your request to: Medical Services Division / Provider Enrollment North Dakota Department of Human Services 600 E Boulevard Ave, Dept 325 Bismarck, ND FAX your request to: your request to: 10

11 General Principles of Medical Record Documentation – NDMA Documentation Criteria Published in North Dakota Medicaid Provider Bulletin, Iss. 64, October 2008 The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services. 1. The medical record must be complete and legible 2. The documentation of each patient encounter must include: – the date, reason for the encounter, relevant history, physical examination findings (when appropriate) and prior diagnostic test results; – assessment, clinical impression or diagnosis; services delivered – plan for care, including drugs and dosage prescribed or administered; and – legible identity/signature of the provider. 11

12 General Principles of Medical Record Documentation continued 3. Past and present diagnoses and health risk factors must be identified and accessible to the treating and/or consulting physician. 4. The rationale for ordering diagnostic tests and other ancillary services must be documented or apparent in the medical record (supporting medical necessity). 5. The patient’s progress, including response to and change in treatment, must be documented. Reasons for diagnostic revision must be documented. 6.The documentation must support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision making. 7. The CPT, HCPCS, and ICD-9-CM codes reported on the health insurance claim form or billing statement must be supported by the documentation in the medical record. 12

13 Reviewing your services from an auditor’s perspective Review of the CMS 1500 claim form Review of the provider’s charge master Review of the provider’s billing sheet Review of the provider’s documentation 13

14 CPT and HCPCS codes submitted to the third party payer on the CMS Insertion of intrauterine device (IUD ) Modifier 53 – Discontinued procedure 2. S4993- Contraceptive pills for birth control ICD-9-CM codes submitted to the third party payer – Do not match the charge master or charge sheet V25.1-Insertion of intrauterine contraceptive device V General counseling for initiation of other contraceptive measures (i.e. fitting of diaphragm or Rx. for foams/creams) 3 units – 3mos. supply # 1 14

15 Procedure ( identified by CPT code) performed and indicated/circled by the provider Rx (described by HCPCS code) prescribed/ dispensed and circled by the provider Date of service and patient information Diagnosis (ICD-9-CM) code identified/ underlined by the provider V General counseling for prescription of oral contraceptives Modifier 53 – Discontinued procedure 15

16 CPT and HCPCS code(s) identify the service rendered ICD-9-CM codes identify the reason for the service but differ from what the provider indicated on the charge master V25.1- Insertion of intrauterine contraceptive device V Surveillance of previously prescribed contraceptive pill 16

17 Documentation illegible due to colored paper cumenta DATE REASON -mirena IUD insertion LMP MEDS - micronor amt. 3 COMMENTS – failed insert “ CLIENT FLOW” DATE / REASON FOR VISIT/ LMP/ BP/ WT/ SUPPLIES-MEDICATION/AMT/ COMMENTS/ INITIALS 17

18 Documentation by provider billing for the service on 1/23/08 Date of service – nurses notes NOTE: Provider documentation should include risks and benefits of procedure, positioning of patient, prepping the site, description of procedure and how patient tolerated the procedure, follow-up instructions Insertion of intrauterine device (IUD) The physician/provider inserts a speculum into the vagina to visualize the cervix. A tool is used to gently pull down the cervix; it is dilated. An intrauterine device (IUD), any of a variety of shapes (coil, loop, T, 7), is guided into the uterus through an insertion tube placed in the cervical os. Modifier 53 – Discontinued procedure 18

19 Example of clear and concise procedure report for the insertion of IUD 19

20 V72.31 – Routine gynecological examination V74.5 – Special screening examination for … venereal disease (STD) V25.41 – Surveillance of previously prescribed contraceptive pill ICD-9-CM codes submitted to the third party payer – Match the charge master or charge sheet Unit of 3 (3 mos. supply oral contraceptives) match the information on the charge master Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision Periodic comprehensive preventive medicine reevaluation …, established patient; years Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique Handling and/or conveyance of specimen …to a laboratory 5. S4993-Contraceptive pills for birth control # 2 20

21 99395 – Est. Pt. - Preventive Medicine Service – age Date of service and patient information Rx (described by HCPCS code) prescribed/ dispensed and circled by the provider Lab tests ordered by the provider Modifier 90 – Reference (Outside) Laboratory Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory V72.31 – Routine gynecological examination V25.41 – Surveillance of previously prescribed contraceptive pill V70.0 – Routine general medical examination at a health care facility V74.5 – Special screening examination for … venereal disease (STD) 21

22 V72.31 – Routine gynecological examination V25.41 – Surveillance of previously prescribed contraceptive pill V70.0 – Routine general medical examination at a health care facility V74.5 – Special screening examination for … venereal disease (STD) V25.09 – Encounter for contraceptive management (family planning service) T1003 – LPN/LVN services, up to 15 minutes This does not correspond with the chargemaster 22

23 Documentation requirements for include reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; years No age and gender appropriate history, risk factor reduction interventions discussed. It appears that history sheet was not submitted for this date of service. Date of service corresponds with charge master and CMS

24 Questions and Answers “Whether we’re giving or receiving help, each one of us has something valuable to bring to the world. That’s one of the things that connects us as neighbors – in our own way, each one of us is a giver and a receiver.” Mr. Rogers 24


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