2016 Blue's Tour Presented by Blue Cross and Blue Shield of Kansas - PowerPoint PPT Presentation

2016 Blue's Tour Presented by Blue Cross and Blue Shield of Kansas

Today's Presenters • Sally Stevens – Provider Consultant, Southern Kansas • Cindy Garrison – Provider Consultant, Northern Kansas • Marie Burdiek – EDI Account Representative 2

Today's Agenda • Top Denials • General Billing • IV Therapy • Wound Therapy • 2017 Policies and Procedures • Quality Based Reimbursement Program (QBRP) • MAP'd Codes • EDI/ASK Updates 3

Top Denials 4

Top Denials ARC 97 – Corrected Claims $406,121,860.06 ARC 18 - Exact duplicate claim/service $170,523,994.71 5

Top Denials ARC A1 – Additional information is required to make a benefit determination $144,044,909.02 ARC 96 – This service is not listed as a covered service in the patient's contract $38,902,171.62 6

Top Denials ARC 23 – The Medicare payment is greater than or equal to the maximum allowable payment under the patient's contract $38,232,053.47 ARC 27 - Expenses incurred after coverage terminated $30,484,195.02 7

Top Denials ARC 32 – The patient was not eligible for benefits at the time the service was performed $29,219,773.55 ARC 31 - The claim was denied as the patient cannot be identified as our member. $20,767,189.62 8

Top Denials ARC A1/M81 – The claim needs to be coded to the highest level of specificity - laterality $19,174,255.60 9

Top Denials Reducing claim denials is a win for everyone! • Use Availity • Improve Administrative Expenses • Better Payment Turnaround 10

General Billing 11

General Billing • No Part B Medicare • Medicare Lifetime Reserve Days Exhausted • Telemedicine • ACA Preventive Services • Cancelled Surgeries and Attempted Surgeries • Take Home Drugs • Discarded Drugs • Swing Bed • Limited Patient Waiver 12

General Billing No Part B Medicare • If the member has no Part B Medicare, then benefits are carved out as if the member had Part B Medicare. • Medigap policies pay only the deductible and coinsurance not paid by Medicare. • The patient is responsible for what Part B Medicare would have paid. 13

General Billing Medicare Lifetime Reserved Days The following information is needed to process a claim when the Medicare lifetime reserve days have been exhausted: • Report BCBSKS as the primary payer • The inpatient claim should show a "from" service date as the first day after Medicare benefits are exhausted • Indicate in the Remarks (Form Locator 80) field the date that Medicare benefits were exhausted • Medicare Remittance (MSN) • Copy of the UB-04 Medicare Inquiry Screen (FISS system) • a copy of the Medicare MSN showing how the Part B services were considered (if applicable) • If the patient does not have Part B Medicare, then this information needs to be indicated in the Remarks field. • If a private room is to be covered in full, then provide the medical reason for the private room as reflected in the physician's order. 14

General Billing Telemedicine BCBSKS will provide reimbursement for originating site telemedicine services that meet established guidelines. Billing guidelines are: • Service must involve a physician's specialty that is not otherwise available in the community. This includes services provided by Mid-level Practitioner. • Telemedicine services for primary care are not covered nor should they be billed to BCBSKS. • Originating site telemedicine services meeting these guidelines should be billed to BCBSKS: Use the UB-04 billing format • Telemedicine services are billable only on outpatient claims. • Revenue code (either of the following): 1. 0780 – telemedicine general classification 2. The revenue code that identifies where the services were performed (i.e. 0450, 0510, 0761). • HCPCS Q3014, telehealth originating site facility fee (This HCPCS code must be used regardless of what revenue code is used). • Additional services provided during the telemedicine encounter (e.g. laboratory, x- rays, etc.) are separately billable. • Facilities cannot bill an originating site and destination site with either of the following conditions: 1. under the same Tax ID 2. on the same UB-04 bill 15

General Billing Preventive Services • Preventive diagnosis in the primary location on the UB- 04 claim form • If not possible or not correct coding, then it is OK to split the claim. Below is a link to the list of preventive services covered at no cost share http://www.bcbsks.com/CustomerService/Providers/Publicat ions/professional/manuals/pdf/preventive-services-guide.pdf 16

General Billing Preventive Services - Claim Example # 1 17

General Billing Preventive Services - Claim Example # 2 18

General Billing Cancelled Surgery and Attempted Surgery • Inpatient claims: Attempted surgery should be billed with revenue code 0229 and ICD-10-CM diagnosis codes Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8 or Z53.9. Hospitals must convert revenue code 0360 (operating room) to revenue code 0229 to avoid edits requiring ICD-10-PCS procedure codes. (When revenue code 0360 is on an inpatient claim, an ICD-10-PCS procedure code is required). • Outpatient claims should reflect the appropriate revenue code where the procedure occurred, 045X, 0360, 0761, 0760 etc., and the CPT code of the intended procedure . 19

General Billing Cancelled Surgery and Attempted Surgery 20

General Billing Take Home Drugs • BCBSKS' intent is to allow take home drugs under Revenue Code 250 provided the quantity given is not in lieu of providing a prescription for the drug. • If revenue code 0253 is submitted on a UB-04, the charge may be denied as the member's responsibility. 21

General Billing Discarded Drugs • Bill the units for the entire vial. • Do not split the lines for the amount used and the amount discarded. • Documentation of the drug amounts used and discarded must be in the medical record. 22

General Billing Swing Bed • Patient is discharged from acute to skilled care • Documentation should clearly reflected the change from acute to swing bed in the medical record. • If it is a direct admission to swing bed/skilled care, this must be reflected in the medical record as well. • Swing bed/skilled admissions must be prior approved by the BCBSKS medical review staff. 23

General Billing Billing for Swing Bed or SNF Provider submits 2 separate claims: If the patient has skilled benefits and the skilled admission is prior approved, the provider will submit the charges for the entire stay (room and board pus all ancillaries) using your skilled provider number. Claim #1: Provider Number Acute Number Type of Bill 111 Date of Service 02/01/16 – 02/08/16 # of covered days 7 Include in charge R&B plus ancillaries Claim #2 : Provider Number Skilled Number Type of Bill 18X for swing bed; 2X for SNF Date of Service 02/08/16 – 02/16/16 # of covered days 8 Include in charge R&B plus ancillaries 24

General Billing Billing for Swing Bed or SNF Provider submits 3 separate claims: If the patient does not have skilled benefits or the stay is not approved, the provider must give the patient an LPW prior to the service in order to bill them for the non- covered room and board charges. Claim #1: Provider Number Acute Number Type of Bill 111 Date of Service 02/01/16 – 02/08/16 # of covered days 7 Include in charge R&B plus ancillaries 25

General Billing Billing for Swing Bed or SNF Provider submits 3 separate claims (continued): Claim #2: Provider Number Skilled Number Type of Bill 18X for swing bed; 2X for SNF Date of Service 02/08/16 – 02/16/16 # of Days 8 non-covered Include in charge R&B only Claim #3: Provider Number Acute Number Type of Bill 131 Date of Service 02/08/16 – 02/16/16 # of Days Not applicable Include in charge Ancillary only 26

General Billing Limited Patient Waiver (LPW) Some providers have their own waivers and they may or may not meet BCBSKS requirements. If providers want to use their own waiver form, then BCBSKS recommends that you have your BCBSKS Institutional Provider Consultant review your waiver form to confirm that it includes everything that is included on the BCBSKS Limited Patient Waiver (LPW). • Submit an electronic claim with a GA modifier appended to the CPT/HCPCS code. • The waiver is retained in the patient's file. • By obtaining a signed LPW, the not medically necessary, experimental or investigational charges are denied as the patient’s responsibility 27

IV Therapy 28

IV Therapy IV Therapy and Injection Billing When billing for the administration of drugs: • The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. • Infusions are primary to pushes, which are primary to injections. • This hierarchy does not apply to physician reporting. 29

IV Therapy Not Separately Reportable • Use of local anesthesia • IV start • Access to indwelling IV, subcutaneous catheter or port • Flush at conclusion of infusion • Standard tubing, syringes and supplies • If there are orders to hydrate prior to chemotherapy administration, hydration may be reported separately as long as it is not concurrent to chemotherapy. 30