Presented by The Department of Social Services & HP ... · •RCC 324 and 329 were automatically loaded to the hospital RCC rate file. •The following CPT codes related to Screening

1

Hospital Refresher Workshop

Presented byThe Department of Social Services& HP Enterprise Services

2CT interChange MMIS

Training Topics

• Provider Bulletins• Electronic Messaging• Inpatient APR DRG Reminders• Explanation of Benefit Codes• Hospital Billing Changes• Provider Drug Search• Claims Paid at Per Diem Rate• Web Claim Adjustments• Remittance Advice• Hospital Modernization Page• Messages Archived• ICD-10• Questions


Provider BulletinsProvider Bulletins• Access the Publications page by selecting Publications from

either the Information box on the left hand side of the home page (www.ctdssmap.com) or from the Information drop-down menu.

• Bulletin Search allows you to search for specific bulletins (by year, number, or title) as well as for all bulletins relevant to your provider type. When searching by provider title, you can search by any

word as long as that word is in the title of the bulletin.

http://www.ctdssmap.com/


Provider BulletinsProvider Bulletins – Searching by Year and Type


Provider BulletinsProvider Bulletins – Searching by Title

• Searching by the word “Electronic Messaging”,” only brings up bulletins with the word “Electronic Messaging” in the title of the bulletin.


Electronic Messaging• Provider Bulletin 2015-23 “Implementation of Electronic Messaging - Replacement to the Mailing of Bulletins/Policy Transmittals”

• The Department of Social Services (DSS) and HP are pleased to announce the implementation of electronic messages replacing the mailing of bulletin/policy transmittals.

• Hospital providers and their office staff can subscribe to receive pertinent CMAP program information via e-mail messages.

• DSS will no longer distribute any paper communications to providers as of June 30, 2015.


Electronic Messaging • DSS and HP will use electronic messaging to distribute: Provider bulletins and policy transmittals Workshop invitations Program updates and reminders

• There are many benefits to the electronic delivery of communication. Faster distribution of information to the provider community.Any office personnel can subscribe to receive program information via e-mail.Provides a simplified subscription process that can be completed very quickly allowing information to get into the right hands.


Electronic Messaging • To subscribe for electronic messaging, providers and office staff must perform the following steps:Access the www.ctdssmap.com Web site.Select Provider > E-mail Subscription from the drop-down menu.



Electronic Messaging Once on the E-mail Subscription page, enter the e-mail address you wish to subscribe under New Subscriber.Re-enter the e-mail address for verification and click Register

A confirmation message will be displayed at the top of the page

If you receive an error message, correct the error(s) and click Register again


Electronic Messaging From the right hand side of the page, use the checkboxes to select the available subscriptions you would like to receive.

Once complete, select Save.


Electronic Messaging • Providers that supplied e-mail addresses at the time of enrollment or re-enrollment in CMAP, or during the setup of their Secure Web portal account, will automatically be subscribed for e-mail notifications. Please note that the email addresses on file for clerk accounts will not be included in the auto-subscribe process and will need to subscribe separately.

• Once you have subscribed, you may modify your subscriptions at any time by performing the following steps.Access the www.ctdssmap.com Web site.Select Provider > E-mail Subscription from the drop-down menu.



Electronic Messaging Once on the E-mail Subscription page, enter the e-mail address you wish to modify in the Existing Subscribers section of the panel and click Update.

From the right hand side of the page, use the checkboxes to modify your subscriptions and click Save.

• Once you have successfully modified your subscriptions, you will receive a confirmation notice that includes the provider type(s) and/or topic(s) you selected from the checkboxes.


Electronic Messaging • To Unsubscribe your subscription, you will need to do the following steps: Access the www.ctdssmap.com Web site.Select Provider > E-mail Subscription from the drop-down menu.Once on the E-mail Subscription page, enter the e-mail address you wish to unsubscribe in the Unsubscribe section of the panel. Once complete, click Unsubscribe.

A confirmation message will be displayed at the top of the page



Inpatient APR DRG Reminders• Hospital’s payment will not exceed the total amount billed on inpatient claims with an admission or after January 1, 2015.

• Organ Acquisition costs (RCC 81X) will be reimbursed outside of the APR DRG payment methodology effective with admissions on or after January 1, 2015. Claims that contain organ acquisition charges will be suspended to allow the claim to be manually priced. Once finalized, these claims will contain both a DRG payment and an organ acquisition payment and will include EOB 6000 “Claim was Manually Priced or Denied for Missing Information”.To determine the rates for organ acquisition costs, from the Hospital Modernization page on www.ctdssmap.com Web site on the right side under DSS links click on DSS reimbursement Home Page.



Inpatient APR DRG RemindersOn the Reimbursement Modernization page click on the link at the bottom of the page “Return to Medicaid Hospital Reimbursement Page.” On the Medicaid Hospital Reimbursement page click on “Rates & Settlements.”Scroll down to Organ Acquisition and the chart is used to reimburse hospitals for organ acquisition.

• Additional information on Organ Acquisition can be found under Provider Bulletin 2014-79 “Inpatient Hospital Payment Modernization/All Patient Refined-Diagnostic Related Group (APR-DRG).”


Inpatient APR DRG Reminders• Effective with inpatient hospital admissions on or after January 1, 2015, interim claims can no longer be billed by the hospital, with one exception. One interim claim may be billed when the actual length of stay reaches 29 days.

• If the hospital tries to split a claim for admission that the primary reason for the stay in medical changes to behavioral health or behavioral Health to medical, the claim will deny. Hospitals should bill for the entire stay on one claim. For claims prior to April 1, 2015, if there is only one PA, the

claim will pay based on the DRG assignment. If the hospital received 2 separate prior authorizations, the

hospital should submit a claim that admission as a discharge and re-admit for the behavioral health or medical services.


• EOB code 0674 “DRG Interim Claims not Allowed” Cause

−If an inpatient claim is submitted with a patient discharge status of 30 “Still Patient”, indicating the patient is still in the hospital, it will be denied with EOB code 674 “DRG interim claims not allowed” if the number of days submitted is less than 29 days for admission on or after January 1, 2015.

• EOB code 5075 “Only One Interim Claim Allowed Per Stay” Cause

−If a second interim bill is submitted and there is a paid interim claim for the same admit date in history.

Resolution−Hospitals can adjust an interim claim, replacing it with an extended interim claim.

Explanation of Benefit (EOB) Codes


Explanation of Benefit (EOB) Codes• EOB Code 0920 “3M Grouper Error” Cause

−The diagnosis code and client birth weight submitted on the inpatient claim for the newborn are in conflict.

Resolution−Correct either the diagnosis code or client birth weight and resubmit the corrected newborn’s claim.

• Example: If the birth weight submitted on the claim is 2400 grams, and the diagnosis description states “Preterm NEC 2500+ grams”, the hospital would need to correct either the birth weight or diagnosis code.


Explanation of Benefit (EOB) Codes• EOB Code 0692 “Edit Invalid Birth Weight or Age/Birth Weight Conflict” Cause− The diagnosis and client birth weight submitted on the

inpatient claim are in conflict with the client’s age in days.Resolution

−Correct either the diagnosis code or client birth weight and resubmit the corrected claim.

• Tip: The client birth weight must be between 150 and 9000 grams if the client’s age in days is less than or equal to 14 days.


Explanation of Benefit (EOB) Codes• EOB Code 0682 “Invalid Discharge Status” Cause−The patient discharge status submitted on the inpatient claim is either missing or invalid when the patient discharge status is needed to identify the DRG.

Resolution−Enter a valid patient discharge status and resubmit the corrected claim.

• Additional EOB codes can be found under Provider Manual Chapter 12 – Claim Resolution Guide on the www.ctdssmap.com Web site.



Hospital Billing Changes• Provider Bulletin 2015-20 “Establishment of Fixed Fees for Certain Outpatient Procedures” The purpose of this policy transmittal was to inform Hospital providers that the Department of Social Services changed its pricing for Revenue Center Code (RCC) 324 - Chest X-Ray and RCC 403 - Screening Mammography. Effective with dates of services on or after April 1, 2015, the above codes has transitioned to a fixed fee.

• The following CPT codes related to chest x-ray (excluding x-rays with fluoroscopy) must be billed only under RCC 324: Procedure code 71010, 71015, 71020-71022, 71030 and 71035.

• The following CPT codes related to Chest x-ray with fluoroscopy must be billed only under RCC 329: Procedure code 71023 and 71034.


Hospital Billing Changes• RCC 324 and 329 were automatically loaded to the hospital RCC rate file.

• The following CPT codes related to Screening Mammography must be billed only under RCC 403: Procedure code 77052, 77057 and G0202.

• CPT codes related to diagnostic mammography services must be billed under RCC 401 – Diagnostic Mammography.

• Effective June 1, 2015 and forward, RCCs 720-722 and 724 will require a valid CPT or HCPCS procedure code on outpatient claims: All claim details with these RCCs that are not billed with a valid CPT/HCPCS code will deny for EOB code 0390 ”Revenue Center Code Requires a HCPCS/Procedure Code.”


Hospital Billing Changes• Effective June 1, 2015 and forward, 340B Pharmacies will require a valid HCPCS code on outpatient claims when billing the following RCC codes:RCC 250-253, 258-259, and 634-637.− 340B entities will remain exempt from the Deficit

Reduction Act (DRA) requirements to include the National Drug Code (NDC) on the UB-04.

• All claim details with these RCCs that are not billed with a valid HCPCS code will deny for EOB code 840 “HCPC Required when Drug Revenue Code is Billed.”

• For a complete list of RCCs requiring a CPT or HCPCS, go to the www.ctdssmap.com Web site, go to “Publications” Scroll to Provider Manual Chapter 8 and select “Hospitals” from the drop down box and refer to Attachment B “List of All Revenue Center Codes Requiring CPT/HCPCS Codes”.


Provider Drug Search• When billing for National Drug Codes (NDC) on outpatient claims, please refer to the provider drug search on the Web to determine the corresponding HCPCS code. A drug search can be performed at the Web site www.ctdssmap.com, by selecting “Provider” then “Drug Search” and entering the NDC.



Provider Drug Search• If the hospital performs a search and no HCPCS is returned, but it is a rebateable NDC, the hospital can bill with one of the following HCPCS codes: J3490 “Unclassified Drugs”, J3590 “Unclassified Biologics”, J8999 “Prescription Drug, Oral, Chemotherapeutic, NOS” and J9999 “Not Otherwise Classified, Antineoplastic Drugs.”


Claims Paid at Per Diem Rate• For admissions prior to April 1, 2015 per diem rates were paid based exclusively on the DRG assignment. Inpatient behavioral health per diem rate if the DRG range was 740 – 776. Inpatient Rehabilitation per diem rate if the DRG assignment was 860.

• Effective for admissions on or after April 1, 2015, inpatient services will no longer be reimbursed a per diem rate based exclusively on the DRG assignment. Rehabilitation or behavioral health claims, to pay at the per diem rate, will need a Prior Authorization (PA) reflecting a per diem PA on file.


Claims Paid at Per Diem Rate• Effective for admissions April 1, 2015, any emergent admission into the hospital where a medical PA is received from CHNCT where it is later determined the DRG assignment would be behavioral health or rehabilitation, will require a per diem PA to be eligible for the per diem rate.If the hospital does not obtain a per diem PA at the time of service, the claim could pay entirely based on the DRG assignment.


Claims Paid at Per Diem Rate• If a client, who received a medical authorization upon admission from CHNCT, requires further inpatient behavioral health or rehabilitation care, the hospital must administratively discharge the client from medical and re-admit the client for behavioral health or rehabilitation services to qualify for the per diem rate. A per diem PA for behavioral health services must be requested from CT BHP and acute rehabilitation per diem services must be requested from CHNCT.

• If the hospital fails to obtain the per diem PA the Department will reimburse the hospital based on the DRG assignment.

• In this case there will be two separate inpatient claims, with two different admit dates. These claims should not be billed as two interim claim (Type of bill 112 “Inpatient – First Claim” and 114 “Inpatient – Last Claim”).


Claims Paid at Per Diem Rate• If a client, who received a behavioral health authorization upon admission from CT BHP, requires further inpatient medical or rehabilitation care, the hospital must administratively discharge the client from behavioral health and re-admit the client for medical services or rehabilitation services to qualify for further payment.The hospital must obtain a medical PA from CHNCT for that readmission.

• If the hospital does not obtain a medical PA from CHNCT in the time frame specified by the department, the medical claim will be denied.

• In this case there will be two separate inpatient claims, with two different admit dates.


Claims Paid at Per Diem Rate• The DRG calculator should not be used to price claims that are exempt from the inpatient payment methodology.

• The following EOB codes will continue to post to claims paying at per diem rate: –EOB code 8606 “Reimbursed via General BH Pricing” will post to inpatient behavioral health per diem claims.

–EOB code 8607 “Reimbursed via Rehab Pricing” will continue to post to inpatient rehab per diem claims.


Web Claim Adjustments• The following are web claim adjustment that cannot be submitted through the secure Web site www.ctdssmap.com.Adjusting claims that are past timely filing. −If the hospital tries to adjust these claims, they will be denied for timely filing and the original payment will be re-couped.

−If the hospital tries to adjust claims using different revenue center codes (RCC) or procedure codes, even if it was within timely filing based on when the claim was previously processed, it could deny for timely filing.

• For example: Hospital bills RCC 905 for date of service (DOS) January 1, 2015 and it was processed on March 1, 2015. If the hospital tries to adjust that claim through the Web on May 15, 2015 with a different RCC i.e. 913, it will deny for timely filing.



Web Claim Adjustments• Even though it is within the timely filing guidelines for behavioral health services of 120 days based on when the claim was last submitted, the RCC was changed and the system looks at the claim as a new day claim and it will base timely filing off of the date of service. In these cases the hospital should complete a Paid Claim Adjustment Request (PCAR) form with a copy of the original Remittance Advice (RA) to have the claim adjusted.− PCAR forms are located on the www.ctdssmap.com Web

site under the Publications page, then scrolling to “Forms” and under “Claim and Adjustment Forms.”

− PCARs are submitted to:HPPO Box 2981Hartford, CT 06104



Web Claim AdjustmentsAnother option is to void the original claim and submit a paper claim with the updated RCC and the RA to HP written correspondence requesting the claim be resubmitted with an override of timely filing.−Written correspondence request are submitted to:

HP – Written CorrespondencePO Box 2991Hartford, CT 06104

• Claims with an ICN that begins with either 12 or 13. These claims were specially handled by HP. The hospital should contact HP before attempting to adjust these claims on the Web.


Remittance Advice• Reading Adjustments (including mass adjustments) on a Remittance Advice.


Remittance Advice• The first adjustment was a void performed by the hospital. This is identified by the ICN starting with a region 59 “Internet Adjs, 837 Adjs, POS Reversals” and EOB code 8188 “Provider Recouped Claim.”

• The amount paid ($109.32) will be recouped from the provider’s RA.


Remittance Advice• The amount originally paid will be recouped from the provider’s RA under Accounts Receivable.


Remittance Advice• The amount recouped will be added to RA summary page under Accounts Receivable and be subtracted from the claims payment. The net payment is how much the EFT payment will be for the claim cycle.


Remittance Advice• Some adjustments will not be recouped in the current cycle if there is not enough funds to cover the recoupment amount.


Remittance Advice• Under Accounts Receivable if there is an amount next to “Total Balance”, this would be the amount that is still due to DSS and will be recouped in the next cycle if there is monies available to pull from.


Remittance Advice• In cases where there is a balance due to DSS, the summary payments will show the net payment as zero.


Remittance Advice• The following claim adjustment resulted in the hospital receiving additional payment. The original claim was recouped in the amount of ($104.98) and the adjusted claim paid $291.38. The hospital was paid an additional $186.40 on this claim due to the adjustment.


Remittance Advice• The new paid amount will be included under POS Claims Adjustment $291.38 and the original amount that was adjusted ($104.98) will be included under Accounts Receivable, claim specific current cycle under the RA summary page.


Hospital Modernization Web Page• The Hospital Modernization Web page on the www.ctdssmap.com Web site is still available to assist hospitals with the changes in the reimbursement methodology. The Web page includes the following: Hospital Inpatient Payment Methodology Links, DRG Provider Publications, Hospital FAQs, Hospital Important Messages, DRG Calculator, Provider Manuals and Contact Information.



Hospital Modernization Web Page• The following were recently updated on the Hospital Modernization page: Claim Paid Per Diem Rate – updated the FAQs section. Provider Manual Chapter 12 – Added APR DRG Explanation of Benefit (EOB) codes. Provider Manual Chapter 8 – Hospital Billing Changes updates.

• All APR DRG related questions can be e-mailed to [email protected].

mailto:[email protected]


Hospital Modernization Web Page

• Phase Two: Outpatient – Ambulatory Payment Classifications (APCs). Over arching policy direction of consistency with industry standard payment practices; specifically, Medicare payment policy. Maintain a long-term commitment to goals of improved accuracy, predictability, equity, timeliness, and transparency of hospital payments for all Medicaid beneficiaries. Modifying billing practices and requirements, as necessary, to provide accurate payment.

• Keep an eye out for APC hospital workshops between September and December 2015.


Messages Archived• DSS and HP has started archiving RA Banner and Important Messages on the www.ctdssmap.com Web site. To access archived messages, hospitals will need to access the Messages Archived page by selecting Messages Archived from the Information drop-down menu on the home page. RA Banner and Important Messages dated January 1, 2014 and forward will be saved on the Web site and be available for review.



ICD-10ICD-10 Changes• On October 1, 2015 the ICD-9 code set used to report medical diagnosis and inpatient procedures will be replaced by ICD-10 code sets.

• ICD-10-CM: The clinical modification diagnosis classification system was developed by the World Health Organization (WHO) and the National Center for Healthcare Statistics (NCHS) for use in all U.S. health care treatment settings. (The CM codes increase from 13,000 to 68,000-plus in the ICD-10-CM code set.)

• ICD-10-PCS: The procedure classification system was developed by the Centers for Medicare & Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings only. (There are 71,920 procedure codes in the ICD-10-PCS code set.)


ICD-10ICD-10 Changes ICD-10 codes must be used on all HIPAA transactions including outpatient and professional claims with dates of service (DOS) and inpatient claims with dates of discharge (DOD) on or after the ICD-10 implementation date.

• Hospitals will be required to split outpatient claims if they overlap October 1, 2015 so all ICD-9 are listed for DOS through September 30, 2015 and all ICD-10 codes are listed for DOS October 1, 2015 and forward.

• Inpatient admissions will not be required to be split if the entire stay overlaps October 1, 2015. All inpatient claims with DOD after October 1, 2015 is billed using ICD-10.

• ICD-10 does not affect CPT coding for outpatient services.


ICD-10ICD-10 Changes ICD-10 Testing is available for all hospitals -If you would like to become a beta tester, please e-mail the CMAP testing team at [email protected]. In the subject of the e-mail enter “ICD10 testing.”Include your trading partner ID, NPI and AVRS ID for the claims you will be testing, your contact name and phone number, e-mail address you wish the PDF RA to be mailed to, and type of claims you will be testing. A list of NPIs with associated AVRS IDs and taxonomies for each provider (Attending, operating, referring) that will be included in your test file.



ICD-10ICD-10 Changes Prepare the 837 fileEnsure ISA15 (test/production indicator) is set to T for test.Include no more than 25 claims to be tested.Use ICD10 codes for all diagnosis and surgical codes (if applicable).Dates of service can between 10/01/2014 – 4/24/2015 no future dates of service.

• Submit the 837 fileSubmit file through the secure Web portal www.ctdssmap.com using the Trading Partner Web account.Capture the tracking number after file is uploaded.



ICD-10ICD-10 Changes Submit email notifying us a file has been sent to [email protected] including the file tracking number and contract information.

• The electronic file will be tested for HIPAA compliance. If compliant, the claims will be processed in our test system, allowing us to ensure the claims are adjudicating correctly. No 835 remittance will be produced for this activity. However a PDF version of the paper remit is available upon request please ensure you send the email address where it is to be sent.

• If the file is not compliant, we will email you the 999 and our EDI staff will contact and inform you of the error and corrective action.



ICD-10ICD-10 Changes • The transition to ICD-10 is required for all providers, payers and vendors.

• Do make it a point to refer to the ICD-10 Implementation Information Important Message from the home page of our Web site www.ctdssmap.com frequently to keep abreast with the most recent ICD-10 developments.



Training Session Wrap Up• Hospital Modernization Web page

• Important Messages Hospital interChange IM updated monthly

• Provider Bulletins

• HP Provider Assistance Center (PAC): Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays:1-800-842-84401-800-688-0503 (EDI Help Desk)


Time for Questions

• Questions & Answers

Hospital Refresher Workshop Training Topics�Provider Bulletins��Provider Bulletins��Provider Bulletins��Electronic Messaging�Electronic Messaging Electronic Messaging Electronic Messaging Electronic Messaging Electronic Messaging Electronic Messaging Electronic Messaging ��Inpatient APR DRG Reminders��Inpatient APR DRG Reminders��Inpatient APR DRG Reminders��Slide Number 17�Explanation of Benefit (EOB) Codes��Explanation of Benefit (EOB) Codes��Explanation of Benefit (EOB) Codes��Hospital Billing Changes��Hospital Billing Changes��Hospital Billing Changes��Provider Drug Search��Provider Drug Search�Claims Paid at Per Diem RateClaims Paid at Per Diem RateClaims Paid at Per Diem RateClaims Paid at Per Diem Rate��Claims Paid at Per Diem Rate��Web Claim AdjustmentsWeb Claim AdjustmentsWeb Claim AdjustmentsRemittance AdviceRemittance AdviceRemittance AdviceRemittance AdviceRemittance AdviceRemittance AdviceRemittance AdviceRemittance AdviceRemittance Advice�Hospital Modernization Web Page��Hospital Modernization Web Page��Hospital Modernization Web Page ��Messages Archived��ICD-10��ICD-10��ICD-10��ICD-10��ICD-10��ICD-10�Training Session Wrap UpTime for Questions

Documents

Presented by The Department of Social Services & HP ... · •RCC 324 and 329 were automatically loaded to the hospital RCC rate file. •The following CPT codes related to Screening