1 UNISYS Louisiana Medicaid DHH – Bureau of Primary Care Practice Management Technical Assistance Workshop August 13 th, 2008

2 Professional Services for Physicians Nurse Practitioners RNs School Based Health Centers

3 Billing for Professional Services  Individual Physicians Practicing Independently or within a Group  Fee Schedule with procedure – link Fee Schedules  Nurse Practitioners  Must be supervised by a Physician  Provide services only within scope of license  Paid 80% of physicians’ fees (100% for immunizations)  Registered Nurses  Can only provide KidMed Screenings/Immunizations  Must be supervised by a Physician  School Based Health Centers  Can only perform services for which they have staff and that they are enrolled to provide

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5 KIDMED SCREENINGS  In order to obtain KIDMED linkage, providers MUST CALL ACS to verify the screening provider on record for the date that the screening is being rendered  RS-0-07 reports are now online and are no longer mailed to providers  Only Medical, Vision, and Hearing Screenings are billed on KM-3 (hardcopy) or 837P with the K-3 (KIDMED) segment (electronically)  Immunizations, Laboratory Tests, Interperiodic Screenings, Consultations, and Low Level Visits are billed on the CMS-1500 (hardcopy) or on the 837P (electronically)

6 KIDMED Screening Policy Medical Screening Must perform all 5 components Providers must use the age appropriate code in order to avoid claim denial TD Providers should use the TD modifier to report a screening that was performed by a nurse.

7 KIDMED Screening Policy VISION SCREENING  Subjective Vision Screening  Included in medical component  Objective Vision Screening 4  Begins at age  Bill with procedure code with the EP modifier HEARING SCREENING  Subjective Hearing Screening  Included in medical component  Objective Hearing Screening 4  Begins at age  Bill with procedure code 92551

8 2 yr old receiving a medical screening by a physician – Immunizations current. Suspected medical condition/referral info inc

9 7 yr old receiving screenings by a nurse – Immunizations are not current. Suspected medical condition and referral info included.

10 Interperiodic Screening by a Physician

11 Four Immunizations Given

12 Billing for Procedure Code  Physicians may write prescriptions for injections covered under the Pharmacy program and have the prescription filled by a Medicaid enrolled pharmacy.  The recipient may then bring the dispensed medication to the physician’s office and a low-level office visit (99211) could be billed as long as a higher level visit had not been billed on that particular date.  If the injection is given during a more complex visit, that appropriate code for the visit should be billed and there would not be a separate charge for administering the injection. NOTE: This policy excludes RHC’s, FQHC’s, and KidMed Clinics.

13 Common Billing Errors  General Claim Form Completion Codes  003 – Recipient # invalid or less than 13 digits  028 – Invalid or missing CPT code  Recipient Eligibility Error Codes  215/216/222/223 – Recipient not on file/not eligible on one or more DOS  217 – Name/# on claim does not match file  CommunityCARE Error Codes  106 – Billing provider is not PCP/Services not authorized by PCP  Timely Filing Error Codes  272/371 – Claim exceeds 1 year filing limit/attachment requires review  TPL Error Codes  273 – TPL carrier code missing  290 – No EOB from primary carrier attached  Miscellaneous Error Codes  299/232 - Procedure not covered by Medicaid/type of service not covered

14 Timely Filing Guidelines Filing Limits  Initial Filing Limits  Dates of Service Past Initial Filing Limit  Two-Year Filing Limit  KidMed Filing Limits

15 Appeals Process  Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys  Appeals may be filed when all efforts to get the claim paid have been exhausted  Requests must be submitted in writing to DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La

16 CommunityCARE  Program Description  Exempt Recipients  Primary Care Physician (PCP)  Non-PCP Providers  Exempt Services

17 Provider Assistance: ACS:  Linkages/Monitoring/Certification –  Referral Assistance – Unisys Provider Relations:  Billing/Claims – or Recipient Assistance:  ACS CommunityCARE

18 Outpatient Visit Limits  If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP  Can either treat the recipient and not bill Medicaid  Offer to see the recipient as a private pay patient (enrollee pays out of pocket)  Request an extension using the 158-A form  Issue a referral to a physician who will treat the recipient

19 Mental Health Services  Effective 10/01/07, LA Medicaid reimburses professional service providers for select procedure codes specific to psychiatric services  Providers must use procedure codes , ,  Services are counted toward the outpatient visit limits allowed per calendar year  Psychiatrists  Independently practicing or groups  Services covered are those provided by any physician under the scope of the psychiatric license  Reimbursement is based on fee-for-service

20 Federally Qualified Health Centers And Rural Health Clinics

21 Billing for Services in an FQHC/RHC Setting  Must bill with encounter code T1015 for both Professional Services and KidMed Screenings  Attending provider information also reported on claim form as well as Group provider info  Clinic is paid based on the Encounter Rate set by DHH for that particular provider

22 FQHC/RHC Physician Encounter

23 KIDMED Periodic Screening by a Nurse

24 Common Billing Errors  FQHC/RHC Error Codes  092 – Invalid procedure modifie  136 – No eligible service paid, encounter denied  210 – Provider/Procedure conflict  517 – KidMed format required  518 – KidMed information missing  715 – Duplicate edit – only one encounter paid per day

25 Timely Filing Guidelines Filing Limits  Initial Filing Limits  Dates of Service Past Initial Filing Limit  Two-Year Filing Limit  KidMed Filing Limits

26 Appeals Process  Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys  Appeals may be filed when all efforts to get the claim paid have been exhausted  Requests must be submitted in writing to  DHH Bureau of Appeals P.O. Box 4183 P.O. Box 4183 Baton Rouge, La Baton Rouge, La

27 CommunityCARE  Program Description  Exempt Recipients  Primary Care Physician (PCP)  Non-PCP Providers  Exempt Services

28 Provider Assistance: ACS:  Linkages/Monitoring/Certification –  Referral Assistance – Unisys Provider Relations:  Billing/Claims – or Recipient Assistance:  ACS CommunityCARE

29 Outpatient Visit Limits  If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP  Can either treat the recipient and not bill Medicaid  Offer to see the recipient as a private pay patient (enrollee pays out of pocket)  Request an extension using the 158-A form  Issue a referral to a physician who will treat the recipient

30 Mental Health Services  Billing for Psychiatrist Services  PCP Referral NOT required for services rendered by a Psychiatrist  MUST enter psychiatrist’s provider number and/or NPI as attending Billing for Social Workers/Psychologists  Services DO require a PCP referral  Must enter the RHC/FQHC group number and/or NPI as the attending and billing provider  Refer to Professional Fee Schedule for procedure codes  Services are paid based on an Encounter Rate established by DHH  Services are counted toward the outpatient visit limits allowed per calendar year

31 Provider Assistance  Provider Relations Telephone Inquiry Unit: or  Correspondence Unit: Unisys-Provider Relations P.O. Box P.O. Box Baton Rouge, LA Baton Rouge, LA  Field Analyst  Phone Numbers for Provider Assistance

32 Thank You For Attending this 2008 Provider Workshop.