ACS & HIPAA: PROVIDER BILLING CHANGES · 2016. 7. 26. · W8005 Per month Per month Unit Type Targeted Case management Non waiver DD child assessment W8001 T2023 HA Targeted Case

ACS & HIPAA: PROVIDER ACS & HIPAA: PROVIDER BILLING CHANGESBILLING CHANGES

ShereeSheree Howell and Sara WalkHowell and Sara WalkACS Field RepresentativesACS Field Representatives

July 28July 28th,th, 2929thth, and 30, and 30thth, 2003, 2003

What’s NewWhat’s New

! ACS will have thirtydays to key a claim,

rather than the current four days.

! Nursing Homes and DD waiver providers

are required to bill electronically

EqualityCare WebsiteEqualityCare Website

! Effective 09/29/03,you will not be able to access your RA’s from the EqualityCare Website.

Fee SchedulesFee Schedules

! There will be two fee schedules available to providers containing CPT codes and HCPCS codes. This is so ACS will be able to update the EqualityCare Website more timely.

Accepted Claim FormsAccepted Claim Forms

! CMS 1500- Professional (previously called HCFA 1500)

! UB02- Institutional (previously called UB92)

! ADA 2002 (dental)! Universal pharmacy claim

form

NotNot Accepted Claim FormsAccepted Claim Forms

! ACS will no longer accept the waiver claim forms, the transportation claim form, the LTC Screening claim form, or the Nursing Home TAD form, after September 28, 2003.

What Forms to Use For What What Forms to Use For What ServicesServices

! Nursing Facilities- will bill on the UB02

! For LT101, screening or evaluation of PASARR Level II- will bill on the CMS 1500

! Federally Qualified Healthcare Centers- will bill on the UB02

What Forms to Use For What What Forms to Use For What ServicesServices

! Rural Health Clinics- will bill on the UB02

! Waiver and Transportation providers- will bill on the CMS 1500

! Indian Health Services-will bill on the UB02

Attachments to ClaimsAttachments to Claims

! Providers will be able to submit electronic claims with paper attachments. ACS will institute a process to match electronic claims with the appropriate paper attachment. Please see next slide.

W yom ing EqualityC are Program

A ttac hm ent C o ntro l N um be r – F or O ff ic e Use O nly

P rovider Nam e _______________________________________________________________ P ay-to -P rovider N um ber R ecipient N am e __ __ __________ __ __ ________ _______ __ __________ __ __ ___ __ __________ __ __ R ecipient State ID N um ber D ate o f Service (M M D DY Y ) T ype o f D ocum ent – One m ust be checked

" A – A m bu la nc e T rip R e po rt " C – C o nsent F orm (A bo rt ion, H yste rec to my, S te riliza tio n) " H – H o spice P ha rm ac y W a iv er " I – Inv o ice " M – M e dica re EO M B " P – P rio r A utho riza tio n F o rm a nd/o r D oc um e nta tio n " R – M e dica l R eports (Su rg ery , ER , A nesthe sia , e tc .) " S – S w ing B ed Exem ptio n L e tte r " T – Th ird P arty L ia b ility D oc um e nta tion (E OB ’s, D e nia l L etters, Le tte rs a ttem pting to co llec t)

Claim Attachment Control Document

Please use this form when submitting a claim electronically which requires an attachment. The attachment can besubmitted on paper along with this form. If this form is not attached to your documentation, your request CANNOT beprocessed.

RETURN THIS DOCUMENT WITH ATTACHMENTS TO: ACS State Healthcare

P.O. Box 547 Cheyenne, WY 82003

DD/LTC Waiver InformationDD/LTC Waiver Information! LTC and DD Waiver

Providers: After September 29, 2003, the Prior Authorizations will contain HCPCS codes, rather than local codes.

! DD Providers: The PA’s will be terminated as of August 31, 2003, and new PA’s will begin on September 1, 2003.

! The new PA’s will be mailed in the middle of September.

Medicare CrossoversMedicare Crossovers

! ACS will receive Medicare crossover claims in X12 837 directly from Medicare contractors. This includes part A and B claims. ACS will receive paid and denied claims as Medicare crossovers.

TPLTPL! Providers need not make any changes to

current practices on claims where Medicaid is a secondary payer behind Blue Cross Blue Shield, Worker’s Compensation or another third party payer (other than Medicare). Providers will continue to be responsible for submitting claims to other payers.

AdjustmentsAdjustments

! If the claim was billed on paper, the adjustment will be done on paper.

! If the claim was sent electronically, the adjustment will be done electronically in the X12 837 format.

Remittance AdvicesRemittance Advices! Providers will continue to receive paper

Remittance Advices with the specific explanation of benefit (EOB) codes. These will not change.

! Providers will be able to to receive electronic Remittance Advices in the X12 835 format. These will show the standard claim adjustment reason and payment remark codes. Providers will be required to enroll in order to receive an 835 transaction

Prior AuthorizationPrior Authorization! Paper process- provider can request PA by mail,

fax, or receive a pending PA by phone. Provider will receive pending, denied, or approved PA on paper.

! Electronic- X12 278 format- provider can request PA electronically, they will receive response electronically in X12 278 format.

! Web Portal- providers will be able to transmit PA requests via the Internet. More details will be available at a later date.

Provider ManualsProvider Manuals

! Providers will receive new billing manuals in August. They will also be available on our website, wyequalitycare.acs-inc.com.

DD/LTC Waiver InformationDD/LTC Waiver Information! After September 12,

2003, DD and LTC waiver providers will not be allowed to bill through ACE$.

! ACE$ will not be able to process any waiver claims after September 12, 2003.

Who and When to CallWho and When to Call

Contact ACS Provider Relations for :* Claim status* Check status* Recipient eligibility

Cheyenne- (307) 772-8401Outside Cheyenne-1-800-251-1268Monday through Friday, 9am

to 5 pm MST

Who and When to CallWho and When to CallContact Florida EDI

for:! ACS EDI Support Unit-

WINASAP 2003/Enrollment:1-800-672-4959

! Technical Support for Vendors, Billing Agents, Clearing House.1-850-201-11718 am to 5 pm MST

Who and When to CallWho and When to CallContact Florida EDI

for: Registering to receive

electronicresponses such as RA’s, PA’s, Eligibility, and Claims Status.

ModifiersModifiers

! ACS will be able to accept four modifiers on claims, rather than the current two modifiers.

New ModifiersNew Modifiers

Medicaid Level of Care 3 (Case Management By Substance Abuse)U3

Medicaid Level of Care 5 (Community Mental Health Substance Abuse)U5

Medicaid Level of Care 4 (Free Standing Substance Abuse)U4

Intermediate level of careTF

Clinical social workerAJ

Clinical psychologistAHMandated services (this replaces RE modifier)32

Part of Medicaid EPSDT program ( Related to EPSDT)EP

Medicaid Level of Care 2 (Case Management By Community Mental Health)U2Group settingHQ

Medicaid Level of Care 1 (Community Mental Health)U1

Program group, child and/or adolescentTJ

DescriptionModifier

New ModifiersNew Modifiers

State and/or federally-funded programs/servicesSE

Specialized mental health programs for high-risk populationsHK

Follow-up serviceTS

Multi-disciplinary teamHIDoctoral levelHP

Outpatient physical therapy plan of careGPOutpatient speech language pathology plan of careGN

Outpatient occupational therapy plan of careGO

Employee assistance programHJNew equipmentNU

Child/adolescent programHAAdult program, not geriatricHB

Complex/high tech level of careTGDescriptionModifier

! The following slides will show the new CPT, HCPCS, and revenue codes that will replace the current Local Codes for various services beginning September 29, 2003, unless otherwise advised.

Crosswalks: Local Codes Vs. Crosswalks: Local Codes Vs. CPT/HCPCS CodesCPT/HCPCS Codes

Children’s Special HealthChildren’s Special Health

Est. Ped. Follow-up- Complex Dis. 10/min.TJ99212X5911

Init. Comp. Ped. Cons. Complex DisorderTJ99245X5910




DescriptionDescriptionModifierModifierCPT CPT CodeCode

Local Local CodeCode

Children’s Special HealthChildren’s Special Health

Genetic Clinic Initial ExamTJ99244X5915




DescriptionDescriptionModifierModifierCPT CPT CodeCode

Local Local CodeCode

Community Mental Health & Community Mental Health & Substance AbuseSubstance Abuse

Per 15 min

Per 15 min

Per 15 min

Per 15 min

Per 15 min

Per 15 min

Per 15 min

Unit Type

Intensive Ind. Rehab ServiceHK, U1H2014X2896

Individual Rehab ServiceU1H2014X2893

Family PreservationU1, U4, U5H2021X2892

Group TherapyU1, HQ, U4, U5H2019X2853

Comp. Medication ServiceU1, U4, U5H0034

Individual Therapy (Agency based)

U1, U4, U5H2019X2841

Clinical AssessmentU1, U4, U5H0031X2801

DescriptionModifier(s)CPT CodeLocal Code

Community Mental Health & Community Mental Health & Substance AbuseSubstance Abuse

Med. Case Management /ExpandedDELETEDX3127

Adult Case ManagementU2, U3Per 15 minT1017X2912

Ongoing Case ManagementEP, U2, U3Per 15 minT1017X2905

Trans. Case ManagementEP, U2G9012X2903

Inten. Child Treatment ServiceEP, U1Per dayS5145X2901

Inten. Sub Abuse OP Prog. (NEW)U4, U5T1008NEW

Day TreatmentU1, U4, U5Per 15 minH2017X2899

DescriptionModifier(s)Unit TypeCPT CodeLocal Code

Developmental CentersDevelopmental Centers

Therapeutic activities, direct (1 to 1) patient contact by provider/per 15 min.

97530X3130

Therapeutic procedure(s), group/per 15 min.97150X3129

Treatment – speech, language, voice comm., and/or auditory process. Disorder; group/per 15 min.

92508X3128

Treatment – speech, language, voice comm., and/or auditory process. Disorder; individual per 15 min.

92507X3126

Evaluation - speech, language, voice, comm., and/or audio process. Disorder;/individual per 15 min.

92506X3125X3131

Use individual Therapy evaluation CodesDELETED

X3100

DescriptionCPT Code

Local Code

Developmental CentersDevelopmental CentersDescriptionCPT CodeLocal

Code

DELETEDDELETEDX3138

Therapeutic proc.(s), group/per 15 min.97150X3137

Therapeutic proc./per 15 min.97110X3136

PT re-evaluation per 15 min.97002X3135

PT evaluation per 15 min.97001X3134

Occupational Therapy re-evaluation per 15 min.97004X3133

Occupational Therapy evaluation per 15 min.97003X3132

Health Check Health Check ––You must use diagnosis code V20.2, and bill with the You must use diagnosis code V20.2, and bill with the

appropriate CPT code and Modifier below. Payment includes appropriate CPT code and Modifier below. Payment includes incentive payment amount:incentive payment amount:

Est. Pt. 18-20 yrs3299395

Est. Pt. 12-17 yrs3299394

Est. Pt. 5-11 yrs3299393

Est. Pt. 1-4 yrs3299392

Est. Pt. Under 1 year3299391

New Pt. 18-20yrs3299385

New Pt. 12-17yrs3299384

New Pt. 5-11yrs3299383New Pt. 1-4 yrs3299382

New Pt. Under 1 year3299381Preventive Medicine ServicesModifierCPT-4 Codes

Office & Outpatient ServicesOffice & Outpatient Services

Group counseling, per 15 min.

AH (Clinical Psychologist)AJ (Clinical social worker/master’s level counselor) Use of modifiers will pay at

75% of fee

9085790853

X3003

Ind. Or family counseling, per 15

min.

AH (Clinical Psychologist)AJ (Clinical social worker/master’s level counselor) Use of modifiers will pay at

75% of fee

90804908159084690847

X3001

E&M code for new pt.E&M code for est. pt.

99205 OR 99215

X5878


99204 OR 99215

X5874


99202 OR 99214

X5870DescriptionModifiersCPT CodeLocal Code

Hearing ServicesHearing Services

Advanced Hearing Aid InsuranceX5613X5613

Standard Hearing Aid InsuranceX5612X5612

Hearing aid rentalDELETEX5608

DescriptionProcedure CodeLocal Code

Dental ServicesDental Services

Dental Extraction/Restorative, Hospital Outpatient

D7111-D7250X5846

Dental Extraction/RestorationD7111-D7250X5840

DescriptionProcedure CodeLocal Code

LTC Waiver ServicesLTC Waiver Services

HCBS- Respite care in facilityDELETEDW6006

Per meal

Per 15 min.

Per 15 min.

Per 15 min.

Per day

Unit Type Modifier

HCBS-Home deliver. MealsS5170W6007

HCBS-Respite care in home-HRS5150W6005

HCBS-Personal Care Attend.-HRT1019W6003

Self help assist.T2041W6002

HCBS - Case managementT2024W6001

DescriptionHCPCS Code

Local Code

LTC Waiver ServicesLTC Waiver Services

HCBS-adult day care-HRPer 15 min.S5100W6013

Care coordinatorTFPer dayT2024W6012

HCBS-Non-med. Trans. MonthlyPer trip (one way)

T2003W6011

HCBS-lifeline month.Per monthS5161W6010

HCBS-lifeline install.Per installationS5160W6009

HCBS-skilled nursingPer hourS9123W6008

DescriptionModifierUnit TypeHCPCS Code

Local Code

Assisted Living Facility Assisted Living Facility ServicesServices

Per day

Per day

Per day

Per day

Unit Type

HCBS-ALF-CASE MANAGEMENT

T2024W6099

HCBS-LEVEL IIITGT2031W6098

HCBS-LEVEL IITFT2031W6097

HCBS-LEVEL IT2031W6096

DescriptionModifier(s)HCPCS CodeLocal Code

DD Waiver Services DD Waiver Services –– Targeted Targeted Case ManagementCase Management

Targeted Case management Non waiver DD adult assessment

DELETEDW8002-W8005

Per month

Per month

Unit Type

Targeted Case management Non waiver DD child assessment

HAT2023W8001

Targeted Case management non waiver DD adult assessment

HBT2023W8000

DescriptionModifierHCPCS Code

Local Code

DD Child Waiver ServicesDD Child Waiver ServicesDescriptionModifierUnit TypeHCPCS CodeLocal Code

Special family hab. Home

w/trans.

Per dayT2033W2111

Residential habilitation

Per dayT2016W2107

Respite carePer 15 min.T1005W2105

HomemakerPer 15 min.S5130W2103

Case management subsequent

assess.

TSPer timeT2024W2102

Case management

Init. Assessment

Per timeT2024W2101

Case management

Per monthT2022W2100

DD Child Waiver ServicesDD Child Waiver Services

Environ. Mods. (new)

NUPer timeS5165W2115

Resident. Hab. Trainer w/o trans.

Per hourT2013W2114

Skilled nurs.Per 15 min.T1002W2119

Environ. Mods (exist.)

Per timeS5165W2117

Environ. Mods. (new)

NUPer timeS5165W2115

Resident. Hab. Trainer w/o trans.

Per hourT2013W2114DescriptionModifierUnit TypeHCPCS CodeLocal Code

DD Child Waiver ServicesDD Child Waiver Services

Per 15 min.

Per visit

Per 15 min.

Per 15 min.

Per time

Per time

Per 15 min.

Unit Type

Personal care servicesT1019W2132

Dietician servicesS9470W2129

Psychological H0004W2127

Respiratory therapyG0238W2125

Special. Equip. & supplies (repair)

T2029W2123

Special. Equip. & supplies (new)

NUT2029W2121

Complex skilled nursing T1000W2120

DescriptionModifierHCPCS CodeLocal Code

DD Adult Waiver ServicesDD Adult Waiver Services

Case ManagementPer MonthT2022W3001

Case Management Initial AssessmentPer TimeT2024W3003

Case Management Subsequent AssessmentTSPer TimeT2024W3005

Habilitation/ResidentialPer DayT2016W3011

Habilitation DayPer DayT2020W3015

Habilitation Prevocational Per DayT2014W3017

Per diem

Unit Type

Habilitation support. Employ.T2018W3019



Occupational ther.Per 15 min.

G0152W3051

Home modifications (repair)Per timeS5165W3030

Home modifications (new)NUPer timeS5165W3029

Adapt. EquipPer timeT2029W3028

Adapt. Equip. (new)NUPer timeT2029W3027

Personal carePer 15 min.

T1019W3023

Habilitation in home supp.Per hourT2025W3021DescriptionModifierUnit TypeHCPCS CodeLocal Code


Respiratory therapy servicesPer 15 min.

G0238W3061

Complex Skilled NursingPer 15 min.

T1000W3060

Physical therapy servicesPer 15 min.

G0151W3063

Respite carePer 15 min.

T1005W3071

Skilled nursing ServicesPer 15 min.

T1002W3059

PsychologicalPer 15 min.

H0004W3057

Dietician servicesPer visitS9470W3055

Speech therapyPer 15 min.

G0153W3053DescriptionModifierUnit TypeHCPCS CodeLocal Code

Acquired Brain Injury ServicesAcquired Brain Injury Services

Per diem

Per day

Per time

Per time

Per month

Per hour

Unit Type

ABI day habilitationT2020W3115

ABI Residential habilitationT2016W3111

ABI subsequent Assess.TST2024W3105

ABI initial assess.T2024W3103

ABI case mngmt.T2022W3101

ABI cognitive retrainingT2013W3100

DescriptionModifierHCPCS Code

Local Code


ABI Special. Med. Equip (Subsequent)Per timeT2029W3128

ABI Special. Med. Equip (initial)NUPer timeT2029W3127

ABI Personal Care ServicesPer 15 min.T1019W3123

ABI Habilitation- Support. Employ. ServicesPer diemT2018W3119

ABI Habilitation- Prevocational ServicesPer diemT2014W3117

DescriptionModifier(s)Unit TypeHCPCS Code

Local Code


ABI Psychology Services.Per 15 min.

H0004W3157

ABI Dietician servicesPer visitS9470W3155

ABI Skilled Nursing ServicesPer 15 min.

T1002W3159

ABI Speech, Hearing & Lang. ServicesPer 15 min.

G0153W3153

ABI Occupational TherapyPer 15 min.

G0152W3151

ABI Home Modifications (subsequent)Per timeS5165W3130

ABI Home Modifications (initial)NUPer timeS5165W3129

DescriptionModifier(s)Unit TypeHCPCS Code

Local Code


ABI Complex Skilled NursingDELETEDW3160

Per 15 min.

Per 15 min.

Per 15 min.

Per 15 min.

Unit Type

ABI Respiratory Therapy ServicesG0238W3161

ABI Respite Care ServicesT1005W3171

ABI PT Services. DELETEDW3168

ABI PT Services G0151W3163

ABI Skilled Nursing ServicesT1002W3159


Traumatic Brain Injury/Spinal Traumatic Brain Injury/Spinal Cord DysfunctionCord Dysfunction

Spinal cord dys- children w/out vents123X0008

Spinal cord dys- children w/ vents123X0007

TBI- Children w/out vents123X0006

TBI- Children w/ vents123X0005

Spinal cord Dys- Adults w/out vents128X0004

Spinal cord Dys-Adults w/ vents128X0003

TBI- ADULTS without Vents128X0002

TBI- ADULTS with Vents128X0001

DescriptionRevenue CodeLocal Code

Indian Health ServicesIndian Health Services

VFC administration771NEW

Hospital Physical Visit987NEW

Multi-specialty encounter (within I.H.S. clinic)

DELETEX5865

Physician services (not within I.H.S. clinic)DELETEX5864

Pharmaceutical encounter (within I.H.S. clinic)

259X5863

Optometric encounter (within I.H.S. clinic)519X5862

Dental encounter (within I.H.S. clinic)512X5681

Medical encounter (within I.H.S. clinic)500X5860

Comp. Health screen. Ref.779X5504RE

Comp. Health screen.779X5504DescriptionRevenue CodeLocal Code

General HealthGeneral Health

Nuwave Pain Management SystemDELETEX5018

Barbara Davis CenterPer visitT1015X5009

Environ. Investigation of primary residence to determine

T1029X5008

Environ. Investigation for Lead ToxicityTST1029X5007

Health visit- elevated blood lead levelsS5190X5006

Wheelchair evaluation.E1340 & 97001X5005

DescriptionModifierUnit TypeProcedure CodeLocal Code

TransportationTransportation

Private vehicle per mile- adultA0090NEW

Private vehicle per mile- childSEA0090NEW

Lodging/per diem escort for childA0200NEW

Lodging/per diemA0180X5966

AirplaneA0140X5965

BusA0110X5964

TaxiA0100X5963

Public transitDELETEX5960DescriptionModifierProcedure CodeLocal Code

Inpatient Hospital ServicesInpatient Hospital Services

NH Room and Board658659

Negotiated Heavy Care rate101672

W9105 Negotiated Heavy Care rate

101671

W9100 Negotiated Heavy Care rate

101670

Nursing home billed leave days18XContracted rehab services128682

Inpatient regional treatment center services JCAHO and

non-JCAHO

919681Inpatient maintenance psych124680

Negotiated extraordinary care, monthly rate

101678

Nursery-Neonatal ICU170-174175DescriptionRevenue Code(s)Deleted Local Revenue Codes

Critical Access Hospital Critical Access Hospital ServicesServices

Critical Access Hospital Outpatient pricing revenue

code

970-986683

DescriptionRevenue Code(s)Deleted Local Revenue Code

Federally Qualified Health Federally Qualified Health Care CentersCare Centers

FQHC’s will bill on a UB02 instead of the CMS 1500 form.

T1015

99381

Procedure Code

X5855

X5515

Local Code

FQHC520

FQHC Health Check520

DescriptionRevenue Code

Rural Health ClinicsRural Health ClinicsRural Health Clinics will bill on a UB02 instead of

the CMS 1500 form.

DELETE

T1015

99381

Procedure Code

X5580

X5850

X5514

Local Code

Medicare CrossoverDELETE

RHC Encounter521

RHC Health Check521

DescriptionRevenue Code

Extraordinary Heavy CareExtraordinary Heavy Care

These recipients require skilled nursing facility extraordinary care because they have an MDS Activities of Daily Living Sum score of ten

(10) or more and require special care or clinically complex care as recognized under the Medicare RUG-III classification system for those conditions which have received PA from the Departments.

101678

Extraordinary Care Revenue Code after 9/29/03

Current Extraordinary Care Revenue Code

LT101 and PASARR Level IILT101 and PASARR Level IIThe following services for LT101 and PASARR The following services for LT101 and PASARR

level II Screenings will be billed on the CMS 1500 level II Screenings will be billed on the CMS 1500 form.form.

PASARR Level II-social summaryDELETEW7207

PASARR Level II- psychologistHIPer visitT2011W7205

Per visit

Unit Type

W7201

W7103

W7101

Local Code

PASARR Level II-committee consultDELETE

LT101 by phoneDELETE

LT101T1023

DescriptionModifierProcedure Code

LT101 and PASARR Level IILT101 and PASARR Level IIThe following services for LT101 and PASARR The following services for LT101 and PASARR

level II Screenings will be billed on the CMS 1500 level II Screenings will be billed on the CMS 1500 form.form.

PASARR Level II- CMHC Eval.Per visitT2011W7302

PASARR Level II- psychiatristHPPer visitT2011W7301

PASARR Level II- audio. examDELETEW7215

PASARR Level II- IT/APPDELETEW7213

PASARR Level II- ICAPDELETEW7211

DescriptionModifierUnit TypeProcedure Code

Local Code

TheTheEndEnd

Documents

ACS & HIPAA: PROVIDER BILLING CHANGES · 2016. 7. 26. · W8005 Per month Per month Unit Type Targeted Case management Non waiver DD child assessment W8001 T2023 HA Targeted Case