Utilization Management Appeals - bcbs

A Utilization Management (UM) Appeal is defined as a written request from a provider to review a claim that required an authorization or precertification affecting a claim’s payment. This does not include provider appeals of pre-service determinations (unless required under ERISA), claims status requests, telephone inquiries or post-service claims review regarding the application of benefits or allowed amounts.

UM appeals must be filed pursuant to the timeliness requirements of the applicable Agreement with BCBSF or within five years from payment date. BCBSF will not overturn administrative claim denials based on the provider’s failure to comply with required procedures and time frames. UM appeals should be sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).

• A copy of the remittance advice.

• The necessary medical documentation (e.g., operative report, physician orders, etc.) as indicated by the reason for the reduction or the denial on the remittance advice.

RECEIVED DENIAL AS NON-PAR THOUGH THE PROVIDER WAS ENROLLED

DESCRIPTION OF THE ISSUE

Provider’s TIN# was linked with the individual provider name but it should be linked with the Group name as Prime Hospitalists Group.  So the claims that were filed with individual name was processed under Out of network.

CONCEPT

Provider’s TIN# should be linked to the Group of Prime Hospitalists Group.

REASON

We tested few sample claims under individual provider name and they were also processed as Out-of-network.  Upon analyzes found provider’s TIN# linked to individual name instead of linkage with the Group name.  On reaching Provider Relations Dept, requested us to allow 30 business days to have the correct information updated in their records.  Later on the filed claims were processed under Fee-for-service reimbursements.

Billing Dispute External Review Process

The Billing Dispute External Review Process (BDERP) will provide for a Billing Dispute External Reviewer

(BDER), to resolve disputes with physicians and physician groups arising from covered services provided

to BCBSF’s members by such physicians and/or physician groups concerning:

• For Coding and Payment Rule appeals finally adjudicated on or after August 21, 2008, BCBSF’s application of BCBSF’s coding and payment rules and methodologies for covered fee for service

claims (including any bundling, downcoding, application of a CPT modifier, and/or other reassignment of a code by BCBSF) to patient specific factual situations, including without limitation the appropriate  payment when two or more CPT codes are billed together, or whether a payment enhancing modifier is appropriate. All such Billing Disputes must be submitted to the BDER no more than 90 calendar days after a physician or physician group exhausts the internal appeal process, except the parties have agreed that for appeals finally adjudicated after August 21, 2008 and before November 21, 2008, the date the BDERP will start accepting claims, the physicians and physician groups will have until December 20, 2008 to submit their eligible billing disputes. For calculation purposes, the start date will be the date on the appeal letter and the ending date will be when a Billing Dispute is received by the BDER.

ESPDT CODE UPDATS FOR PHYSICIAN EXAMINATION SERVICES

DESCRIPTION OF THE ISSUE

We haven’t filed claims with N and NU ESPDT codes for physical examination procedures.  Hence we received denial stating “Invalid/need referral check codes”

CONCEPT

For Physical examination codes (99381-99395) we must enter Child Check up code “N” and its valid referral code “NU” in EPSDT fields for Medicaid insurance.

SOLUTION

Based on the denials received from Medicaid, we scrutinized the reason for the given denials and found per Medicaid rules to file Physical Examination codes along with N and NU ESPDT codes to have the claims reimbursed.  Hence the claims were refiled with the same and got reimbursement on the same.  Henceforth the rule was set towards the Charge entry executives file these procedures with ESPDT codes for Medicaid without fail.

DENIAL OF NEW BORN PATIENT SERVICES UNDER HOSPITAL CHARGES

DESCRIPTION OF THE ISSUE

Medicaid does not accept new born services filed with Parent’s Medicaid ID.  Claims were denied for request of exact patient’s Medicaid ID.

CONCEPT

Medicaid requests patient’s parent to get registered for the new born under Medicaid.  In such case a temporary Medicaid recipient number would be generated for the new borns.  On receiving this temporary#, we need to file MCD claims of the newborns with the same for reimbursement.

REASON

Parents of the Newborns does not respond properly for the Medicaid’s request.  This was also initiated to Dr’s office where even the provider could not help us in retrieving exact Medicaid details of the New born patients.  We also tried to get information from the hospitals but per their records, they do hold only parents’ info.

BCBS Coding and Payment Rule Appeals

Coding and Payment Rule Appeals

A Coding and Payment Rule Appeal is a written request from a licensed health care practitioner for

reconsideration of a health care claim based on BCBSF’s application of its coding and payment rules and

methodologies (including without limitation any bundling, downcoding, application of a CPT modifier,

and/or other reassignment of a code by BCBSF). These appeals apply to claims filed by M.D.s and D.O.s

in connection with health care services rendered to a specific individual covered under a policy or plan

insured or administered by BCBSF. A Coding and Payment Rule Appeal does not refer to pre-service

review, concurrent review, claim status requests, and other types of provider communication, such as

telephone inquiries.

Claims processed after the implementation date, regardless of service date(s), will process according to

the updated version. No retrospective claim payment changes are made for processing changes that are

the result of new code editing rules.

DX V61.20 WHEN BILLED WITH OTHER DX WAS DENIED BY MCD & ITS HMOs

DESCRIPTION OF THE ISSUE

While filing V61.20 Dx codes either as primary, secondary or tertiary claims were denied for “Invalid Dx under provider’s contract”.   We are not suppose to file Dx V61.20. for this provider towards MCD and its HMOs

CONCEPT

Provider should renew his contract to get reimbursed for the claims filed with Dx V61.20 since the provider is not in contract to perform the same.

SOLUTION

On receiving denials from the carrier we started omitting DX V61.20 and refiled the claims with the other available DX codes.  This enabled reimbursement of claims.  Hence forth we Charge entry executives were instructed to avoid filing Dx V61.20. for Medicaid and its HMO claims.

When provider can appeal and four type of appeal

Provider Appeals

Providers may request reconsideration of how a claim processed, paid or denied. These requests are

referred to as appeals.

There are four different types of appeals:

• Coding and Payment Rule Appeals

• Utilization Management Appeals

• Adverse Determination Appeals

• All Others

REJECTION OF WHOLE CLAIMS WITH J CODES FOR NDC# UPDATE

cpt code - j7613, j7609

DESCRIPTION OF THE ISSUE

Claims filed without or incorrect NDC#s, MCD HMO carriers (Staywell/Health Ease) rejected entire claim for NDC# updates, instead of processing denial only for J Codes.

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

SOLUTION

Carriers’ database setup has been modified to reject the entire claim when filed with J Code without/Incorrect NDC#s, instead of processing denial only for the J Code.  So we segregated J code as a separate claim.  This enhanced payment for rest of the CPTs and the J code alone was denied for need of NDC#.

Surgical Co-Management (Modifiers 54 and 55)

Medicare covers surgical co-management for appropriate reasons such as inability of the operating surgeon to provide postoperative care, inability of the patient to return to see the operating surgeon in the postoperative period for a variety of reasons or patient preference. For example, one physician may perform the surgery, but another physician may provide the follow-up care. Medicare will pay no more than the total fee schedule approved amount for the surgical procedure regardless of the number of physicians involved. Co-managed care should always adhere to the basic tenets of good patient care, the ethical responsibilities of providers and governmental rules.

When physicians agree on the transfer of care during the global period, use the following modifiers:

* 54 for surgical care only.

Or,

* 55 for postoperative management only.

Providers do not need to specify on the claim that the care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. (Pub. 100-4, Chapter 12, Section 40.2 of the Internet-Only Manual (IOM)).

When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he assumes care of the patient.

NDC# REQUEST FOR INJECTION CODES BY MEDICAID AND ITS HMOs

AFFECTED CPTs - J7613, J7626,J2405, J0696

DESCRIPTION OF THE ISSUE

Medicaid and MCD HMOs denied all injection codes for need of NDC# update.

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

REASON

Compiled list of injection codes that were denied for NDC# update towards Dr’s office, for which we received NDC# information from the provider.  Later we refiled all denied claims with NDC#.  But the still the claims got denied for invalid/missing NDC#.  Hence we analyzes on the NDC# update is still going on.

PAYMENTS FROM THE CARRIER SENT TO OLD BILLING ADDRESS

DESCRIPTION OF THE ISSUE

Insurances that does not pertain EFT option, processed all the provider’s payments towards Old Billing Company of Dr. .  Initially they scanned few EOBs towards Dr’s office and they were again scanned to us for payment posting process. 

CONCEPT

All the payments of any provider should be linked directly to the Provider’s address and not to any Billing Company.

SOLUTION

On facing this issue, we started circulating correct and newly updated W9 form of the provider towards all the carriers to have payments processed to correct payor address

Determing global period days for CPT - surgical procedure

Determining the Duration of a Global Period

To determine the global period for major surgeries, count one day immediately before the day of surgery, the day of surgery and the 90 days immediately following the day of surgery.

Example:

Date of surgery – January 5.

Preoperative period – January 4.

Last day of postoperative period – April 5.

To determine the global period for minor procedures, count the day of surgery and the appropriate number of days immediately following the date of surgery.

Example:

Procedure with 10 follow-up days:

o Date of surgery – January 5.

o Last day of postoperative period – January 15.

Billing Guidelines

The following table outlines the services included in the global surgical package:

Preoperative Visits

Preoperative visits begin with the day before the surgery for major procedures and the day of the surgery for minor procedures. The global package of care includes all visits related to the surgery, in or out of the hospital, on the day of the surgery.

Intraoperative Services

These are services that are normally a usual and necessary part of the surgical procedure.

Complications Following Services

These include all additional medical or surgical services required of the surgeon during the postoperative period of the surgery due to complications that do not require additional trips to the operating room.

Postoperative Visits

These are follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.

Postsurgical Pain Management by the Surgeon

Miscellaneous Services

These services include items such as dressing changes, local incision care and removal of operative pack. Removal of cutaneous sutures, staples, lines, wires, tubes, drains, casts and splints. Insertion irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes, and changes and removal of tracheostomy tubes.

Supplies : Except for those identified as exclusions.

Definition of a Global Surgical Package

Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.

Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies.

Codes with “YYY” are carrier-priced codes, for which carriers determine the global period (the global period for these codes will be 0, 10, or 90 days). Note that not all carrier-priced codes have a “YYY” global surgical indicator; sometimes the global period is specified.

While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.

Surgeons and Global Surgery

A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all carrier jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than intended. The national global surgery policy became effective for surgeries performed on and after January 1, 1992.

The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians. In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.

In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries.

Minor Surgeries and Endoscopies during global surgery period - would get paid?

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.

A. Procedure Codes and Modifiers

Use of the modifiers in this section apply to both major procedures with a 90-day postoperative period and minor procedures with a 10-day postoperative period (and/or a zero day postoperative period in the case of modifiers “-22” and “-25”).

Applying for CLIA certificate

How to Apply for a Certificate of Waiver.

PART I: GENERAL INFORMATION For a new application, leave the CLIA identification number blank. The number will be assigned when the application is processed. Be specific when indicating the name of your facility, particularly when it is a component of a larger entity, for example The Diabetes Clinic in XYZ Hospital. For a physician’s office, you can use the name of the physician. The information provided is the name that will appear on your certificate. The Director should be the individual who is responsible for testing

operations.

Facility street address must be the actual physical location where testing is performed, including floor, suite and/ or room, if applicable. DO NOT USE A POST OFFICE BOX NUMBER OR A MAIL DROP ADDRESS FOR THE NUMBER AND STREET OF THE ADDRESS. If the laboratory has a separate mailing or billing address, complete that section of the application.

PART II: TYPE OF CERTIFICATE REQUESTED: Check “Certificate of Waiver”

PART III: TYPE OF LABORATORY:  Select the type of laboratory designation that is most appropriate for your facility from the list provided. If you cannot find your designation within the list, contact your State agency for assistance.

PART IV: HOURS OF LABORATORY TESTING: Provide only the times when actual laboratory testing is performed in your facility.

PART V: MULTIPLE SITES: Only hospitals or government labs are allowed to have multiple sites. You can only qualify for the multiple site provision (more than one site under one certificate) if you meet one of the CLIA regulatory exceptions outlined on the form. In general, each testing site must have an individual Certificate of Waiver unless it is a mobile lab or all are located on the same hospital campus.

inpatient consultation codes - 99241 - 99275

Consultations Codes - 99241-99275

4.4.1. Inpatient Consults

An initial or follow-up consultation visit occurs each time a provider, from other than the attending clinic service, provides advice/services/treatment to an inpatient on the hospital unit or ward (inpatient visit) but does not assume responsibility for medical control of the condition.

Follow current procedures for capturing consultation to inpatients, using the outpatient appointment type “walk-in.”  When prompted, “Is this Clinic Visit RELATED to Inpatient Episode of Care?” answer the question, “No.”  This will ensure credit is given to the appropriate B MEPRS code for services rendered.

CLIA Certificate of Waiver - Who can apply for certificate

Securing a CLIA Certificate of Waiver

The Metrika A1cNow is classified as a CLIA Waived Category test by the FDA. A CLIA certificate is required any time a clinical laboratory test is performed; however, waived category tests require only a CLIA Certificate of Waiver. Certificate of Waiver labs must register with Medicare, pay a $150.00 fee every two years and agree to follow manufacture’s instructions. No inspections or other CLIA regulations apply.

Who Can Apply for a Certificate of Waiver.

Anyone can apply for a Certificate of Waiver unless your state has imposed additional restrictions. Under CLIA, there are no personnel qualifications for the Laboratory Director or individuals who perform waived tests. 

For example, Pharmacists may be granted a Certificate of Waiver in all states except NY and PA. However, a number of states require them to comply with additional requirements (AL, AZ, FL, ME, MD. MA, NJ, OR, TN and RI). Always check with your State Agency if the Director for the Certificate of Waiver laboratory is not an MD or other licensed health care provider.

To apply for a Certificate of Waiver, go to the internet at www.hcfa.gov/medicaid/clia and download a CLIA application form (HCFA-116) and follow the instructions provided, or complete the attached application form and send it to the appropriate state agency. A list of State Agency addresses is attached and is also available on the internet at www.hcfa.gov/medicaid/clia/saaddres.

Type of CLIA certificate

CLIA Certificates 

Five types of certificates may be issued to providers, who perform waived, moderate, or high complexity tests and procedures: 

Certificate of waiver – Issued to a laboratory to perform only waived tests (i.e., simple examinations or procedures that use methodologies that are so simple and accurate that the likelihood of erroneous results is negligible and poses no reasonable risk of harm to the patient if the test is performed incorrectly). 

Certificate for Provider-Performed Microscopy Procedures (PPMP) – Issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedure (a procedure categorized as moderately complex where the primary instrument for per- forming the test is a microscope). This certificate permits the laboratory to also perform waived tests. 

Certificate of registration – Issued to a laboratory that enables the entity to conduct moderate or high complexity laboratory testing or both until the entity is determined by survey to be in compliance with the CLIA regulations. 

Certificate of compliance – Issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements. 

Certificate of accreditation – Issued to a laboratory on the basis of the laboratory ’ s accreditation organization approved by CMS.

What is CLIA number

Clinical Laboratory Improvement Amendments 

The Clinical Laboratory Improvement Amendments (CLIA), passed by Congress in 1988, established quality standards for all laboratory testing. CLIA ensures the accuracy, reliability, and timeliness of patient test results, wherever a test is performed. 

A laboratory is defined as any facility that performs laboratory testing on specimens derived from humans for the purpose of providing information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health. CLIA is user-fee funded; therefore, all costs of administering the program are covered by the regulated facilities. 

CLIA standards are national and are not Medicare-exclusive. CLIA applies to all providers rendering clinical laboratory and certain other diagnostic services, whether or not claims are filed to Medicare.

CLIA Quality Standards 

CLIA defines quality standards for proficiency testing (PT), patient test management, quality control, personnel qualifications, and quality assurance, as well as specific cytology provisions. 

The Centers for Medicare & Medicaid Services (CMS) administers CLIA, including laboratory registration, fee collection, surveys, surveyor guidelines and training, enforcement, approvals of PT providers, accrediting organizations, and exempt states. The Centers for Disease Control and Prevention (CDC) are responsible for test categorization and CLIA studies.

CLIA Number 

Upon certification, each laboratory is assigned an individual and unique CLIA number. Each CLIA number consists of ten alphanumeric positions. The CLIA number must be on all claims for laboratory services, or the claim will be returned as un- processable. The CLIA number must be entered in block 23 of Form CMS-1500 or the applicable electronic field.

CLIA approved CPT lab code list

CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level. 

The Current Procedural Terminology (CPT) codes that the Centers for Medicare & Medicaid (CMS) considers to be laboratory tests under CLIA (and thus requiring certification) change each year. Make sure your billing staffs are aware of these changes.

Listed below are the latest tests approved by the FDA as waived tests under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test.

CPT Code Effective Date Description

G0434QW from August 21, 2015 to December 31, 2015 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card

G0477QW on and after January 1, 2016 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card

G0477QW March 8, 2016 Tanner Scientific Multi-Panel Drug Test Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Easy Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Split Key Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Cassette

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Dip Card

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Easy Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Split Key Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Cassette

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Dip Card

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Easy Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Split Key Cup

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Cassette

G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Dip Card

87338QW March 22, 2016 Meridian Bioscience Immunocard STAT! HpSA (Stool)

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Dip Card

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Quick Cup

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Strip

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Turn-Key Split Cup

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Dip Card

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Quick Cup

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Strip

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine TurnKey Split Cup

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Dip Card

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Quick Cup

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine  Strip

G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Turn-Key Split Cup

G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Pane Drug Screen Cup Tests

G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Panel Drug Screen Cup with OPI 2000 Tests

The new waived complexity code 87338QW [Qualitative or semiquantitative detection test for helicobacter pylori in stool, multiple-step method] was assigned for the detection of Helicobacter pylori antigens in stool performed using the Meridian Bioscience Immunocard STAT! HpSA (Stool) test

Pre-operative Consultation CPT 99241, 99275 - v72.81 , 336.13

Pre-operative Consultation

The appropriate consultation code (99241-99275) may be reported for a preoperative consultation performed by any provider, to include a patient’s primary care provider, at the request of a surgeon, as long as all the consultation requirements are met and the service is medically necessary.  

In reporting the diagnosis, it is important to remember that the role of each code is to explain why a service was provided.  In reporting “preoperative clearance” the first diagnosis code used would be the code for preoperative examination (e.g., V72.81 throughV72.84).  

Additional ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation should also be documented and reported.  This underlying condition determines the medical necessity for the “preoperative clearance.”  Other diagnoses and conditions affecting the patient may also be documented and reported if appropriate.

Example:

V72.81        Pre-operative cardiovascular examination 

336.13        Anterior subcapsular polar senile cataract – Reason for the patient’s surgery

401.1        Essential hypertension benign – Underlying condition – why medical clearance was needed.

CPT code 99241, 99245 - Emergency department consultation code

Emergency Department Consultations

•    A separate encounter will be created when the emergency department physician requests a consultation.  

•    Use codes 99241 - 99245 to document consultant services when the consultant is called to the Emergency Department to render a consultation at the request of the emergency department.  

•    The consultant will report his work in his specialty MEPRS clinic.  The level of consultation is based on the documentation contained within the medical record.  Documenting the problem(s) to be evaluated by the consultation establishes the medical necessity for the consultation.  The specialist will evaluate the patient and provide separate written documentation furnishing recommendations on the patient’s care.

•    See also Emergency Department referral in the E&M chapter. 

Inpatient consultation codes - 99241 - 99275

Consultations Codes - 99241-99275

Inpatient Consults

An initial or follow-up consultation visit occurs each time a provider, from other than the attending clinic service, provides advice/services/treatment to an inpatient on the hospital unit or ward (inpatient visit) but does not assume responsibility for medical control of the condition.

Follow current procedures for capturing consultation to inpatients, using the outpatient appointment type “walk-in.”  When prompted, “Is this Clinic Visit RELATED to Inpatient Episode of Care?” answer the question, “No.”  This will ensure credit is given to the appropriate B MEPRS code for services rendered. 

Can consultation can be more than one visit

A consultation may be more than one visit. 

 A consultation continues until definite diagnosis is made and treatment begins.

Example:  An orthopedic consultant evaluates a patient with knee pain.  The consultant does not develop a diagnosis and recommends conservative treatment.  There is no improvement with the treatment.  During the next visit (coded as a consult as there is still no definitive diagnosis), a decision for an arthroscopy is reached due to the continued pain (still no definitive diagnosis).  The arthroscopy is completed with shaved plicae.  Any future visits for this problem will be coded as office visits, as there are both a diagnosis and treatment.

Billing NPI and Group NPI - provider number update from Medicaid

Starting in April 2011, electronic Florida Medicaid claims must be submitted with only an NPIin the billing/pay-to provider and the rendering/treating provider loops for providers who are required to obtain an NPI.  Electronic claims that include a Medicaid provider number in these loops will deny as of April 1, 2011.

Some providers are submitting electronic claims with both the Medicaid ID and the NPI on the claim, in the billing/pay-to provider loop and/or the treating/rendering provider loop.  In some cases, the Medicaid ID and NPI being submitted by providers do not match the identifiers that are on the provider’s Medicaid provider file, which will cause problems with claim adjudication when the April 1 changes requiring only an NPI go into effect.  Claims may deny or process for an incorrect provider if the NPI is not associated with the correct Medicaid ID.

To assist providers, claims that are being submitted with mismatched provider numbers in the billing/pay-to provider loop and/or the treating/rendering provider loop are posting the Explanation of Benefits (EOB) 1087, Adjustment Reason Code 208, and Remark Code N521 on paid claims with this problem.  If your paid claims do not post these explanations, stop sending the Medicaid ID on electronic transactions now.  The absence of these explanation codes is an indication that the data you are submitting on claims matches the data on the Medicaid provider file and that your claims will process correctly with only the NPI in these loops.

Rendering NPI vs Billing NPI

What is Rendering NPI and where it will get printed?

If the practitioner rendering the service is part of a billing group, the individual practitioner’s National Provider Identifier (NPI) should be reported in the Rendering Physician # area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

• Note: If you submit claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J. No information should appear in the upper, shaded portion of Item 24J, as your claim will be returned to you as unprocessable.

• The NPI is required for all rendering providers. If the NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in the upper, shaded portion of Item 24J), your claims will be returned as unprocessable.

What is Billing NPI and where it will get printed?

The billing entity’s National Provider Identifier (NPI) should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form. Do not place any information in the 837P 2010AA loop, REF02 (item 33b of the paper form), as it is no longer used.

Important note: The NPI of the billing provider is required on all claims. Claims will be returned as unprocessable if:

• Any information appears in the 837P 2010AA loop, REF02 (item 33b of the paper form). This item should be left blank.

• The billing provider’s NPI is missing, invalid, or is located in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner’s NPI must be reported in the Rendering Physician’s area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. 

If billing services for an Independent Lab, Ambulatory Surgical Center (ASC), Independent Diagnostic Testing Facility (IDTF), Ambulance Supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required.

When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

When do I need to report a rendering provider on my claim?

If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim.

On Electronic EMC form

837P Segment/ Data Element 837P Data Element 837P Location/Loop 

Rendering Provider NPI

 Rendering Provider NPI (Service Line Level) Loop 2420A, NM 109 (NM108 = XX)

 Rendering Provider NPI (Claim Level)   Loop 2310B, NM109 (NM108=XX)

Billing Provider NPI Billing Provider NPI Loop 2010AA, NM109 (NM108=XX)

Billing Provider TIN Billing Provider TIN Loop 2010AA, REF02 (REF01=EI)

Billing Health Care Provider Taxonomy Health Care Provider Taxonomy Code Loop 2000A, PRV03 (PRV01=BI)

On UB 04 FORM

The claim level Rendering Provider (Loop ID 2310D) is required when the Rendering Provider is different than the Attending Provider. For Medicare purposes this is required under federal regulatory requirements that call for a “combined claim”, that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics). 

The line level Rendering Provider is required when the Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). Again, for Medicare purposes this is required under federal regulatory requirements that call for a “combined claim,” that is, a claim that includes both facility and professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural Health Clinics*).

• Place the line item Rendering Physician National Provider Identifier (NPI) in Form Locator 43 (Revenue Code Description) for the line item that contains the services identified.

Do providers need Type 1 (Individual) and Type 2 (Organizational) NPIs?

A. All eligible individual providers (such as physicians, nurses, chiropractors, and physical therapists) are required to obtain a Type 1 (Individual) NPI. Providers who are in a solo practice and who bill currently with their Social Security Number or sole proprietorship Tax ID number may continue to bill as solo practitioners using only their Type 1 NPI. Per the regulation, individuals who have incorporated their practice must also obtain an organizational Type 2 NPI for their corporation. When billing, the individual Type 1 NPI will  be used to identify the provider who performed the service, while the organizational Type 2 NPI will identify the group or entity to be paid.

Individual health care providers who are part of an incorporated group practice will have an individual Type 1 NPI; the practice or clinic must obtain an organizational Type 2 NPI for the group for claims submission purposes.

Large corporations may have many groups working under a shared Tax ID number as DBAs. Since each DBA has its own BCBSIL billing number, each DBA may consider obtaining and using its own Type 2 NPI to maintain the one-to-one relationship.

Can a group of individual providers who are sharing an office space obtain one Type 1 NPI for all the individual practitioners to share?

A. No. An Individual Type 1 NPI cannot be shared. Each individual health care provider that may render health care services must obtain their own Individual Type 1 NPI. The Type 1 NPI of the rendering provider who performs the service is reported on claims, in addition to the appropriate billing NPI.

If my professional group practice has an Organizational (Type 2) NPI, in addition to my Individual (Type 1) NPI, which NPI number do I submit on claims?

A: To correctly submit 837 Professional Health Care Claims to BCBSIL, the sender’s billing and pay-to provider information must be included in the correct loops. The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the referring provider information must be contained in loop 2310A, and the rendering provider information must be contained in loop 2310B. To correctly submit 837 Institutional Health Care Claims to BCBSIL, the billing, pay-to provider, attending physician name, operating physician name, service facility name, and other provider name must be included in the correct loops. 

The billing provider’s information must be contained in loop 2010AA, the pay-to provider information must be contained in loop 2010AB, the attending physician name must be contained in loop 2310A, the operating physician name must be contained in loop 2310B, the other provider name must be contained in loop 2310C, and the service facility name must be contained in loop 2310E

IMPORTANT NPI BILLING INFORMATION:

Do not put the rendering provider NPI in the billing loop of the claim. Rendering information must go in the rendering loop and billing information must go in the billing loop. Claims will be rejected if billed incorrectly. 

Q. Where do I include my NPI on the CMS-1500?

A. The following fields are used for entry of the NPI:

Field 17b: Enter the NPI of the referring, ordering, or supervising provider.

Field 24j (unshaded): Enter the NPI of the rendering provider.

Field 32a: Enter the NPI number of the service facility location.

Field 33a: Enter the NPI number of the billing provider.

NOTE: As of May 23, 2008, the use of only the NPI is required on all claims—claims that include the BCBSIL provider number will be rejected

Filing Claims with NPIs

Your NPI is used for claims processing and internal reporting. Claim payments are reported to the Internal Revenue Service (IRS) using your tax identification number (TIN). To appropriately indicate your NPI and TIN on UB-04 and CMS 1500 claim forms, follow the corresponding instructions for each form included in this manual. Remember, claims processing cannot be guaranteed if you have not notified Blue Cross of your NPI, by using one of the methods above, prior to filing claims. See the first part of this section for more details on how to submit claims to Blue Cross.

For more information, including whom should apply for an NPI and how to obtain your NPI, visit our website or CMS’ site at  www.cms.hhs.gov/NationalProvIdentStand. If you have any questions about the NPI relating to your Blue Cross participation, please contact us at 1-800-716-2299, option 3.

Referring Physician NPIs

Referring physician NPIs are required on all applicable claims filed with Blue Cross and HMO Louisiana. Place the NPI in the indicated blocks of the referenced claim forms:

• CMS -1500: Block 17a

• UB-04: Block 78

• 837P: 2310A loop, using the NM1 segment ad the qualifier of DN in the NM101 element

• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element

For more information on NPIs, visit www.bcbsla.com/providers >NPI.