Presentation is loading. Please wait.

Presentation is loading. Please wait.

1 Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2014 1 1.

Similar presentations


Presentation on theme: "1 Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2014 1 1."— Presentation transcript:

1 1 Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2014 1 1

2 Paper Claim Submission  Clear and Scannable  Send Only Necessary Documentation  Do Not Use Highlight Markers  Do Not Use Pencils  Do Not Submit Handwritten Forms 22 2

3 Multiple Procedure Billing  Use a Single Claim Line to bill the same Lab Procedure, more than once, on the same day  Indicate Quantity in the Units Column  Exceptions are Surgical Pathology CPT-4 codes 88300 through 88309 when billed for separate sites must be billed on separate claim lines with a maximum of one unit for each line. See: path bil cms 2, path surg 2 33 3

4 Claim Form Units Field  On Appeals submit the original claim with the total number of units  Corrected if necessary  Medi-Cal will only pay what is billed See: appeal form 1 4 4

5 Laboratory Services Reservation System (LSRS) Allows Laboratories to Reserve or Determine if a Procedure is Within the Medi-Cal Frequency Limits for that Month Monthly Frequency Limits for all Lab Services are: ▪ Per Recipient ▪ Per Service 5

6 LSRS (cont’d)  Web Based, on the Internet  Calling the Help Desk  Allowing the System to Make a Reservation if a Available by Submitting a Claim 6 3 Ways to Make a Reservation:

7 LSRS (cont’d) Common Mistake When Making a Web Based Reservation: Use only the Patient’s 9 character Identification Number: Use this: 87709090D Do Not Use: 87709090D71249 Exception: The Longer Identification Numbers as with Presumptive Eligibility 7

8 ICD-10  Primary baseline crosswalk is CMS General Equivalency Maps (GEMS)  Mandatory implementation date October 1, 2015 8

9 Error message for the limit exceeded has changed. It reads at it shows here. Error message modified, FROM: "Reservation Limits for this recipient has been exceeded. If you have a valid ICD9 code, you can enter it and resubmit. For additional information please call 1-800-541-5555 and press option 16, then press option 13. Please reference reservation number XXXXXXXXXXXXX" 9

10 10

11 ICD Indicator CMC Claim Image 11 Primary Diagnosis Code ICD Indicator

12 Paper Claim Image – UB-04 Outpatient claim (With Overlay) 12 Primary Diagnosis Code ICD Indicator

13 Paper Claim Image – CMS 1500 claim 13 ICD Indicator Primary Diagnosis Code

14 Electronic Treatment Authorization Request (eTAR) forms. Effective September 22, 2014, an ICD code and an ICD indicator are required on electronic Treatment Authorization Request (eTAR) forms.

15 Quantitative Drug Tests Requiring Justification Documentation must be Submitted with a Claim Justifying the use of a Quantitative Determination of Drug level rather than Qualitative Determination (screening). CPT-4 codeDescription 82101Alkaloids, urine, quantitative 82145Amphetamine or methamphetamine 82205Barbiturates, not elsewhere specified 82649Dihydromorphinone 83840Methadone 83925Opiate(s), drug and metabolites, each procedure 83992Phencyclidine (PCP) See: path drug 1,2 15

16 Maximum Reimbursement Laboratory Services are paid based on the least amount of the following:  The amount billed  The charge to the general public  Medicare’s maximum allowance  Medi-Cal’s maximum allowance See: Cal.Code Regs., tit. 22, § 51529, subd.(a)(2)(B) 16

17 Rate Update for Laboratory Services Effective on or after January 1, 2013: Reimbursement rates for certain laboratory services that were higher than 80 percent of the 2013 Medicare rate will change. Claims processed for dates of service on or after January 1, 2013, will be subject to the updated rates. See: California Code of Regulations (CCR), Title 22, Section 51137.2 17

18 Benefit Update Effective November 1, 2013 CPT-4 codes 88740 (hemoglobin, quantitative, transcutaneous, per day, carboxyhemoglobin) and 88741 (quantitative, transcutaneous, per day methemoglobin) Both are non-benefits for Medi-Cal. See: path bil 5 18

19 Every Women Counts New Benefits Cytopathology CPT Codes Effective retroactively for dates of service on or after July 1, 2013, the following CPT-4 and HCPCS codes have been added as benefits of Every Woman Counts (EWC): 88143 88172 88342 See: ev woman (16–31) 19

20 Presumptive Eligibility Program New Benefit Effective for dates of service on or after January 1, 2014 CPT-4 code 87077 aerobic bacterial identification, definitive identification is reimbursable to Presumptive Eligibility (PE) recipients. See: presum (19, 20) 20

21 Presumptive Eligibility Program New Benefit Cystic Fibrosis Effective for dates of service on or after August 1, 2014 CPT-4 code 81220 (CFTR [cystic fibrosis transmembrane conductance regulator][eg, cystic fibrosis] gene analysis; common variants [eg, ACGM/ACOG guidelines]) is reimbursable to Presumptive Eligibility (PE) recipients with aid code 7G. See: gene coun (4); pre sum (19) 21

22 Fetal Screening Procedures Reimbursable Under PE Program Effective for dates of service on or after May 1, 2014 CPT-4 code 81508 (fetal congenital abnormalities, biochemical assays of two proteins [PAPP-A and hCG (any form)], utilizing maternal serum, algorithm reported as risk score) and CPT-4 code 81511 (fetal congenital abnormalities, biochemical assays of four analytes [AFP, uE3, hCG (any form), DIA], utilizing maternal serum, algorithm reported as risk score) are reimbursable under the Presumptive Eligibility (PE) program. Reimbursable only once for women in the first and/or second trimester of pregnancy. See: presum (20) 22

23 Noninvasive prenatal testing for fetal aneuploidy is billed with A TAR for the test requires documentation of the following criteria: Patient with singleton gestation only. The patient has an increased risk of aneuploidy due to one or more of the following: Maternal age 35 years or older at delivery Fetal ultrasonographic findings indicating an increased risk of aneuploidy History of a prior pregnancy with a trisomy Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or a quadruple screen Parental balanced Robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21 See: path molec 28 23

24 BRCA Testing Procedure Code Rate Update Effective retroactively for dates of service on or after January 1, 2014 The rate for CPT-4 code 81211 is being increased. An Erroneous Payment Correction will be issued, allowing automatic resubmission of claims with dates of service on or after January 1, 2014. When procedure code 81211 is billed with modifier QP, the payment will be the difference between the rate for code 81211 and the rate for either CPT-4 code 81215 or CPT-4 code 81217, depending on the previously performed BRCA test. 24

25 Immunoassay for Tumor Antigens: Diagnostic Restrictions Updated Effective for dates of service on or after April 1, 2014 CPT-4 code 86304 (immunoassay for tumor antigen, quantitative; CA 125) is reimbursable only when billed in conjunction with one of the following ICD-9-CM diagnosis codes: 158.8184.8338.3 158.9198.6789.39 180.0198.82795.82 182.0236.0795.89 183.0236.1V10.41 183.2236.2V10.42 183.8236.3V10.43 V10.44 See: path chem (7) 25

26 Molecular Pathology and Diagnostics Only the Procedures listed in the Provider Manual are Medi-Cal Covered Services. Reimbursement Requirements for Each Procedure include some or all of the following:  Treatment Authorization Request (TAR) and claim documentation requirements.  Allowable diagnosis (ICD-9-CM) codes.  Once-in-a-lifetime and other frequency limitations for reimbursement. See: path molec 26

27 TAR/SAR/CCS/GHPP Override for Genetic Codes For CPT-4 codes 81200-81408: Over-rides include non-benefits listed under Tier 1 Genetics. Authorization must include one of the following: CCS/GHPP Stamp Hardcopy Authorization TAR, TAR ending in 8 or 4 SAR Prefix 91, 97 or 99 27

28 New Benifit Hepatitis C, IL28B testing Effective for dates of service on or after October 1, 2014 Bill with CPT-4 code 81400 (MoPath Level 1). Document “IL28B” on the claim form or on an attachment. The following conditions which must be documented: The patient has genotype 1 hepatitis C virus infection, and, Treatment will be contingent on the test results. See: path molec (15) 28

29 Family PACT and Medi-Cal Family Planning Code Conversions Effective for dates of service on or after December 30, 2013  DHCS has discontinued the use of the Family PACT Program and Medi-Cal Family Planning local diagnosis codes (the S-Codes).  The local codes will have been replaced with HCPCS national HIPAA compliant codes. Ref: 1996 Public Law 104-191, 45 CFR 162.1000 See: lab 2 – 34 (FPACT Manual) 29

30 HIPAA Code Conversion for Local Modifier ZS DHCS will discontinue use of local modifier ZS. ZS will be replaced with a Blank in the modifier position. Anticipated Implementation is May 2015 30

31 31 Bernie Betlach CLS, MT(ASCP) Medical Lab Consultant Xerox State Healthcare, LLC 820 Stillwater Road West Sacramento, CA 95605 bernard.betlach@xerox.com 31 31


Download ppt "1 Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2014 1 1."

Similar presentations


Ads by Google