Information required for PECOS enrollment submission

Information required for PECOS enrollment submission

What information will I need before I begin to complete my enrollment via Internet-based PECOS?

below is a list of the types of information needed to complete an initial enrollment action using Internet-based PECOS. This information is similar to the information needed to complete a paper Medicare enrollment application.

    *   An active National Provider Identifier (NPI).

    *   National Plan and Provider Enumeration System (NPPES) User ID and password.

    *  Personal identifying information. This includes legal name on file with the Social Security Administration, date of birth, Social Security Number

    *   Professional license and certification information. This includes information regarding the physician's or non-physician practitioner's professional license, professional school degrees or certificates.

advantages of Internet-based PECOS

why online PECOS submission is good and what we can do

What are the advantages of Internet-based PECOS?

There are a number of advantages to using Internet-based PECOS, as opposed to mailing in your application.  These advantages include the following:

    * Faster than paper-based enrollment (7 day processing time in most cases)

    * Gives you more control over your enrollment information, including reassignments

    * Easy to check and update your information for accuracy

    * Less staff time to complete and submit enrollment information to Medicare

Electronic claims submission

The following third party-related information is required on the claim, in addition to the other required claim data:

Claim Form Include the Following Third Party Information                In These Claim Fields

CMS-1500 • Other Insured’s name, policy number, insurance             BLOCK 9 - 9D

co.

• Was condition related to (accident)                                                   BLOCK 10                           

• TPL paid dates                                                                                 BLOCK 19

• Amount paid                                                                                     BLOCK 29

Provider Signatures

Provider signature of Medical claims - electronic claim form

Provider Signatures

This section discusses the various requirements for provider signatures when filing electronic or hard copy claims.

Medical Claims

The provider's signature on a claim form/medical submission agreement certifies that the services filed were performed by the provider or supervised by the provider and were medically necessary.

Individual practitioners (not groups  or clinics) may sign a medical claims submission agreement with Medicaid for the submission of paper claims instead of signing individual claim forms.

By signing the claim agreement, the provider agrees to keep any records necessary to enable the provider to perform the following responsibilities:

• Disclose the extent of services the provider furnishes to recipients

• Furnish Medicaid, the Secretary of HHS, or the state Medicaid Fraud Control

Unit, upon request, any information regarding payments received by the provider for furnishing services

• Certify that the information on the claim is true, accurate, and complete, and the claim is unpaid

• Affirm the provider understands that the claim will be paid from federal and state funds, and any falsification or concealment of a material fact may be prosecuted under federal and state laws

Maternity Care Program

Billing maternity care program to Medicaid

Maternity Care Program

The Maternity Care Program is a statewide program that covers maternity services. The state is divided into 14 districts with a Maternity Care Primary Contractor in each district. The primary contractor is responsible for the coordination of care for recipients enrolled in the program.

submission of enrollment application

successfull submission of enrollment application - provider

How will I know if I have successfully submitted my enrollment application?

Once the Internet application has been electronically submitted, the "Submission Receipt" page appears. This page informs the physician or non-physician practitioner that the Internet application has been submitted for processing. The "Submission Receipt" page reminds the physician or non-physician practitioner that the Certification Statement must be signed and the Certification Statement and the supporting documentation must be mailed to the contractor. PECOS sends a notification reminder to each e-mail address listed in the contact person information section of the application.

QMB-only Medicare recipients

QMB-only and QMB Medicare/Medicaid recipients - what is the differnent

QMB-only Medicare recipients

QMB-only Medicare recipients are identified as QMB ONLY by using the Provider Electronic Solutions software, AVRS (Automated Voice Response System) or the Provider Assistance Center.

These recipients are eligible only for crossover services and ARE NOT eligible for Medicaid only services. That is, if Medicare covers the service, Medicaid will consider for payment the deductible and/or co-insurance. Premiums and copayment will be considered for payment if the individual is enrolled in a Medicare Advantage Plan.

Patient 1st

Medical billing concept - Patient 1st plan

Patient 1st

Patient 1st is a statewide Primary Care Case Management (PCCM) system. Medicaid recipients eligible for this program are assigned to a Primary Medical Provider (PMP) who is responsible for primary care services and authorization of referrals.

Medicaid’s Medicare Advantage Managed Care Plan

Does Medicaid cover Medicare advantage plan copay, deductible?

Medicaid’s Medicare Advantage Managed Care Plan

There are currently four companies who contract with the Alabama Medicaid Agency and offer Medicare Advantage coverage in Alabama – United HealthCare’s Medicare Complete, Viva Health’s VIVA Medicare Plus and Blue Cross/Blue Shield of Alabama’s Blue Advantage and Windsor Health Care. 

When one of these companies notifies Medicaid that a Medicaid recipient has enrolled in their Medicare Advantage Plan, Medicaid makes a premium payment to the applicable plan. This payment covers all Medicare coinsurance and deductibles. Therefore, neither Medicaid nor the recipient will pay any co-payments, coinsurance or deductibles for Medicare services incurred during the time that the individual is enrolled in Medicaid’s Medicare Advantage Plan.

Claims can be submitted to Medicaid for copays, deductibles or coinsurances for dates of service that are prior to or after the dates that Medicaid has paid a premium to one of the four Plans listed above. These claims should be billed on a Medicare/Medicaid crossover claim and will be processed like any other Medicare paid claim. (See Section 5.7.1 for specific billing instructions)

There are several Medicare Advantage Plans that are servicing Medicaid recipients. However, the four Plans mentioned above are the only ones with whom Medicaid has a contract to pay premiums. Since Medicare Advantage Plans pay in place of Medicare, any secondary claims to Medicaid for copays, deductibles or coinsurance should be billed on a Medicare/Medicaid crossover claim and will be processed by Medicaid in the same manner as a Medicare paid claim. (See Section 5.7.1 for specific billing instructions) 

The eligibility response from AVRS or Provider Electronic Solutions provides the following information if the recipient is enrolled in a Medicare Advantage

Plan for which Medicaid is making a capitation payment:

• Verification of the recipient’s enrollment in a Medicare Advantage Plan

• Plan telephone number

Claims for services covered under this plan must be filed directly to the applicable Medicare Advantage Plan.

Basic billing question on Medicaid Managed care

MANAGED CARE

How do we find out which network provider to call?

If you check eligibility through the web portal, look for this information in the Managed Care section of the recipient’s eligibility screen. You will find the name, type and phone number of the HMO, PSN or other managed care plan.

Is the network provider the one who is going to give us the authorization for the services?

No, you would get the authorization from the Health Plan. The only time you will get authorization from a provider is for a person managed under MediPass.

Referring to Slide 50: If recipients don’t have managed care, will it be blank or will it state FL Medicaid? 

If the recipient does not have managed care, the Web Portal screen will show ***No rows found.

A patient will come in with a Medicare managed plan yet also show us a Medicaid card. The Medicaid eligibility will show full Medicaid benefits but does not show the Medicare Advantage plan yet we do call and verify eligibility with the Medicare HMO. Does Medicaid pay as a secondary in this case?

Medicaid is not currently paying crossover claims for beneficiaries in Medicare HMOs (Part C plans), but there are changes in the works that may take place as soon as the end of the year. Please watch for any upcoming provider alerts on this subject. You may also contact your Local Medicaid Area Office for questions on this topic. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/

If I have a situation where our claims are being underpaid with our HMO contract and we have sent several requests, spreadsheets and calls to get this rectified; what other recourse do we have as a provider?

The Medicaid contract requires that the provider address any claims/billing disputes through the provider complaint system of the individual Health Plan. Language from the contract is provided below. If the provider is unable to resolve this with the Health Plan, they are able to access an outside claims arbitrator, Maximus, which deals with claims disputes between Health Plans and providers. Application forms and instructions on how to file claims are available from Maximus.

How can I check for eligibility for a specific service by a managed care plan?

You may ask the recipient’s managed care plan when you contact them for authorization. If you do not have a specific recipient, you may contact the managed care plan for general information. Your Area Medicaid office may be able to provide the contact telephone numbers for the managed care plans in your county. 

Medicare rejection CO 24 - covered by Advantage plan

We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.

• Medicare claims must be submitted to the MA plan.

• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.

• Obtain eligibility and benefit information prior to rendering services to patients.

• Ask patients if they have recently enrolled in any new health insurance plans.

• Request to see a copy of all of their health insurance cards.

• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify the beneficiary's eligibility prior to submitting claims to First Coast.

• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).

• Claims that are returned as unprocessable cannot be appealed, for more information click here.

End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/index.html

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.

Incident to other service

Incident to other service? what service will considered?

What qualifications must be met for services to be considered “incident to” services?

Services that qualify as an “incident to:”

• must be part of your patient’s normal course of treatment; during which

• a physician personally performed an initial service; and

• remains actively involved in the course of treatment.

You must provide direct supervision by being present in the office suite to assist if necessary. However, you do not have to be physically present in the patient’s treatment room while these services are provided. In addition, the patient record should document the essential requirements for incident to service.

Medicaid benefit limit

Medicaid benefit limit

Benefit Limits

The Alabama Medicaid Agency establishes annual benefit limits on certain covered services. Certain services are excluded, such as services rendered as a result of an Early Periodic Screening, Diagnosis, and Treatment (EPSDT) screening. The EPSDT program covers recipients under 21 years of age. SOBRA pregnant women under 21 are not covered under EPSDT. When the recipient has exhausted his or her benefit limit for a particular service, providers may bill the recipient

The table below describes the benefit limitations documented as part of  eligibility verification.

Third Party Liability

Medicaid third party liablity how to find any other insurance

Third Party Liability

Providers should verify whether a Medicaid recipient has other insurance prior to submitting a claim to Medicaid. Because federal Medicaid regulations require that any resources currently available to a recipient are to be considered in determining liability for payments of medical services, providers have an obligation to investigate and report the existence of other insurance or liability to Medicaid. Cooperation is essential to the functioning of the Alabama Medicaid Program.

Medical billing - prior authorization request

Submitting a Prior Authorization Request

To receive approval for a PA request, you must submit a complete request using one of the approved submission forms. This section describes how to submit online and paper PA requests, and includes the following sections:

• Submitting PAs (278 Health Care Services Review-Request for Review and Response) using Provider Electronic Solutions

• Submitting Paper PA Requests

Prior authorization - electronic request require attachment

Prior authorization - electronic request require attachment

Electronic PA Requests Requiring Attachments

If attachments are required for PA review the attachments must be sent to HP to be scanned into the system. Do not fax this information to the Alabama Medicaid Agency unless a request is made for specific information by the agency reviewer. Attachments scanned can be located in the system and are linked by the PA number on the Prior Authorization response returned by the system. Refer to Chapter 15 of the Provider Electronic Solutions Manual for specific information. 

Submitting Denied Claims to Medicaid

Providers may submit denied third party claims to Medicaid. The following third party-related information is required on the claim, in addition to the other required claim data:

Claim Form - CMS-1500

Include the Following Third Party Information                             In These Claim Fields

• Other Insured’s name, policy number,                                             BLOCKS 9 -9D

insurance co.                                                                                 

• Was condition related to (accident)                                                  BLOCK 10

• TPL denied dates                                                                           BLOCK 19

• Amount paid                                                                                   BLOCK 29

Guidance Regarding NDC’s on the CMS-1500 Form

Guidance Regarding NDC’s on the CMS-1500 Form

Effective August 2008, Alabama Medicaid mandated that the National Drug Code (NDC) number be included on the CMS-1500 claim form for the Top 20 physician administered drugs as defined by CMS. Alabama Medicaid would like to clarify the required format for the NDC number that is submitted on this claim form. Medicaid requires that each submitted NDC contain 11-digits (no dashes or spaces). The first 5-digits identify the labeler code of the manufacturer of the drug. The next 4-digits identify the specific strength, dosage form, and formulation of that drug. The last 2- digits identify the package size of the drug.

There may be some instances when an NDC does not contain all eleven digits on the product’s container.

UB 04 - NDC number

Guidance Regarding NDC’s on the UB-04 Form

Effective August 2008, Alabama Medicaid mandated that the National Drug Code (NDC) number be included on the UB-04 claim form for the Top 20 physician administered drugs as defined by CMS. Alabama Medicaid would like to clarify the required format for the NDC number that is submitted on this claim form. Medicaid requires that each submitted NDC contain 11-digits (no dashes or spaces). The first 5-digits identify the labeler code of the manufacturer of the drug. The next 4-digits identify the specific strength, dosage form, and formulation of that drug. The last 2- digits identify the package size of the drug.

There may be some instances when an NDC does not contain all eleven digits on the product’s container. 

Refunds

Billed amount, allowed amount and paid amount. - EOB terms

Understanding EFT enrollment process

INSTRUCTIONS FOR COMPLETING SWINGBED CLAIMS

Refunding payment to insurance company

Refunds

If you receive payment for a recipient who is not your patient or are paid more than once for the same service, it is your responsibility to refund the Alabama Medicaid Program.

Provide refunds to the Medicaid Program by using the Check Refund Form (a sample can be found in Appendix E) accompanied by a check for the refund amount. Make the check payable to:

HP – Refunds

P.O. Box 241684

Montgomery, AL 36124-1684

Please provide the following information in the appropriate fields on the Check Refund Request exactly as it appears on your Remittance Advice (RA) for each refund you send to HP:

• Provider Name and NPI

• Your check number, check date, check amount

• 13 digit claim number or ICN (from RA)

• Recipient’s Medicaid ID number and name (from RA)

• Dates of service

• Date of Medicaid payment

• Date of service being refunded

EOB Claim Page Field Descriptions

Most of the field descriptions for each of the claim type Adjusted, Paid, Denied, and In Process are the same. Each claim type/Status may have fewer of the fields and a few have fields specific to the claim type. For example, Dental contains tooth references, Drug contains NDC codes.

The following table lists the fields in all the claims sections. The table includes all fields that display on all claim types. The Adjustments pages contain a few more fields that are described in the next section.

Note: The fields listed in the following tables are based on information available at the time of publication. The information is subject to change based on further review.

Field Description

Name Displays the recipient's last name, and first name. Claims are displayed in alphabetical order by last name.

Pat Acct No. Displays the Patient Account Number assigned to the recipient by the provider.

ICN Displays the internal control number of the claim. Use this number when inquiring about the claim.

MRN Displays the Medical Record Number assigned to the recipient by the provider.

Rendering Provider Displays the National Provider Identifier (NPI) of the rendering provider.

Attending ID Displays the National Provider Identifier (NPI) of the attending physician, if applicable.

Recipient ID Displays the 12 digit recipient Medicaid ID number as submitted by the provider.

Admit Date Displays the admitting date submitted on the claim, if applicable.

Dispense Date Displays the dispense date submitted on the claim, if applicable.

Days Displays the number of days submitted on the claim, if applicable.

Dates Of Service First Date Of Service - Last Date Of Service, Displays the dates of service submitted on the claims in

MMDDYY format. This displays for each line item billed,if applicable.

Dist Plan (District Plan) Displays the District Plan Code for the inpatient claim, if applicable

Surf (Tooth Surface) Displays the tooth surface on the detail line, if applicable.

POS Or PL SERV (Place Of Service) Displays the place of service as submitted on the claim,

if applicable.

TN (Tooth Number) Displays the tooth number on the detail line, if applicable.

Procedure/Revenue/ NDC Code Displays these codes as they were submitted on the claim. This displays for each line item billed, if applicable.

Modifiers Displays the procedure code modifiers as they were submitted on the claim.

Desc Displays the first six characters of the NDC code description

Billed Amount Displays the amount billed on the claim. This displays for each line item billed, if applicable.

Non Allowed Displays the amount of the billed amount that Medicaid will not cover. This displays for each line item billed, if applicable.

Allowed Amount Displays the amount of the billed amount that Medicaid will cover. This displays for each line item billed, if applicable.

Patient Liability This displays the patient liability applied to the claim payment, if applicable.

TPL Amount Displays the amount paid by a third party insurance. This displays for each line item billed, if applicable.

Paid Amount Displays the amount Medicaid paid the provider for the claim. This displays for each line item billed, if applicable.

Recipient Signatures

Importance of recipient or patient signature

Recipient Signatures

While a recipient signature is not required on individual claim forms, all providers must obtain a signature to be kept on file, (such as release forms or sign-in sheets)  as verification that the recipient was present on the date of service for which the provider seeks payment. Exceptions to the recipient signature are listed below:

• The recipient signature is not required when there is no personal contact between recipient and provider, as is usually the case for laboratory or radiology.

• Illiterate recipients may make their mark, for example, "X," witnessed by someone with his dated signature after the phrase "witnessed by."

• A representative may sign for a recipient who is not competent to sign because of age, mental, or physical impairment.

different way of submitting electronic claims

different way of submitting electronic claims

Electronic claims may be submitted using a variety of methods:

• Provider Electronic Solutions software, provided at no charge to Alabama Medicaid providers

• Value Added Networks (VANs) or billing services on behalf of an Alabama Medicaid provider

• Tapes or other electronic media, as mutually agreed to by the Alabama Medicaid Agency and the vendor

Electronic Claims Submission (ECS) offers providers a faster and easier way to submit Medicaid claims. When you send your claims electronically, there is no need to complete paper Medicaid forms. Your claim information is submitted directly from your computer to HP.

Format of NPI

Format of NPI, HOW long it will take, need to enroll Medicare program

How long will it take to get an NPI?

We cannot predict the amount of time it will take to obtain a National Provider Identifier (NPI) because several factors come into play. Such factors include the volume of applications being processed at a given time, whether the application was submitted electronically or on paper, and whether the application was complete and passed all edits. We expect that a health care provider who submits a properly completed electronic application could have its NPI in 10 days. 

Taxonomy Guide

In accordance with SNIP level 4 edits, a valid taxonomy is a requirement for all providers when submitting both paper and electronic claims. This guide will provide basic information to further instruct and educate all providers in assistance with taxonomy submittals. Taxonomy code is constructed of 10 digits- numeric and alpha: (see example 1)

Example: 282N00000X

Electronic:

Billing- Loop 2000A-PRV01 “BI” PRV02 = “ZZ” qualifier PRV03 = 10 character taxonomy 

Rendering- Loop 2310B PRV01 “PE” = Referring PRV02 = “ZZ” qualifier PRV03 = 10 character taxonomy code

Referring- Loop 2310A PRV01 “RF” = Referring PRV02 = “ZZ” qualifier PRV03 = 10 character taxonomy code

Tips:

* Qualifiers are to be included on both paper and electronic claims for proper submission

of claim

* Provider should be billing with the taxonomy that is filled with DCH

*  See the following websites for additional information billing information: www.NUCC.org and www.NUBC.org

Taxonomy guide for CMS 1500 from wellcare insurance

Wellcare -Taxonomy Guide

In accordance with SNIP level 4 edits, a valid taxonomy is a requirement for all providers when submitting both paper and electronic claims. This guide will provide basic information to further instruct and educate all providers in assistance with taxonomy submittals.

Taxonomy code is constructed of 10 digits- numeric and alpha: (see example 1)

Tips:

 Qualifiers are to be included on both paper and electronic claims for proper submission of claims

 Provider should be billing with the taxonomy that is filled with DCH

Wellcare taxonomy code rejection - How to resolve it - paper and electronic claim

Taxonomy Guide

In accordance with SNIP level 4 edits, a valid taxonomy is a requirement for all providers when submitting both paper and electronic claims. This guide will provide basic information to further instruct and educate all providers in assistance with taxonomy submittals. Taxonomy code is constructed of 10 digits- numeric and alpha: (see example 1)

Example: 282N00000X

Provider Taxonomy Codes update

Update to the Healthcare Provider Taxonomy Codes (HPTC) April 1, 2011

Provider Types Affected

Providers who bill carriers including DME MAC.

Provider Action Needed: Impact to You

CMS has released the summary of changes reflected in the Health Care Provider Taxonomy Code (HPTC) list. Medicare carriers and DME MACs will update their HPTC tables with this new version effective on April 1, 2011.

What You Need to Know

The Health Insurance Portability and Accountability Act (HIPAA) requires that submitted data, which is part of a named code set, be valid data from that code set. Claims accepted with invalid data are non-compliant.

What You Need to Do

Please review the information included here and stay current on all HIPAA requirements to assure timely processing of your claims.

Background

Under HIPAA, code sets that characterizes a general administrative situation, rather than a medical condition or service, are referred to as non-clinical or non-medical code sets. 

The provider taxonomy code set is an external non-medical data code set designed for use in classifying health care providers according to provider type or practitioner specialty in an electronic environment, specifically within the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) health care transaction.

HIPAA requires that submitted data, which is part of a named code set, must be valid data from that code set. The health care provider taxonomy is a named code set in the 837 professional implementation guide, thus carriers must validate the inbound taxonomy codes against their internal HPTC tables.

Institutional provider Taxonomy code list

Institutional providers may submit a taxonomy code on claims they submit to Medicare. Medicare does not use the taxonomy code for matching a provider’s NPI to the appropriate legacy identifier. 

Medicare uses other claims data for this purpose. Medicare does not use the taxonomy code for any other claims processing purpose. Payers other than Medicare may have requirements for taxonomy codes. 

Medicare will pass any taxonomy code submitted on a Medicare claim to our trading partners on crossover claims, to allow for the possibility that those payers may use it.

If an institutional provider chooses to submit taxonomy codes, the following table supplies the crosswalk from Medicare’s legacy identifier (the OSCAR number) to the appropriate taxonomy code based on the provider’s facility type:

OSCAR Provider Type      SCAR Coding       Taxonomy Code

Short-term (General and Specialty) Hospitals    0001-0879 *Positions 3-6  282N00000X

Critical Access Hospitals   1300-1399 *       282NC0060X

Long-Term Care Hospitals 2000-2299 *      282E00000X

Hospital Based Renal Dialysis Facilities  2300-2499*     261QE0700X

Independent Renal Dialysis Facilities  2500-2899*               261QE0700X

Rehabilitation Hospitals   3025-3099 *        283X00000X

Children’s Hospitals       3300-3399 *        282NC2000X

Psychiatric Hospitals  4000-4499 *      283Q00000X

Organ Procurement Organization (OPO) P in third Position    335U00000X

Psychiatric Unit M or S in third Position     273R00000X

Rehabilitation Unit R or T in third Position     273Y00000X

Hospital Based Satellite Renal Dialysis Facilities 3500-3699

Type of Bill code 72X + 261QE0700X + different zip code than any renal dialysis facility issued an OSCAR that is located on that hospital’s campus

Swing-Bed Unit   U, W, Y, or Z in third Position

Type of Bill Code X8X (swing bed) with one of the following taxonomy codes to define the type of facility in which the swing bed is located

275N00000X if unit in a short-term hospital (U),

282E00000X if unit in a long-term care hospital (W), 

283X00000X if unit in a rehab facility (Y),

282NC0060X if unit in a critical access hospital (Z) 

PCP Office Lab List - covered list

85032 Blood count; manual cell count (erythrocyte leukocyte or platelet) each

85049 Blood count; platelet automated

85610 Prothrombin time

85651 Sedimentation rate, erythrocyte; non-automated

85730 Thromboplastin time, partial (PTT); plasma or whole blood

86308 Heterophile antbodies; screening

86403  Particle agglutination; screen, each antibody

86580 Skin test; tuberculosis, intradermal

86710 Antibody; influenza virus

87070 Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates

87081 Culture, presumptive, pathogenic organisms, screening only

87086 Culture, bacterial; quantitative colony count, urine

87088 Culture, bacterial; with isolation and presumptive identification of isolates, urine

87177 Ova and parasites, direct smears, concentration and identification

87205 Smear, primary source with interpretation, Gram or Giemsa stain for bacteria, fungi, or cell types

87210 Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)

87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies)

87400 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Influenza, A or B, each

87430 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Streptococcus, group A

87480 Infectious agent detection by nucleic acid (DNA or RNA); candida species, direct probe technique

87510 Infectious agent detection by nucleic acid (DNA or RNA); gardnerella vaginalis, direct probe

technique

87660 Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, direct probe technique

87802 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B

87803 Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A

87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza

87807  Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus

PCP Office Lab List - covered list

81000 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 -  Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

81002 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

81003 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

81005 - Urinalysis; qualitative or semiquantitative, except immunoassays

81025 Urine pregnancy test, by visual color comparison methods

82044 Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay)

82270-Blood, occult, by peroxidase activity (eg, guaiac); feces, 1-3 simultaneous determinations

82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources

82272 Blood, occult, byperoxidase activity, single specimen

82274 Blood, occult, byfecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations

82947 Glucose; quantitative, blood (except reagent strip)

82948 Glucose; blood, reagent strip

82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use

83036 Hem oglobin; glycosylated (Al C)

83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

83014 Helicobacterpylori; drug administration

84030 Phenylalanine (PKU), blood

Cost Sharing (Copayment)

Does Medicaid has copay or cost sharing ? How much Medicaid copay?

Cost Sharing (Copayment)

The copayment amount for physician office visit (including crossovers, and optometric) is $1.00 per visit. Copayment does not apply to services provided for pregnant women, nursing facility residents, recipients less than 18 years of age, emergencies, and family planning.

The provider may not deny services to any eligible Medicaid recipient because of the recipient’s inability to pay the cost-sharing (copayment) amount imposed.

Limitations on Services

How many visit Maximum per year - insurance allowed for office and ESRD

Limitations on Services

Within each calendar year each recipient is limited to no more than a total of 14 physician visits in offices, hospital outpatient settings, nursing facilities, rural health clinics or Federally Qualified Health Centers. Visits not counted under this benefit limit will include, but not be limited to, visits for: EPSDT, prenatal care, postnatal care, and family planning. Physicians services provided in a hospital outpatient setting that have been certified as an emergency do not count against the physician benefit limit of 14 per calendar year. If a patient receives ancillary services in a doctor's office, by the physician or under his/her direct supervision, and the doctor submits a claim only for the ancillary services but not for the office visit, then the services provided will not be counted as a visit.

Medical billing school

Medical billing school - Is it necessary or we can learn by our own

How to learn Medical billing and Medical coding. Is it required to go to the school or how can we learn?

Basically Medical coding which is difficult because we should know about medical terms to do this job hence going to this school is good option.

To obtain a career in medical billing, you do not have to take a course.  Coding and billing are different from one another.  Coding is linking a code to a diagnosis and cpt code.  Remember a diagnosis (or dx for short) is the code that describes what is wrong with a patient and the cpt code is the code that describes what is being done.  If you decide to become a coder then this is something that you should go to school for but billing is different.  A lot of people think medical billing and coding are the same thing but they aren't.

NEW DIAGNOSIS CODES

  

The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM

Diagnosis

Code                 Description

V15.53  Personal history of retained foreign body fully removed

V25.11  Encounter for insertion of intrauterine contraceptive device

V25.12  Encounter for removal of intrauterine contraceptive device

V25.13  Encounter for removal and reinsertion of intrauterine contraceptive device

V49.86  Do not resuscitate status

V49.87*                Physical restraints status

V62.85  Homicidal ideation

V85.41  Body Mass Index 40.0-44.9, adult

V85.42  Body Mass Index 45.0-49.9, adult

V85.43  Body Mass Index 50.0-59.9, adult

V85.44  Body Mass Index 60.0-69.9, adult

V85.45  Body Mass Index 70 and over, adult

V88.11  Acquired total absence of pancreas

V88.12  Acquired partial absence of pancreas

V90.01  Retained depleted uranium fragments

V90.09  Other retained radioactive fragments

V90.10  Retained metal fragments, unspecified

V90.11  Retained magnetic metal fragments

V90.12  Retained nonmagnetic metal fragments

V90.2     Retained plastic fragments

V90.31  Retained animal quills or spines

V90.32  Retained tooth

V90.33  Retained wood fragments

V90.39  Other retained organic fragments

V90.81  Retained glass fragments

V90.83  Retained stone or crystalline fragments

V90.89  Other specified retained foreign body

V90.9     Retained foreign body, unspecified material

NEW DIAGNOSIS CODES

The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM 

Diagnosis

Code            Description

786.30   Hemoptysis, unspecified

786.31   Acute idiopathic pulmonary hemorrhage in infants [AIPHI]

786.39   Other hemoptysis

787.60   Full incontinence of feces

787.61   Incomplete defecation

787.62   Fecal smearing

787.63   Fecal urgency

799.51   Attention or concentration deficit

799.52   Cognitive communication deficit

799.53   Visuospatial deficit

799.54   Psychomotor deficit

799.55   Frontal lobe and executive function deficit

799.59   Other signs and symptoms involving cognition

970.81   Poisoning by cocaine

970.89   Poisoning by other central nervous system stimulants

999.60   ABO incompatibility reaction, unspecified

999.61   ABO incompatibility with hemolytic transfusion reaction not specified as acute or

delayed

999.62   ABO incompatibility with acute hemolytic transfusion reaction

999.63   ABO incompatibility with delayed hemolytic transfusion reaction

999.69   Other ABO incompatibility reaction

999.70   Rh incompatibility reaction, unspecified

999.71   Rh incompatibility with hemolytic transfusion reaction not specified as acute or

delayed

999.72   Rh incompatibility with acute hemolytic transfusion reaction

999.73   Rh incompatibility with delayed hemolytic transfusion reaction

999.74   Other Rh incompatibility reaction

999.75   Non-ABO incompatibility reaction, unspecified

999.76   Non-ABO incompatibility with hemolytic transfusion reaction not specified as

acute or delayed