Information on Monthly coding audit summary report

Monthly Coding Audit Summary Report

Facilities are encouraged to use the monthly audit form on the UBU website for completing the Monthly Data Quality Commander’s Statement.  On the Monthly Coding Audit Summary Report, identify the number of records requested and the number of records received from the facility.

•    Identify the number of records received containing encounter documentation for the encounter.

•    Document the number of records with illegible documentation.

•    Document the number of records with use of non-approved abbreviations or acronyms.

Avoiding Medicare timely filing deadlines

Avoid Untimely Claim Denials

To avoid receiving an untimely claim denial for services rendered from October 1, 2008 through December 31, 2009, Highmark Medicare Services must receive these claims prior to 4:00 PM Eastern Standard Time (EST) on Thursday, December 30, 2010.  Once received electronically, they must also be accepted on the initial acknowledgement report and the next day edit report.  Our business office will be closed on Friday, December 31, 2010, in observance of the New Year’s Day holiday.  

Therefore, any electronic claims that are received and accepted by Highmark Medicare Services after 4:00 PM EST on Thursday, December 30, 2010, will not be considered received until our next business day of Monday, January 3, 2011, due to our standard system operating hours. We recommend you submit these claims at least 2-3 business days prior to December 30, 2010, to allow time for potential report error resolutions and claim resubmissions.   

All claims for services furnished on January 1, 2010 and after, must be filed with Highmark Medicare Services no later than one calendar year (12 months) from the date of service or the claim will be denied as being past the timely filing deadline.  Please remember the holiday at the end of the year and the first of the year and submit your claims before one year from the date of service for timely processing.

For more information, please refer to Medicare Learning Network (MLN) Matters Articles MM6960 and MM7080.

Appeal sample letter - Timely filing denial : [Sample Appeal Letter for Timely Filing]

Name of Insurance Company

Address (get address for appeals if it exists)

Re:    Appeal of Denial for Timely Filing

Patient Name:

Group Number:                        DOS: 

Subscriber No:                        Reference No.: 

(etc – get this information from the denial)

We are appealing the denial of claims for (patient name) and request that these claims be reviewed and paid.

On (original submission date) we submitted claims for services rendered to the above patient. This was well within your timely filing deadline.

The promptly and properly submitted claims were neither paid nor denied by your company. On (date of resubmission) we resubmitted the claims for consideration. On (date of denial) we received a denial of the claims for “timely filing”. Please see the attached EOB from your company.  

I have attached copies of the original claims showing the date they were printed. Our office policy is to send all claims on the date they are produced. The printed date is the date of submission and is well within your deadline. (or) I have attached a copy of our Claims Submittal Report provided by our electronic claims clearinghouse showing that the original submission date was well within your deadline.

We respectfully request that these claims be promptly processed and that are office is paid for the services rendered to your subscriber as allowed by the State prompt payment regulations. If this claim is further denied, we intend to then file a complaint with the Office of the Insurance Commissionaire.

If you have any questions, you are welcome to contact me directly at (123) 456-7890.

Sincerely,

Timely Filing denial - Delaware Physicians Care insurance

It is the responsibility of the provider to maintain their account receivables records, and we recommend providers perform reviews and follow up of their account receivables on at least a monthly basis to determine outstanding Delaware Physicians Care, Incorporated (DPCI) claims. 

DPCI will not be responsible for claims that were not received and the date of service exceeds the timely filing limit of one hundred twenty days (120) from the date of service.

Recognizing that providers may encounter timely filing claim denials from time to time, we maintain a process to coordinate review of all disputed timely filing claim denials brought to our attention by providers.

DPCI criteria to initiate a review to override timely filing:

Electronic submission

Electronic claim submission (EDI) reports are available from each provider’s claims clearinghouse after each EDI submission. These reports detail the claims that were sent to DPCI and received by DPCI. Provider must submit hard copy or electronic copy of the acceptance report from the provider’s clearinghouse that indicates the claim was accepted by DPCI within the 120-day timely filing limit to override timely filing denial and pay the claim.

Please confirm that the claim did not appear on your rejection report. If DPCI determines the original claim submission was rejected, the claim denial will be upheld and communicated in writing to the provider.

Paper submission

Provider must submit a screen print from the provider’s billing system or database with documentation that shows the claim was generated and submitted to DPCI within the 120-day timely filing limit.

Documentation should include:

The system printout that indicates somewhere on the printout:

· That the claim was submitted to DPCI

· Name and ID number of the DPCI member

· Date of service

· Date the claim was filed to DPCI

· A copy of the original CMS-1500 or UB-04 claim form that shows the original date of submission

Emergencey department referral procedure

Emergency Department Referrals

The transfer of care or portion of care is a referral.

•    The Emergency Department provider requests that the specialist take over care or a portion of care.  The Emergency Department does not intend for the patient to receive follow-up care in the Emergency Department. 

•    To code Emergency Department services with separate specialist services, there will be two ADM records created.

•    An appointment will be generated in the Emergency Department.  The Emergency Department provider will document services he provided.  In the documented plan of care, the Emergency Department provider will indicate a portion or all of the care will be transferred to the specialist.  The Emergency Department provider will generally use a code in the 99281-99285 series and collect the care in the BIAA MEPRS. 

Medicaid reimbursment rate by state to state

Reimbursement will vary from state state. The following factors are will determine the cost.

CMS has approved cost allocation plans from States which include the following types of administrative costs necessary for the proper and efficient administration of the State plan:

•         Medicaid eligibility determinations;

•         Medicaid outreach;

•         Prior authorization for Medicaid services;

•         Medicaid Management Information System development and operation;

•         Early and Periodic Screening, Diagnostic and Treatment administration;

•         Third Party Liability activities; and

•         Utilization review

Here is the overview of Medicaid

When to use unconfirmed diagnosis

Unconfirmed Diagnosis

When a provider is not certain of a diagnosis, capture the known manifestations, signs, symptoms, or abnormal test results.

Example:  The diagnosis documented, as “rule out malignant neoplasm of the pancreas” cannot be coded, as the diagnosis is unconfirmed.  The documentation indicates a “mass on the pancreas.”  The terms “mass” and “neoplasm” are not synonymous.  Therefore, the most appropriate code would be 577.9, unspecified disease of pancreas. 

Although ADM permits designation of uncertain (unconfirmed) diagnoses with a “u” instead of a number, unconfirmed diagnoses are not traditionally coded.  If a “u” designator is used for a diagnosis in ADM, then that data is only available at the local server.  The “u” designated diagnosis cannot be the only diagnosis captured (there must be a primary diagnosis other than the “u” diagnosis).  Currently, Air Force is the only Service that permits use of a “u” designator in ADM. 

Example:  A patient comes in with chest pain, and the provider wants to rule out myocardial infarction.  The provider would document the specific symptom of chest pain as the primary diagnosis and document the myocardial infarction code as an unconfirmed diagnosis.  The provider could document the myocardial infarction code as an unconfirmed (u) diagnosis if that Service permits the designation.  

For inpatient professional services – refer to Chapter 9 Industry Based Workload Assignment (IBWA).

How to do the Medical coding - Basic tips

The following guidelines are to be followed when reporting diagnoses in ADM.  The ICD-9-CM diagnostic codes are used for professional services furnished in both the inpatient and ambulatory setting.  ICD-9-CM procedure codes are only used for inpatient institutional DoD coding and not professional services DoD coding.   

Prioritized Diagnoses

All conditions that are documented in the medical record and require or affect patient care, treatment, or management during the encounter are to be coded.  

The primary diagnosis will be the reason for the encounter, as determined by the documentation. When a diagnosis has a codable manifestation, comorbid condition, or etiology, the linked codes should be sequenced together whenever possible (e.g., diabetic skin ulcer of the ankle, coded with 250.8x and 707.13).  For some cases, ICD-9-CM conventions indicate that the underlying cause should be coded first, before a manifestation.  In these instances, manifestations cannot be coded as a primary diagnosis.

Conditions/diseases that exist at the time of the encounter, but do not impact the current encounter are not coded. Conditions/diseases that impact the current encounter are coded.Conditions that always impact the encounter and will be coded if space is available are:

    Hypertension

    Diabetes Mellitus

    Asthma

    Congestive heart failure

    Parkinson’s disease

    Chronic obstructive pulmonary disease

    Emphysema.

If space is not available for all conditions/diseases treated and impacting treatment, and the seven chronic conditions that are always coded are present, code the reason the patient presented for care, conditions/diseases treated and the chronic condition that most impacts care.

Specificity in the Coding Classification

Specificity in coding is assigning all the available digits for a code. Diagnostic codes should be assigned at the highest level of specificity.  If a code has five digits, all five digits must be used.

•    Assign three-digit codes only if there are no four-digit codes within that code category. 

•    Assign four-digit codes only if there is no fifth-digit sub classification for that category.  

•    Assign the fifth-digit sub classification code for those categories where it exists. 

•    Assign a DoD Extender code if one exists (refer to the DoD Extender Code Section).

Example:  A patient is seen for abdominal pain in the upper right quadrant and no specific cause has been determined.  The appropriate diagnostic code would be the five-digit code of 789.01, Other symptoms involving abdomen and pelvis, right upper quadrant, as opposed to the four-digit code of 789.0 (Other symptoms involving abdomen and pelvis, unspecified site).

Select the Most Explicit Code

Coding should be as explicit as the documentation permits.  For instance, when the provider documents “Acute serous OM,” code 381.01 Acute serous otitis media, not 382.9 Unspecified OM.

Unconfirmed Diagnosis

When a provider is not certain of a diagnosis, capture the known manifestations, signs, symptoms, or abnormal test results.

Example: The diagnosis documented, as “rule out malignant neoplasm of the pancreas” cannot be coded, as the diagnosis is unconfirmed. The documentation indicates a “mass on the pancreas.”  The terms “mass” and “neoplasm” are not synonymous.  Therefore, the most appropriate code would be 577.9, unspecified disease of pancreas.  

Although ADM permits designation of uncertain (unconfirmed) diagnoses with a “u” instead of a number, unconfirmed diagnoses are not traditionally coded.  If a “u” designator is used for a diagnosis in ADM, then that data is only available at the local server.  The “u” designated diagnosis cannot be the only diagnosis captured (there must be a primary diagnosis other than the “u” diagnosis).  Currently, Air Force is the only Service that permits use of a “u” designator in ADM. 

Example:  A patient comes in with chest pain, and the provider wants to rule out myocardial infarction.  The provider would document the specific symptom of chest pain as the primary diagnosis and document the myocardial infarction code as an unconfirmed diagnosis.  The provider could document the myocardial infarction code as an unconfirmed (u) diagnosis if that Service permits the designation. 

Insurance ID format - major insurance of Florida

Insurance ID format - major insurance of Florida

 Here is the list of some major insurance and insurance id format

Insurance name	ID# Format	Comments
AARP Health care	961574644	9 Digit Number and this Insurance always be a secondary because this medicare supplement plan
AARP Medicare Complete	915336628	9 Digit Number and this Insurance always be a Primary because this Medicare HMO plan
Advantra Coventry	809118617	9 Digit Number
Advantra Freedom Medicare	809323417	9 Digit Number and this Insurance always be a Primary because this Medicare HMO plan
Aetna	W101444750	Commercial
	BBJV4HQA	Aetna HMO
	578822521	Commercial
American Pioneer	031102740	9 Digit Number and this Insurance always be a secondary
Amerigroup	714891947	9 Digit Number
APWU	914135950	9 Digit Number
AVMED	A1027011906	Always ID# begin with A followed by 10 digits
Bankers Life Casualty	209074071	9 Digit Number
BCBS	POKH92835893 XJMH91442935	Florida BCBS always has Letter "H" after three Alpha character
	R51006221	ID# begin with "R" followed by 8 digit
	YLS890449801 YJX88001309101	Blue option plan
Champva	ID# is Patient SSN#	Champva is secondary to most other health plan and champva is primary to medicaid
Cigna	U33611831	Always ID# begin with "U" followed by 8 digits
Careplus	1206720	7 Digit Number and This is Medicare HMO Plan
Cigna - Baycare	100119500	9 Digit Number
Evercare	857716531	9 Digit Number and This is Medicare HMO Plan
Freedom Health	P0003496501	Always ID# begin with "P" followed by 10 digits
GEHA	21228436	8 Digit Number
GHI	930632448	9 Digit Number
Golden Rule	058827372	9 Digit Number
Hospice	ID# is Patient SSN#	Always primary and hospice does not insurance company
Humana	H46899857	Mostly ID# begin with "H" it might be Medicare HMO plan and Non-Medicare HMO plan
	700375124	9 Digit Number and this Non - Medicare HMO plan
MHBP (Mail HandlersBenefit plan	784080159-02	11 Digit Number
Medicaid	7915832042	10 Digit Number
Medicare	206344498A and 340018309C1	9 Digit followed by one alpha and ( Exception case 340018309C1)
NALC	N32233015	ID# begin with "N" followed by 8 digit
Optimum Health	T0001965601	Always ID# begin with "T" followed by 10 digits
QHP	MCR515769	Always ID# begin with "MCR" followed by 6 digits
Rail Road Medicare	A721031033	ID# begin with alpha beore numeric
Tricare	ID# is Patient SSN#	9 Digit Number
UHC	854728427	9 Digit Number
Universal Healthcare	MM557410087	ID begin with TWO alpha followed by 9 digit numbers

BCBS of TEXAS - Alpha Prefix Importance

Most members with coverage through a Blue Cross Blue Shield Plan are assigned a three letter alpha prefix as a part of their unique identification number. The alpha prefix can easily be identified as it is the first three characters.

The alpha prefix is very important to the identification number. The prefix acts as a key element in confirming the members’ eligibility and coverage information. Prefixes are also used to identify and correctly route claims to the appropriate Blue Cross Blue Shield Plan for processing.

There are two types of alpha prefixes: plan-specific and account-specific.

Plan-Specific alpha prefixes are assigned to each plan. The first two characters of the prefix identifies each plan and the third character identifies the type of product the member is enrolled in.

Example: Prefix "ZGP" (Blue Cross Blue Shield of Texas - PPO Product)

1st Character "Z" Plan Specific (letter assigned to the BCBS Plan)

2nd Character "G" Plan Specific (letter assigned to the BCBS Plan)

3rd Character "P" PPO Product (letter assigned by the BCBS Plan to identify product type elected by the member)

Account-Specific alpha prefixes are assigned to national accounts. National accounts are employer groups that have offices across multiple states but offer standardized coverage to their employees. Normally, the alpha prefix assigned to national accounts will associate to the employer group name.

Example: Prefix "UTS" (University of Texas - National Account)

Identification Cards without an Alpha prefix:

Some identification cards may not include an alpha prefix, which may indicate that the claim filing instructions for these type policies are different. We suggest that you verify claim filing instructions during the time eligibility information is obtained. If not, please follow the instructions on the back of the member's ID card or contact the plan directly. Member eligibility can be obtained at 1 (800) 676-BLUE (2583). Once connected, you will then simply provide the alpha prefix and the operator will then route you to the member's plan.

Helpful Tips Related to the Alpha Prefix:

    * Do not omit or randomly select an alpha prefix.

    * Do not substitute another Blue Cross Blue Shield Member’s prefix.

    * Include the alpha prefix and all alpha numeric characters preceding the alpha prefix on all correspondence and claims submitted to Blue Cross Blue Shield of Texas.

    * The alpha prefix is always three letters followed by the member's ID number which can be from 6 up to 14 characters total.

    * If possible, make copies of the member's ID card (front and back) for your records.

    * We recommend that you obtain a copy of the ID card any time there has been a coverage or policy change. If there are no changes, we suggest that you obtain card copies annually.

Medical billing insurance card terms and definition - ID format

INSURANCE CARDS ID FORMAT

Insured Name – Should always be set up EXACTLY as it appears on the card.  This is especially important since Medicare and Medicaid will deny if the name on the claim sent does not match the name on the card.

Group, Policy and ID#’s – Should be entered WITHOUT any dashes.  Example: policy# 475-70-5040 would be entered as 475705040.

Blue Cross/Shield – For Federal plans where ID begins with “R” and outstate plans that have an alpha prefix before the ID (example:  XZA475705040) claims are filed to your home plan.  For non-prefixed ID’s (example: 475705040) claims would go to the Blue Cross/Shield plan specified on the card.  It is very important that the employer and group are included in the registration.

PPO vs. NON-PPO – If you belong to the PPO, claims are submitted to them.  If not, the cards should indicate where to send the Non-PPO claims.  Examples:  Wynnewood Refining Company, PPO Claims go to PPO Oklahoma, Non-Network claims go to Gallagher Benefit Administrators.  Mid-South Iron Workers, PPO claims go to CompMed Physicians, Non-Network claims go to Zenith Administrators.

Worker’s Compensation Claims – Always try to obtain the worker’s compensation claims information and send the claims to them, rather than an employer.  There are a few unscrupulous employers who will have the bill sent to them and then have never filed the claim and fail to reimburse the facility.

Auto Insurance - Auto accident information should be entered even if the patient was not at fault or does not have auto insurance in case litigation is warranted.  Any information entered, even in notes, can be helpful.  Auto accidents can take many years to reach a settlement and documentation taken near the time of the accident can be critical to the site being reimbursed for treatment costs.

Tribal Self-Insurance – Even though it is not billable for Federal IHS sites, the information still needs to be entered and adjusted off for cost accounting purposes.  Contract Health Services needs this to coordinate benefits.

Dental, Pharmacy, Vision, and Mental Health Insurance – Often, if patient has dental, pharmacy, vision or mental health insurance coverage, a different company is administering the benefits, not the medical insurance carrier.  The ROI/AOB and MSP are conditions of participation (CoP) in the Mcare program. 

abortions DX code - 635, 636,637 series

Abortions

On an annual basis, the number of legal, elective, or therapeutic, and illegal abortions that are performed in DoD MTFs must be reported to Congress.  Use of the 635, 636 and 637 codes should be carefully scrutinized.  Do not use 635-638 unless you received authorization from your Service coding representative.  Some of the basic rules that apply include the following:

•    Fifth-digit-1, incomplete, indicates that all of the products of conception have not been expelled from the uterus prior to the episode of care. 

•    Fifth-digit-2, complete, indicates that all of the products of conception have been expelled from the uterus. 

•    Code 635 requires additional code to identify the reason for the abortion.  Codes from categories 640-648 and 651-657 (with fifth digits “3”) may be used as additional codes with an abortion code to indicate the complication leading to the abortion.

Outpatient hospital billing and CPT questions list

OUTPATIENT HOSPITAL

Is a pre-certification required from Health Care Excel (HCE) for outpatient services and/or surgical procedures?

No, a pre-certification from HCE is not required for outpatient services and/or surgeries.

If a hospital has an outpatient claim that requires the submission of a second page for services provided on the same date, should two separate claims be filed or can a two-page claim be submitted with the total appearing on the second page?

In this instance, the provider should submit two separate claims and total each individual claim page. When billing for an outpatient facility charge, should a CPT/HCPCS code be entered in addition to the outpatient facility revenue code?

No. Enter only the appropriate outpatient facility revenue code. Do not list a CPT or HCPCS code along with the facility revenue code.

Can a provider bill for two emergency room visits on the same day for the same patient?

If the second ER visit is essentially for the same reason as the first, the hospital cannot bill for it. If the second visit is for a different reason, the hospital can bill for the visit. The two visits must be billed on the same paper claim and the ER notes for each visit attached to it.

If the patient has two ER visits on the same day at two different hospitals, whichever hospital submits a claim first will be paid. The provider that bills second will have its claim denied and will have to refile a paper claim with the ER notes attached to it.

How are emergency room services billed that continue from the initial day into the following day?

For any ER service that continues past midnight, including the facility charge, use the date the patient was initially seen in the ER as the date of service.

How are observation services billed that continue from the initial day into the following day?

For any observation room services that continue past midnight, including the facility charge, use the date the patient initially was put in observation as the date of service. Bill only one observation room facility charge for the entire stay. Do not bill one for the first day and a separate one for the second day.

Can a hospital bill for multiple dates of service on the same claim for either emergency room services or therapy services and use the AJ condition code to exempt the patient from the $3.00 cost sharing amount for each date of service reported on the claim?

No. Only one date of service can be reported on an outpatient hospital claim on which the AJ condition code is reported. The AJ condition code is used on the outpatient hospital claim to exempt the patient from the $3.00 cost sharing for emergency room services or outpatient therapy services (physical therapy, chemotherapy, radiation therapy, psychology/counseling and renal dialysis).

A MO HealthNet patient presents to the hospital emergency department for non-emergent care. Eligibility is checked and it is determined the patient is administratively locked-in to a provider. The ER department tries to contact the designated lock-in provider who either is not available or will not authorize the services through the PI-118 lock-in form. Since the ER department cannot get a referral from the lock-in provider, can these services be billed to the patient or does the hospital have to write them off?

The patient can be billed for the care. Patients who have been administratively locked-in to a designated provider know this and know who their lock-in provider is. Further, they know that if they try to obtain non-emergent services from another provider, the patient can be held responsible for the costs of the service if the treating provider is unable to obtain a referral from the lock-in provider.

How does a hospital bill for an injection for which there is no J-code?

If there is no appropriate J-code for an injection, the hospital can bill one of the following codes.

J-3490 – unclassified drug

J-7599 – immunosuppressive, not otherwise classified

J-8499 – prescription drug, oral, non-chemotherapeutic, NOS

J-8999 – oral prescription, chemotherapeutic, NOS

The injection code can be filed on a paper UB-04 claim form. An invoice must be attached which shows the name, the national drug code and the cost for the drug. The injection code also can be billed on the emomed.com electronic UB-04 claim form. 

If the claim is filed using this method, then a provider must click on the "Add/View Invoice of Cost" link at the bottom of the claim Web page. This opens up a Web page titled "Invoice of Cost Information" page which must be completed and submitted along with the claim.

Can the hospital bill for a non-payable medication under medical supplies?

No. An injection or medication that is not payable under MO HealthNet cannot be billed under revenue code 270 (medical supplies).

Are hospital’s required to keep paper copies of attachments used for physicians’ outpatient services, e.g. Second Surgical Opinion Form, Sterilization Consent form, etc.?

Yes. The hospital must maintain a copy of these forms in the patient’s permanent file.

Can HCPCS “Q” codes be used to bill for MO HealthNet services?

HCPCS “Q” codes are national codes given by the Center for Medicare Services (CMS) on a temporary basis. In general, “Q” codes are not to be used to bill for MO HealthNet services and are considered non-covered.

Does MO HealthNet have allowable quantities that can be billed for outpatient services?

Yes. Each procedure code has an allowable quantity that can be billed to MO HealthNet without additional documentation. A provider can access the MO HealthNet fee schedules, which include allowable quantities, through the MO HealthNet Division Web site, www.dss.mo.gov/mhd/providers/index.htm. 

Note – The fee schedule for the technical component of laboratory procedures does not include hospitals. Contact Provider Communications, 573/751-2896, for information relating to the allowable quantity and reimbursement for outpatient laboratory procedures.

How is a claim billed when more than the allowable quantity of a procedure was performed?

A provider cannot bill for more than the MO HealthNet allowable quantity on a single line on the claim. The additional quantities have to be billed on subsequent lines and the hospital’s notes sent with the claim for manual review and processing. 

Example - the MO HealthNet allowable for a procedure is two but the hospital wants to bill for five. The hospital would bill one line with the procedure code and a quantity of two, a second line with the procedure code and a quantity of two, and a third line with the procedure code and a quantity of 1, and the hospital notes submitted with the claim.

What is the proper way to bill for a comprehensive metabolic panel, procedure code 80053?

If only CPT code 80053 was performed, bill the code without any modifiers. Providers should be aware that 80053 might be included in CPT code 80050 (general health panel) if certain other lab services are being billed for the same date of service.

CPT code 80050 includes 80053 in addition to:

Blood count, complete (CBC), automated and automated differential WBC count (85025) or (85027 and 85004) or,

Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009)

Thyroid stimulating hormone (TSH) (84443)

What is the correct way to bill for outpatient cardiac rehabilitation services?

Providers should bill using the appropriate revenue code, 0943 - cardiac rehabilitation. Do not list a CPT procedure code with this revenue code. Are there special documentation requirements for billing for outpatient missed abortions/miscarriage services?

MO HealthNet does not cover elective abortion services.

Any claim with a diagnosis of miscarriage, or missed or spontaneous abortion, diagnosis codes 632, 634.00-634.92, 635.00-635.92, 636-636.92 and 639-639.9, must be submitted on a paper UB-04 claim form with all appropriate documentation attached. 

The documentation must include the operative report, an ultrasound, the pathology report, the admit and discharge summary, etc. to show that this was not an elective abortion. If no ultrasound was performed, the reason for not performing it must be clearly documented in the patient’s medical record.

The above information is required also when submitting a claim with one of the following CPT codes: 59200, 59812, 59821, or 59830.

CPT codes 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, and 59866 also require a completed Certification of Medical Necessity for Abortion form in addition to the previously noted documents.

Observation Care: Are You ‘Inpatient’ or ‘Outpatient’? It Makes a Difference

If you are in the hospital, occupying a bed, are you an inpatient of the hospital, or not? You probably think you are, but that may not necessarily be true. Here’s why:

Being ‘inpatient’ means you have been formally admitted to the hospital with a doctor’s order. Being ‘outpatient’ means that you are getting emergency department services, observation services, or having outpatient surgery, tests, etc., at the hospital, but a doctor has not written an order to admit you into the hospital. 

The amount of time you spend in the hospital, even if it is overnight, does not determine your hospital status. You are not an inpatient until you are admitted to the hospital formally on a doctor’s order.

Outpatient observation services are performed in a hospital on the hospital’s premises, including use of a bed and at least occasional monitoring by a hospital’s nursing or other staff, to help your doctor determine if it’s necessary to admit you formally to the hospital as an inpatient, or if you can be discharged. Generally, patients are not kept in outpatient observation status for more than 48 hours.

Why does your hospital status matter? 

Your status, inpatient or outpatient, has an effect on how Medicare pays the hospital, and how much you may have to pay for the hospital services. 

You can pay more for services received when you are in outpatient hospital observation status because instead of being responsible for one Part A deductible for all of your hospital services, you are instead responsible for a separate copayment for each outpatient hospital service. 

The total of your copayments for outpatient services, including tests, procedures and observation, can be more than your Part A deductible would be as an inpatient. 

Also, Medicare Part B does not cover self-administered drugs, including your prescription drugs and over-the-counter drugs that you may receive as an outpatient.

What determines whether you are admitted as an inpatient? Generally, you will not be admitted as an inpatient if you are not expected to need medically necessary hospital care for two of more midnights.

Here are some examples of how Medicare pays for observation services:

• I am admitted to the hospital from the emergency room, based on a doctor’s order. Part A will pay for the hospital stay, and Part B (Railroad Medicare) will pay for the doctor’s services.

• In another scenario, I visit the emergency room, I am sent to the intensive care unit or any other room so that my condition can be monitored. My condition gets better and the doctor lets me go home. Part A pays nothing, and Part B (Railroad Medicare) pays for the doctor’s services.

• In cases where Part A does not pay, the outpatient services (such as the doctor’s services, lab services, radiology/x-rays, etc.) are paid for by Part B. I pay my deductibles and co-pays out of pocket. Each of these services is billed separately.

• I visit the emergency room and the hospital staff keeps me for two nights. If one of those nights a doctor writes an order for me to be admitted to the hospital, Part A will pay for my hospital stay, and Part B pays the rest, minus my deductibles and co-pays.

There are many other cases and scenarios and situations in which Part A may or not pay. The most critical situation is for patients going to a skilled nursing facility (SNF) after a hospital stay. 

If the beneficiary has not been a hospital inpatient for three consecutive days, Medicare will not cover the SNF stay or services – regardless if the patient was physically at the hospital for three days or more.

Update on Medication coverage policy - BCBS of california

blueshieldca - Medication Policy Update

Medication Coverage Policy Updates

Please note: As a result of the December 2010 Pharmacy and Therapeutics (P&T) Committee  meeting, Blue Shield of California is announcing updates to some medication coverage policies for office-based drugs covered in the medical benefit, as follows:

                           

New Office-Administered Medication Coverage Policies:

Iprivask

Xeomin

Drug Formulary Updates

 Please note: The Blue Shield Drug Database & Formulary has been updated to reflect the changes from the December 2010 Pharmacy and Therapeutics (P&T) Committee meeting.

Drugs Added to the Formulary:

Exelon Patch

Exelon Oral Solution

Vyvanse

Drugs Removed from the Formulary:

Avandia (Effective 3/1/2011) – Formulary Alternatives: metformin, sulfonylureas, Actos

Avandamet (Effective 3/1/2011) – Formulary Alternatives: metformin, sulfonylureas, Actos

Update on Medication coverage policy - BCBS of california

blueshieldca - Medication Policy Update

Medication Coverage Policy Updates

Please note: As a result of the December 2010 Pharmacy and Therapeutics (P&T) Committee  meeting, Blue Shield of California is announcing updates to some medication coverage policies for office-based drugs covered in the medical benefit, as follows:

                          

New Office-Administered Medication Coverage Policies:

Iprivask

Xeomin

DoD-Unique V-Code Guidance for Exam - V70.50 - V70.59

DoD-Unique V-Code Guidance for Exams, Education, and Counseling Services

DoD extender codes have also been paired with selected V codes to further specify education and counseling services.  The addition of DoD extender codes to the root code V70.5 enables the differentiation of the types of health examinations routinely imposed on the active duty and individuals working in support of the DoD.  When entering these codes in ADM, enter the root code, one space, and then the extender.

V70.5_0    Armed Forces Medical Exam - used for pre-enlistment exams.  This is an initial qualifying exam; a "yes" test that someone meets the requirements to join the military.

V70.5_1    Aviation Exam - This is the initial qualifying and any recurring exam.


    V70.5_2    Periodic Prevention Exam – Age-specific exam according to Service specifications.  This exam also includes non-military populations such as preschool and other students, and detainees under DoD control.

V70.5_3    Occupational Exam - Used for both initial qualifying and recurring exams due to the individual working in a specific occupation or in support of occupational medicine programs (Worker’s compensation).  For return to duty, following a non-aviation occupational related condition, use V70.5  7.

V70.5_4    Pre-deployment Examination/Encounter – A medical exam administered prior to designate military deployment.  These exams could include family members experiencing a pre-deployment related condition.

V70.5_5    During Deployment Examination/Encounter - Any deployment related exam performed while individual (AD, contractor, etc.) is deployed.  These exams could include family members experiencing a deployment related condition.

V70.5_6    Post Deployment Examination/Encounter - An exam specifically performed because an individual was deployed.  This code is also used for individuals (e.g., family members, significant others) with post deployment related issues impacting medical care.  (See further explanation in Post Deployment Exams.)

V70.5_7    Fitness for Duty Examination/Encounter - Used when the primary reason a patient is seen is to be returned to work/duty.  This is also for temporary and permanent duty retirement list (TDRL/PDRL), medical evaluation board (MEB) assessments, and return to duty following pregnancy, or surgery/treatment.

V70.5_8    Accession Exam - A special medical examination on individuals being considered for special programs prior to Service entry.  Exams are usually for officer candidates [Reserve Officer Training Corps (ROTC) programs, college graduates, professional schools, etc.]  Other examples are DoD Medical Review Board (Dormer) exams, Health Professional School Program (HPSP) exams, and supplemental exams in support of Medical Examination Processing Stations.

V70.5_9    Termination Exam – Exams performed at the end of employment and for retirement or separation.

An Armed Forces exam, not otherwise specified, should be coded using V70.5_0.

V-Code Guidance for Exams, Education, and Counseling Services

V70.5 enables the differentiation of the types of health examinations routinely imposed on the active duty and individuals working in support of the DoD.  When entering these codes in ADM, enter the root code, one space, and then the extender.

V70.5_0    Armed Forces Medical Exam - used for pre-enlistment exams.  This is an initial qualifying exam; a "yes" test that someone meets the requirements to join the military.

V70.5_1    Aviation Exam - This is the initial qualifying and any recurring exam.

V70.5_2    Periodic Prevention Exam – Age-specific exam according to Service specifications.  This exam also includes non-military populations such as preschool and other students, and detainees under DoD control.

V70.5_3    Occupational Exam - Used for both initial qualifying and recurring exams due to the individual 

working in a specific occupation or in support of occupational medicine programs (Worker’s compensation).  For return to duty, following a non-aviation occupational related condition, use V70.5  7.

V70.5_4    Pre-deployment Examination/Encounter – A medical exam administered prior to designate military deployment.  These exams could include family members experiencing a pre-deployment related condition.

V70.5_5    During Deployment Examination/Encounter - Any deployment related exam performed while individual (AD, contractor, etc.) is deployed.  These exams could include family members experiencing a deployment related condition. 

V70.5_6    Post Deployment Examination/Encounter - An exam specifically performed because an individual was deployed.  This code is also used for individuals (e.g., family members, significant others) with post deployment related issues impacting medical care.  (See further explanation in Post Deployment Exams.)

V70.5_7    Fitness for Duty Examination/Encounter - Used when the primary reason a patient is seen is to be returned to work/duty.  This is also for temporary and permanent duty retirement list (TDRL/PDRL), medical evaluation board (MEB) assessments, and return to duty following pregnancy, or surgery/treatment.

V70.5_8    Accession Exam - A special medical examination on individuals being considered for special programs prior to Service entry.  Exams are usually for officer candidates [Reserve Officer Training Corps (ROTC) programs, college graduates, professional schools, etc.]  Other examples are DoD Medical Review Board (Dormer) exams, Health Professional School Program (HPSP) exams, and supplemental exams in support of Medical Examination Processing Stations.

V70.5_9    Termination Exam – Exams performed at the end of employment and for retirement or separation. 

comparison of HMO, PPO, POS, EPO

HMO:

Need a referral from PCP to see a specialist.

Need to select a PCP with in network

Low premium

Dose not covered the out of network service

PPO:

Don’t need a referral from PCP to see a specialist.

Don’t necessary have to choose a PCP

High premium

dose cover the out of network

Determining level of E & M code - Encounter duration Determination of Level of E&M Code

The three key elements in selecting the appropriate complexity of the E&M code are history, examination, and medical decision-making.  These components must meet or exceed the minimum requirements specified in the E&M guidance of the CPT references.  When determining the level of history for an E&M code the documented elements in the History of Present Illness (HPI) may also be counted in the Review of Systems (ROS) and/or the Past Family Social History (PFSH) when appropriate.  It is not necessary to repeat a documented item of history in order to count in two or all three elements of the history component.  There are four contributory factors, which include nature of presenting illness, coordination of care, counseling and time.  More E&M documentation guideline information may be found on the CMS website at http://www.cms.hhs.gov/.

Encounter Duration