HP Provider Relations May 2012 IHCP Updates. IHCP Updates May 2012 2 Agenda –Objectives –Primary...

HP Provider Relations

May 2012

IHCP Updates

IHCP Updates May 20122

Agenda– Objectives

– Primary diagnosis for atypical providers

– Health Insurance Portability and Accountability Act (HIPAA) version 5010 implementation update

– Coverage of implantable cardioverter defibrillator

– Electronic Health Records (EHR)

– International Classification of Diseases, Tenth Revision (ICD-10) implementation

– Taxonomy Codes

– Top call center calls

– Claim denials

– Helpful tools

– Questions


Objectives

– Learn about the changes for reporting the primary diagnosis for atypical providers

– Review the HIPAA 5010 implementation

– Understand the coverage of implantable cardioverter defibrillator devices

– Describe the EHR incentive program

– Provide an update about ICD-10 implementation

– Review taxonomy codes

– Review the top call center inquiries

– Explain how to resolve claim denials

LearnPrimary Diagnosis Code for Atypical Providers

IHCP Updates May 2012 5

Primary Diagnosis CodeRequirement for claim submission

– With the implementation of HIPAA version 5010, the transaction requirement for a primary diagnosis code was changed from situational to required for 837 claim transactions.

– Effective April 1, 2012, this billing requirement will also apply to both Indiana Health Coverage Programs (IHCP) paper and Web interChange claim submissions.



– This change for reporting the primary diagnosis affects providers that are currently exempt from submitting a diagnosis code specific to transportation, waiver, or durable medical equipment (DME) services.

• Transportation and waiver providers should bill diagnosis code 7999 as the primary diagnosis code for claim submissions in which the actual diagnosis is not known.

• For DME providers, the primary diagnosis code will need to be obtained from the physician who ordered the DME supplies or equipment.



– If a claim is submitted through Web interChange without a primary diagnosis code indicated, the error message "Primary diagnosis is required” will display.

– Paper claims missing the primary diagnosis code will be denied for edit 258 – Primary diagnosis code missing.

InformHIPAA 5010 Implementation Update


HIPAA Claim UpdateHIPAA 5010 claim process

– HIPAA qualifiers• 837 I electronic billing qualifier is ME for milligram as a unit of measure when billing a

procedure code requiring a National Drug Code (NDC).

• Paper claims CMS-1500/UB-04 can use the ME or MG qualifier to represent a milligram as a unit of measure when billing a procedure code requiring a National Drug Code (NDC).

– Patient status is required for all institutional claim types (UB-04).• Including outpatient claims

– Implementation is scheduled for June 27, 2012.

UnderstandImplantable Devices


Implantable Cardioverter DefibrillatorBT 201203 and BR201209

– Effective March 1, 2012, the IHCP began reimbursing the cost of implantable cardioverter defibrillator devices separately from reimbursement for the implantation procedure when the implantation is performed in an outpatient surgical setting.

– This change in coverage and reimbursement policy is retroactive for dates of service (DOS) on or after January 1, 2009.

– Outpatient facilities bill the device on the CMS-1500 claim form or the 837P transaction


Implantable Cardioverter DefibrillatorBT201203 and BR201209

– For DOS January 1, 2009, through June 30, 2011, you must submit a retail invoice or a manufacturer’s cost invoice with your claim, along with a copy of the front page of bulletin BT201203.

– For DOS July 1, 2011, through February 29, 2012, you must submit both a cost invoice and documentation of the manufacturer’s suggested retail price (MSRP) with your claim, along with a copy of the front page of BT201203.

– For DOS March 1, 2012, and after, you must submit both a cost invoice and documentation of MSRP with your claim.

DescribeEHR Incentive Program


EHR Incentive Program

– The American Recovery and Reinvestment Act of 2009 provides for incentive payments to eligible professionals (EP) and eligible hospitals (EH) who are meaningful users of certified EHR technology.

– EPs include the following:• Doctor of medicine or osteopathy

• Dentist

• Certified nurse midwife

• Nurse practitioner (advanced practice nurse)

• Physician assistant (PA) when practicing at a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is led by a PA

– EHs include the following:• Acute care hospital

• Children’s hospital

• Critical access hospital


Meaningful use of EHR

– The Centers for Medicare & Medicaid Services (CMS) has determined that meaningful use focuses on establishing the functionalities in certified EHR technology that allow for the following:• Continuous quality improvement

• Ease of information exchange

• Electronically capturing health information in a structured format

• Using that information to track key clinical conditions and communicating that information for care coordination purposes

• Implementing clinical decision support tools to facilitate disease and medication management using EHRs to engage patients and families

• Reporting clinical quality measures and public health information

EHR Incentive Program


EHR Incentive ProgramEHR Regrestration

– EPs and EHs register for the incentive program through a two-step process:

1. Providers must register using the CMS Registration and Attestation system and select Indiana as their state. A registration number will be created on the CMS website

Use the registration number when registering in the Web interChange

2. Providers register their EHR system using the Provider Profile feature of Web interChange.


EHR Incentive ProgramEligible Professional

– According to federal rule, EPs must register for EHR incentive payments no later than calendar year 2016.

– EPs must meet patient volume criteria as follows:• EPs, other than pediatricians, must have a minimum 30 percent patient volume

attributable to Medicaid-funded services; for pediatricians, the patient volume minimum requirement is 20 percent.

• EPs must practice predominantly in an FQHC or RHC and have a minimum 30 percent patient volume attributable to needy individuals.

– Hospital-based providers are not eligible for the EHR incentive program.• EPs are considered to be hospital-based when 90 percent of their services are

furnished in a hospital inpatient or emergency room setting.


EHR Incentive ProgramEligible Professional

– An EP may not receive EHR incentive payments from both Medicare and Medicaid programs in the same year.

– If an EP qualifies for EHR incentive payments from both Medicare and Medicaid programs, the EP elects to receive payments from only one program.

– After the EP qualifies for the EHR incentive payment under one program, an EP can switch between the Medicare and Medicaid programs once prior to 2015.

UpdateICD-10


ICD-10Implementation October 1, 2013

– On January 16, 2009, the Department of Health and Human Services (HHS) released a final rule mandating HIPAA-covered entities to implement ICD-10 for medical coding by October 1, 2013.

– The ICD-10 codes must be used on all HIPAA transactions including outpatient and professional claims with DOS and inpatient claims with dates of discharge (DOD) on or after October 1, 2013.

– The ICD-10 implementation does not affect Current Procedural Terminology (CPT®2) coding.

– To accommodate ICD-10, the new transaction standard HIPAA 5010 must be operational.


ICD-10CMS Mandate

– Providers will not be able to continue to report ICD-9 codes for services provided on or after October 1, 2013.

– After October 1, 2012, there will be only limited code updates to both ICD-9 and ICD-10 code sets to capture new technologies and new diseases.

– After October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and new diseases.• There will be no updates to ICD-9 on or after October 1, 2013, as the code set will no

longer be a HIPAA standard.

– On October 1, 2014, regular updates to the ICD-10 code sets will begin.


ICD-10Frequently Asked Questions (FAQs)

– What is the current implementation timeframe?• The HHS and CMS have provided no definitive strategy or timeline for a delay in ICD-

10 implementation. As such, Indiana’s plans for migration to ICD-10 remains unaltered. Further information will be forthcoming once definitive guidance is received regarding the ICD-10 implementation dates for both the International Classification of Diseases, Tenth Edition, Clinical Modification and the International Classification of Diseases, Tenth Edition, Procedure Coding System code sets.

• Hewlett-Packard (HP) has completed the assessment for the Medicaid Management Information System and is on target for the October 1, 2013, implementation of ICD-10.


ICD-10Frequently Asked Questions (FAQs)

– Will there be vendor testing? When?• Yes, there will be vendor testing that will include managed care entities. Vendor testing

is scheduled to begin January 1, 2013.

– Will providers and vendors be able to use the ICD-9 codes after the October 1, 2013, implementation?• No, you must use ICD-10 codes for DOS or DOD on or after the October 1, 2013,

implementation date. There is no grace period.


ICD-10Provider Readiness Surveys

– The third provider survey will be released May 8, 2012, and will close May 24, 2012.

– Survey results will help us help you by tracking your progress and capturing your issues.

– HP and the Family and Social Services Administration have committed to surveying contracted vendors and IHCP providers every 90 days through August 2013.

– The purpose of continually surveying contracted vendors and IHCP providers is to understand where they are in preparation for the change to ICD-10 and to track progress.

– Information about these surveys is available in the IHCP Newsletters available on indianamedicaid.com.


ICD-10Advice to IHCP providers

– Now is the time to begin the ICD-10 planning process, if you have not already.

– If you have not been contacted by your software vendor and/or clearinghouse about ICD-10 readiness, be proactive and contact them.

– The IHCP has posted ICD-10 information pages at indianamedicaid.com which include the following:• ICD-10 Information page with links to relevant websites

• ICD-10 FAQs page with answers to ICD-10 questions posed by providers, vendors, and other stakeholders

• ICD-10 Decisions page with explanations of decisions that have been made and issues for your consideration. Providers, vendors, and stakeholders are encouraged to weigh in on these issues during the open (posted) discussion period.

• ICD-10 Training page, which is new to the website and contains a list of ICD-10 training resources from state agencies and associations which will be updated frequently.

UnderstandThe Importance of Taxonomy Usage

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Importance of Taxonomy Code(s)Best Practice

– Taxonomy codes are national codes providers use to indicate their specialties when submitting claims.

– Reporting the correct National Provider Identifier (NPI) and taxonomy combination ensures that claims—both paper and electronic 837 transactions—are processed under the correct service location and provider type.

– Submitting the proper billing provider ZIP Code + 4 and taxonomy code that are on file with the Indiana Health Coverage Programs (IHCP) identifies your billing provider office location. • A provider may have multiple service locations or provider types that use the same

NPI.

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Importance of Taxonomy Code(s)Best Practice

– When an erroneous NPI and taxonomy combination is entered on the claim, it can cause claims to deny, or to report to the wrong service location or provider type.

– Providers are encouraged to check with their vendors and clearinghouses to ensure the correct taxonomy is being submitted on their claims.

– To find out what taxonomy is linked to your NPI for your service locations, go to the PROVIDER PROFILE on Web interChange and choose the Specialty tab for each of your locations.

ExploreTop Call Center Inquiries


Top Call Center Inquiries• Manual pricing … what is and is not acceptable documentation?

• BR201206 explains what constitutes acceptable documentation of MSRP and how claims are reimbursed if the MSRP is not available for a manually priced medical supply or DME procedure code.

• How do you determine who the accounts receivable (A/R) is for on a Remittance Advice (RA)?

• A/R control numbers identify system-generated A/Rs on the RA along with the original internal control number (ICN) for reference.

• Nonclaim-specific financial transactions affect a provider’s payment and are unrelated to a particular claim.


Top Call Center Inquiries

• Why do claims deny for edit 6652 – Multiple surgeries must be billed on same claim?• A surgical procedure code for the same physician for the same DOS has been

previously paid.

• To request payment for additional surgical procedures, replace the original paid ICN via Web interChange so the appropriate multiple surgery reduction can be applied.• Request the adjustment using the paper Adjustment Request Form when the DOS is greater

than 365 days old.


Top Call Center Inquiries• How do you bill claims using Web InterChange?

• Step-by-step billing guidelines are located under the Help and Reference Materials links on the Web interChange at https://interchange.indianamedicaid.com/Administrative/logon.aspx.


Top Call Center Inquiries

– How do you find NDC codes for the J codes? • Information on NDCs can be found at

http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm.

• CMS maintains a list of rebating labelers that can be found at the following Web site: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp.

– Why do you receive a check with no RA?• Effective September 1, 2009, RA documents are available on Web interChange at

https://interchange.indianamedicaid.com/Administrative/logon.aspx under the Check/RA Inquiry tab.

• RAs are no longer printed or mailed to providers.

• RAs are removed in 28 days

• A 15 cents per page fee is assessed for duplicate RA copies

HelpTop Claim Denials


Top 5 Claim Denials

– EOB 558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim.• Coinsurance and deductible amounts must be included on all crossover claims.

– EOB 593 – At least one detail submitted contains Medicare COB data, resulting in a review of all detail COB data.• When submitting Medicare crossover claims, ensure that all Medicare coordination of

benefits information is on the claim for all details. This applies to CMS-1500 claims.

– EOB 5001 – This is a duplicate of another claim.• Review claims to see if any billed services were previously paid. Verify previous claim

payments and denials using Web interChange to avoid erroneous rebilling of paid claims.


Top 5 Claim Denials

– EOB 4021 – Procedure code is not covered for the dates of service for the program billed.• Verify that the procedure code is covered for the DOS via the Fee Schedule at

indianamedicaid.com.

– EOB 2510 – Member is eligible for Medicare B/D.• Claim must be billed to Medicare before billing the IHCP.

Find HelpResources Available


Helpful Tools

– IHCP website at indianamedicaid.com

– IHCP Provider Manual (Web, CD-ROM, or paper)

– IHCP Fee Schedule

– Customer Assistance• 1-800-577-1278 toll free or (317) 655-3240 in the

Indianapolis local area

– Written Correspondence• P.O. Box 7263

Indianapolis, IN 46207-7263

– Provider field consultant contacts at provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

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