TR592Molina Healthcare, Inc., CMS1500 Billing Presentation

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CMS-1500
October 2005
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Agenda

• Preface
• CMS 1500 Procedures
• Nurse Line
• Enrollment
• Prior Authorization
• Self Referral Services
• Emergency Services
• Anesthesia
• Care Coordination
• Physician Services
• School Services
• Questions Answers

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Preface
CMS-1500 Procedures It is the
intent of Molina Healthcare of Indiana to mirror
as closely as possible the claim completion
requirements and reimbursement policies of
traditional Medicaid. Detailed information and
instructions are contained in the IHCP Provider
Manual, pages 8-101 through 8-345
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Preface
CMS-1500 Procedures Molina
Healthcare of Indiana has an open provider
network non-contracted facilities and providers
are welcome to provide services to Molina
members. Services rendered by non-par providers
will be reimbursed at 100 of the Indiana Health
Coverage Programs Fee Schedule.
Reminder Eligibility must be verified each time
a service is rendered !
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Nurse-Line

• Nurse-Line is available 24/7 - 365 days a year
• Review need for Emergency Room Visits

• Bilingual Staff (English/Spanish)
• Interpreters available for other languages

1-888-275-8750
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Enrollment

• Providers
• Providers are enrolled in the IHCP in one of the
  following categories
• Billing Provider
• Defined as the payee at the service location and
  can be a facility, group, clinic or sole
  proprietor
• Billing s, are noted in Fields 24K and 33 on the
  CMS-1500. Field 33 also must include the alpha
  character location code.
• Rendering
• The provider who renders the service as an
  employee of a group or clinic
• Rendering s are linked to the group
• Each rendering provider within a group reports
  under the same Tax ID
• Rendering s are noted in Field 24K on the
  CMS-1500
• Sole Proprietor
• Sole proprietors are both the billing and
  rendering provider
• The provider is noted in both Field 24K and
  Field 33 on the CMS 1500

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Enrollment

• Providers (contd)

Any provider file changes that are submitted to
EDS must also be submitted to Molina
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Prior Authorization

• Prior Authorization
• PA is required for most surgical procedures
• PA is not required for Caesarean sections
• PA is not required for Family Planning services
• Tubal Ligations, Vasectomies
• Routine Requests 2 business days
• Urgent Requests - 24 hours (immediate as
  appropriate)
• Retro-authorization is available on a case by
  case basis based upon medical necessity
• No tracking is required for claim processing

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Self-Referral Services
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Self-Referral Services

• Self-Referral Services
• Molina Healthcare reimburses for the following
  services that do not require a referral from the
  PMP
• Chiropractic services
• Family planning services
• HIV/AIDS case management services
• Podiatry services
• Services rendered for treatment of a true medical
  emergency
• Eye care services (except for surgical services)

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Emergency Services

• Emergency Services
• Non-emergent ER service claims will pay as
  follows
• If the treatment was authorized by the PMP, the
  fee schedule rates will be paid
• If the member was instructed to go to the ER by
  the Molina Nurse Line staff, the fee schedule
  rates will be paid.
• If treatment was provided for a non-emergent
  condition without authorization, the physician
  will be paid a triage fee of 15.00

Procedure codes 99281, 99282 or 99283 are
utilized for ER services
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Anesthesia Services
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Anesthesia

• Anesthesia
• Providers submitting anesthesia charges must
  utilize anesthesia CPT codes 00100 through 01999.
• Charges must be submitted using the CPT code that
  corresponds to the surgical procedure performed.

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Anesthesia

• Anesthesia (contd)
• Time
• The actual time of the procedure (in minutes) is
  noted in Field 24G.
• One unit is allowed for each 15 minutes or
  fraction thereof.

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Anesthesia

• Anesthesia (contd)
• Base Units
• Base unit values have been assigned to each CPT
  that would normally allow for anesthesia
  services.
• Providers should not report the base units on the
  claim form. QMACS automatically determines the
  appropriate base units for each procedure code
  submitted on the claim form or via an 837P
  transaction.
• Additional Units
• Additional units are recognized and calculated by
  QMACS for the following
• Patient Age additional units will be added for
  members under one year of age or over seventy
  years of age
• Procedure Code 99140 The code is to be noted on
  a separate line of the claim to indicate the
  anesthesia service provided was complicated by
  emergency conditions.

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Anesthesia

• Anesthesia (contd)
• Physical Status Providers must use the
  appropriate status modifier to denote the
  following conditions

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Anesthesia

• Anesthesia (contd)
• Utilization Anesthesiologists performing the
  following must bill with the AA modifier. These
  also must be billed in units.
• 36620
• 36625
• 93503
• 99116
• 99183
• 99185

Note Procedure Code 99140 Anesthesia
complicated by emergency conditions should not be
billed with the AA modifier
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Anesthesia

• Anesthesia (contd)
• Medical Direction CRNA Requirements
• Medical Direction details billed by an
  anesthesiologist are priced at 30 of the allowed
  amount.
• Pursuant to IAC 5-10-3, reimbursement for medical
  direction of a procedure with an anesthetist only
• when the direction is by an anesthesiologist and
• when the anesthesiologist medically directs 2, 3
  or 4 concurrent procedures involving qualified
  anesthetists

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Anesthesia

• Anesthesia (contd)
• Medical Direction CRNA Requirements (contd)
• Anesthesia details submitted by a CRNA are priced
  at 60 of the allowed amount.
• CRNAs must use anesthesia CPT codes (00100
  01999) and bill with the appropriate modifiers
• Anesthesiologists billing for Medical Direction
  should use the QK modifier

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Anesthesia

• Anesthesia (contd)
• Anesthesia for Vaginal or Cesarean Deliveries
• Provider billing for services for labor and
  delivery use the anesthesia CPT delivery CPT
  codes. This method of billing is the same as for
  any other surgery and is used for all obstetrical
  anesthesia regardless of the type.
• When the anesthesiologist starts an epidural for
  labor and it becomes necessary to switch to a
  general for the delivery, the total times are
  combined and billed for the procedure performed
  (vaginal or C-section).
• When a provider, other than the surgeon or
  obstetrician, is billing for epidural anesthesia,
  the provider is reimbursed in the same manner as
  general anesthesia.

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Anesthesia

• Anesthesia (contd)
• Regional Anesthesia (Epidural, Nerve Block,
  Spinal) are covered services and will be
  reimbursed in accordance with the IHCP standards.
• Postoperative Pain Management
• Postop epidural catheter management is billed
  using procedure code 01996.
• This code is paid separately on the same day the
  epidural is placed.
• The procedure is limited to one unit per day of
  management and is only reimbursable during active
  administration of the drug.

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Care Coordination
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Care Coordination

• Care Coordination
• Care Coordination services are available to
  Molina members who
• have HIV/AIDS or
• are pregnant
• Reimbursement is made on a fee-for-service basis
• Services must be rendered by an appropriate and
  enrolled care coordination provider
• The principal diagnosis code billed must be V68.9
  Unspecified administrative purpose

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Care Coordination

• Detailed billing instructions for care
  coordination may be found in the IHCP Provider
  Manual, pages 8-131 through 8-139

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Physician Services
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Physician Services - OB

• Obstetrical Services Antepartum Care
• The date of the last menstrual period (LMP), must
  be noted in Field 14 and the appropriated
  diagnosis code entered in Field 21 of the CMS
  1500.
• Providers will be reimbursed for up to 14 visits
  for normal antepartum care, one more than the
  minimum recommended by the American College of
  Obstetricians and Gynecologists.
• Three visits in trimester one
• Three visits in trimester two
• Eight visits in trimester three

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Physician Services - OB

• Obstetrical Services Antepartum Care (contd)
• Each antepartum care should be billed separately
  from the delivery and postpartum visits.
• Claims may be submitted after each visit, or at
  the end of the trimester
• Visits 1-6 are submitted with procedure code
  59425
• Visit 7 and subsequent visits are submitted with
  59426
• Providers may use a new or established E/M code,
  99201 99215 for the first visit to accommodate
  the greater level of service for the visit.
• If an E/M code is used, the claim must include
  the appropriate trimester modifier and the LMP.

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Physician Services - OB

• Obstetrical Services Antepartum Care (contd)
• Modifiers are used in conjunction with the
  procedure codes are used to denote trimesters.
  The modifier is placed following the CPT code in
  Field 24 of the CMS-1500.

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Physician Services - OB

• Obstetrical Services Sonography
• Sonography is available when when warranted by
  one of the following diagnoses
• Early diagnosis of ectopic or molar pregnancy
• Fetal age determination if necessitated by the
  following
• Discrepancy in size versus fetal age
• Lack of fetal growth or suspected fetal death
• Fetal postmaturity syndrome
• Guide for amniocentesis
• Placental localization associated with abnormal
  bleeding
• Polyhydramnios or ologohydramnios
• Suspected multiple births

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Physician Services - OB

• Obstetrical Services Echography
• Reimbursement is not available for routine
  echographies.
• A diagnosis of normal pregnancy does not
  explain the reason for the echography
  documentation in the medical record must
  substantiate the medical need for the echography.
• Echographies performed to detect fetal
  malformations or intrauterine growth retardation
  should have an ICD-9-CM code from the V22 series
  as the primary diagnosis and a code from the V-28
  series as the secondary diagnosis
• V28.3 Screening for malformation using
  ultrasonics
• V28.4 Screening for fetal growth using
  ultrasonics

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Physician Services - OB

• Obstetrical Services Delivery and Postpartum
  Care
• Delivery services include
• Admission to the hospital
• The admission history and physical examination
• Management of uncomplicated labor
• Delivery
• Up to two postpartum visits within 60 days post
  delivery are allowed.
• For a normal pregnancy, the following diagnosis
  codes are used
• V22.0, V22.1, V22.2
• Details regarding High Risk pregnancy services
  may be found in the IHCP Provider Manual, pages
  8-217 through 8-222

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Physician Services - OB

• Obstetrical Services Package B (Pregnancy and
  Urgent Care)
• Package B Members are entitled to coverage of
  services related to pregnancy as well as
  conditions that may complicate the pregnancy
• Drug coverage
• Transportation
• Family Planning
• Routine prenatal, delivery and postpartum care
• Conditions that may complicate the pregnancy
• Chronic or abnormal disorders identified by
  diagnosis codes 630 648.94 and 652.00 676.94
• Urgent Care Services are also covered for Package
  B members
• Claims must be marked and coded as an emergency
• The primary diagnosis code must be pregnancy
  related

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Physician Services

• Family Planning
• Reimbursement for sterilization may be made only
  if the member meets the following criteria
• Is 21 years old or older at the time consent in
  given, (42 CFR 441.253)
• Is neither mentally incompetent nor
  institutionalized, (42 CFR 441.251)
• Has voluntarily given informed consent, (42 CFR
  441.257 441.258)
• Informed Consent
• If the required consent form (State Form 46314)
  is not obtained prior to the procedure because of
  a retroactive eligibility situation or because
  the member failed to inform the provider of IHCP
  eligibility, the procedure is not a covered
  benefit.

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Physician Services

• Family Planning (contd)
• Informed Consent (contd)
• A completed consent form must accompany all
  claims for sterilization and related services.
  This requirement extends to all providers
• Attending physicians and surgeons
• Assistant Surgeons
• Anesthesiologist
• Inpatient or outpatient hospital facilities or
  surgical centers
• Molina Healthcare must receive a properly
  completed consent form prior to making payment,
  (42 CFR 441.256)
• To ensure timely payment to related service
  providers, the primary provider should forward
  exact copies of the completed consent form to all
  related providers.

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School Services

• School Services
• Special Education services provided by a public
  school and contained in an Individual Education
  Plan (IEP) are exempt from PA and managed care
  referral requirements.
• If a student is enrolled in an MCO, school
  corporation providers must submit claims for IEP
  services to EDS.
• Although IEP services are carved out of the
  IHCP managed care programs, provider cooperation
  and communication is strongly encouraged to keep
  the PMPs informed of health-related services
  provided to IHCP-eligible special education
  students.

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Therapy Services

• Therapy Services
• Prior Authorization is required for all therapies
  with the following exceptions
• Initial evaluations
• Emergency respiratory therapy
• Any combination of therapies ordered in writing
  prior to a members discharge from inpatient
  hospital care, not to exceed 30 units, sessions
  or visits in 30 calendar days.

Additional details regarding the provision and
billing of therapy services can be found in the
IHCP Provider Manual, Chapter 8, pages 8-238
8-241
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The Molina Mission

• Molina Healthcare is an innovative health care
  leader providing quality care and
• accessible services in an
  efficient and caring manner
• Core Values
• We strive to be an exemplary organization
• We provide quality service
• We are healthcare innovators and respond
  quickly to change
• We respect each other and value ethical
  business practices
• We are careful in the management of our
  financial resources
• We care about the people we serve.
• This is the
  Molina Way

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www.molinahealthcare.com 1-800-642-4509
450 E. 96th St., Suite 5006 Indianapolis, IN.
46240 8001 Broadway, Suite 400, Merrillville,
IN. 46410