Wyoming Optometric Association Meeting

Wyoming Medicaid

Covered Services & Billing Requirements

January 30, 2015

Presenter: Kilee Thompson, Field Representative

CMS-1500 Provider Manual

Located on the Wyoming Medicaid Website o http://wymedicaid.acs-inc.com o Select Provider o Select Provider Manuals and Bulletins (Navigation Bar on Left) o Select Vision Services within the CMS-1500 Provider Manual and

Bulletins section o Select CMS-1500 Provider Manual o Review for New/Updated Information Important Policy Changes/Additions section CMS-1500 Provider Bulletins section

o Additional Links section Medicaid and State Healthcare Benefit Plans NDC Crosswalk Carrier Code List

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CMS-1500 Provider Manual General Information

Chapters 2 – 9 Contains general Wyoming Medicaid Policy that relates to all providers that bill with the CMS-1500 Claim Form or submit an 837P claims transaction o Chapter 2 – Getting Help When You Need It

Contains phone numbers and websites o Chapter 3 – Provider Responsibilities

Enrollment When to bill a client When NOT to bill a client Record keeping requirements

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CMS-1500 Provider Manual General Information

Chapters 2 – 9 (continued)

o Chapter 4 – Utilization Review Review of claims and state/fiscal agent access to records Fraud and abuse, and how to report

o Chapter 5 – Client Eligibility

Types of eligibility Importance of client identification Eligibility verification

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CMS-1500 Provider Manual General Information

Chapters 2 – 9 (continued) o Chapter 6 – Common Billing Information

Basic claim information Completing the claim form & examples Cap limits Co-payments Prior authorization Electronic claims with attachments Remittance Advices Adjusting claims Timely filing Failure to notify providers of eligibility

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CMS-1500 Provider Manual General Information

Chapters 2 – 9 (continued)

o Chapter 7 – Third Party Liability Dealing with other insurance

o Chapter 8 – Electronic Data Interchange (EDI)

Wyoming Medicaid electronic services Registering for the Secured Provider Web Portal

o Chapter 9 – Wyoming Specific HIPAA 5010 Electronic

Specifications Wyoming Medicaid specific electronic billing and transaction

requirements

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CMS-1500 Provider Manual Covered Services

Chapter 10 – Covered Services o Section 10.15.24-Vision Services

Covered services and billing requirements specific to vision services Covered Services for clients 21 years of age and older Covered Services for clients under the age of 21

• Examinations • Eyeglasses • High Index Aspheric Policy • Contact Lenses

Vision Therapy • Training Aids

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Wyoming Medicaid Vision Services

Who Can Provide Services o A licensed Ophthalmologist 207W00000X

o A licensed Optometrist 152W00000X

o Optician 156FX1800X

Reminder: Wyoming Medicaid Provider Re-

Enrollment Must be Completed by December 31, 2015

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Covered Vision Services – 21 and Older

Eye Examination o Codes: 92002, 92004, 92012, and 92014 Treatment of eye disease or eye injury only Based on appropriate ICD-9 diagnosis codes

o Contacts and glasses are not covered Payment of deductible and/or coinsurance due on

Medicare crossover claims for post-surgical contact lenses and/or eyeglasses

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Covered Vision Services – 20 and Younger

Eye Examination o Codes: 92002, 92004, 92012, and 92014 o Medically Necessary Ophthalmologic Codes: 92015-

92140 Eyeglasses o Lenses Single vision, bifocal, or trifocal lenses are covered

• Ophthalmologist or optometrist must deem medically necessary and physician records must reflect medical necessity

Codes: V2700-V2799 require prior authorization (PA) Codes: V2715 and V2784 do not require PA Polycarbonate lenses (V2784), includes scratch resistant coating,

must be billed as an add-on to a standard C-39 lens

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Covered Vision Services – 20 and Younger (continued)

High Index Aspheric Lenses o Codes: V2410, V2430, V2499 Covered when medically necessary and meet the

guidelines • Can be used when the power in the highest meridian is –

(minus) 6.00 diopters or more • Can be used for plus prescriptions when the power in the

highest meridian is + (plus) 4.00 diopters or more • Lenses should be ordered in pairs – when one side is

aspheric or high index, then the matching lens should also be aspheric or high index even if it doesn’t meet the threshold

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Covered Vision Services – 20 and Younger (continued)

Frames o Codes: V2020-V2499 o One set of frames covered per 365 days Eligibility

• Provide client ID, date of birth, and date of service • Verify eligibility for date of service and date of delivery if they will

be in separate months

o Exceptions Repair or replace frames if warranty available

• If no warranty, it will be the client’s responsibility Replacement of lenses within 365 days must be due to

medical necessity • Must use existing frames

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Covered Vision Services – 20 and Younger (continued)

o Medicaid allows up to $76 for standard frames o No Balance Billing If the client wants frames that cost more than $76, two

options exist: • Accept $76 as payment in full from Medicaid for the frames –

client pays nothing • Client pays the full price and the frames are NOT billed to

Medicaid – agreement in writing must be placed in the client’s file

o Client may contract to pay for optional add-on services (tints, coatings, etc.) Obtain agreement in writing specific to additions client is

agreeing to pay for

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Vision Covered Services – 20 and Younger (continued)

Contact Lenses o Codes: V2500-V2599 require PA o Covered for correction of pathological conditions

when useful vision cannot be obtained with regular lenses.

o PA documentation provided must support medical necessity and address why the client’s vision cannot be corrected with eyeglasses.

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Vision Therapy - Covered Services

Who’s Eligible o Clients under the age of 21 o Clients 21 and over on the Acquired Brain Injury

Waiver (ABIW) Plan, Comprehensive Adult Waiver (COAW) Plan, and Supports Adult Waiver (SUAW) Plan

Procedure Codes o Code: 92065 – vision therapy

Does not require PA

o Code: 99070 – therapy training aids Submit claims with therapy training aid invoice and

documentation of medical necessity

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Vision Therapy-Limitations

Cap Limits o 32 vision therapy visits per 365 days o Medical necessity is required for services beyond the allowed

32 sessions Diagnosis Codes o Services are covered for specific diagnosis codes (see

following charts) o If a diagnosis code is not covered, an appeal may be

submitted Appeals must be submitted in writing to Provider Relations asking that

the diagnosis code be covered Appeals will be reviewed by the Division of Healthcare Financing and if

approved, claims can be submitted for payment

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Wyoming Medicaid Vision Therapy Covered Diagnosis Codes

Vision Therapy Diagnosis Codes Amblyopia

368.01 Strabismic amblyopia

368.02 Deprivation amblyopia

368.03 Refractive amblyopia

Strabismum (Concomitant) 378.01 Monocular esotropia

378.05 Alternating esotropia

378.11 Monocular exotropia

378.15 Alternating exotropia

378.21 Intermittent esotropia, monocular

378.22 Intermittent esotropia, alternating

378.23 Intermittent exotropia, monocular

378.24 Intermittent exotropia, alternating

378.35 Accommodative component in esotropia

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Wyoming Medicaid Vision Therapy Covered Diagnosis Codes (continued)

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Vision Therapy Coding

Non-strabismic disorder of binocular eye movements

378.83 Convergence insufficiency

378.84 Convergence excess

378.85 Anomalies of divergence

Ocular Motor Dysfunction

379.57 Deficiencies of saccadic eye movements

379.58 Deficiencies of smooth pursuit movements

Heterophoria

378.41 Esophoria

378.42 Exophoria

General Binocular Vision Disorder

368.30 General Binocular Vision Disorder

Accommodative Disorder

367.51 Paresis of accommodation

367.52 Total or complete internal ophthalmoplegia

367.53 Spasm of accommodation

Nystagmus

379.51 Nystagmus

Wyoming Medicaid Vision Therapy Covered Diagnosis Codes (continued)

Acquired Brain Injury Program and Adult Waiver 438.7 Disturbances of vision 907.0 Late effect of intracranial injury without mention of skull fracture

997.00 Nervous system complication, unspecified 997.01 Central nervous system complication 997.02 Iatrogenic cerebrovascular infarction or hemorrhage 997.09 Other nervous system complications V57.4 Care involving orthoptic training

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ICD-10 Implementation Date o October 1, 2015 ICD-10 Coding Information o The International Classification of Diseases, 10th Edition, (ICD-10) is

a diagnosis coding system of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, and a procedure coding system for inpatient procedures

o ICD-10 CM for diagnosis coding This is for use in all health care settings Diagnosis coding under ICD-10 uses 3 to 7 alphanumeric digits Wyoming Medicaid does not conduct coding training

o Date of service driven o For additional information please visit http://www.wyomingicd10.com/

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Common Denial Reasons and Solutions Client not eligible for date of service or the service is

not covered under the client’s plan o It is important to verify eligibility of each client, keeping

in mind that eligibility is authorized on a monthly basis and can change from month to month. Not all Medicaid and State Benefit plans cover vision services;

some are limited to prescriptions only, payment of Medicare premiums, or coverage for limited diagnoses or conditions.

Client eligibility can be verified via the IVR (800-251-1268), using either the client’s Medicaid ID or their SSN.

• Frames eligibility can be verified via options 1, 5, and then 0. Please provide client ID, date of birth, and date of service

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Common Denial Reasons and Solutions Procedure Code/Age Conflict o As certain services are only covered for individuals of a certain age, it

is important to verify the covered ages for the procedure codes before performing the service and billing, as well as the age of the client.

o The Wyoming Medicaid website contains a fee schedule search engine which will allow the provider to enter any procedure code to view information related to: Allowed amount Prior authorization requirement Age limitations Allowed taxonomies Maximum units Allowed/disallowed modifiers Medicare coverage (required to be billed to Medicare if client is covered

under Medicare)

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Common Denial Reasons and Solutions

Client is covered by Medicare or another insurance – commonly referred to as TPL (Third Party Liability)

o Medicaid is the payer of last resort. This means that providers must bill their claim to other payers first, obtain any payment or denial, and include this information when billing claims to Medicaid.

o If providers find that they are having difficulty obtaining response from any insurance (not including Medicare), they may include a letter documenting at least 2 attempts over a minimum of 90 days and Medicaid will process as primary and obtain payment from the other insurance.

o If providers are non-participatory with any insurance (not including Medicare), they may include a letter documenting this in place of the other insurance’s EOB.

o Note: Medicare must be billed primary in all cases, and providers must include the Medicare EOMB if the procedure code is marked as Medicare: Y on the fee schedule

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Common Denial Reasons and Solutions

Procedure code requires PA o Certain services require PA for medical necessity

prior to the service being rendered. o Verify if the code being billed requires PA

View Fee Schedule on the website Contact Provider Relations

o Fill out the PA Form Available on the website Chapter 6, Section 6.12 of the CMS-1500 Manual

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References The information reviewed in this presentation can be found in the CMS-

1500 Manual Wyoming Medicaid Website – http://wymedicaid.acs-inc.com

o Provider Manuals and Bulletins Click on Provider / Provider Manuals and Bulletins / Vision / CMS-1500 Provider Manual

o Fee schedule Click on Provider / Fee Schedules / Accept / Procedure Code Search Page

o IVR Navigation tips Helps to direct providers to the appropriate options for each department Click on Provider / Contact Us / Click here for helpful Provider IVR Navigation Tips

o Remittance Advice Retrieval From the Secure Provider Web Portal

o Medicaid and State Healthcare Benefit Plan document Click on Provider / Provider Manuals and Bulletins / Additional Links

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References IVR – 1-800-251-1268

o 24 hours a day / 7 days per week o NPI is required IVR Functionality

o Verify client eligibility Client ID or client SSN and date of service is required Benefit plan

• Covered services • Limitations

Cap Limits Lock-in TPL / Medicare Buy-in

o Verify claim status o Verify Payment o Opt out to agent

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References Provider Relations – 800-251-1268 (Option 1,5,0)

o 9-5 MST Monday - Friday o Bulletin / Manual inquiries o Cap limits o Claim inquiries o Claim submission problems o Client eligibility o Questions on completing forms o Payment inquiries o Timely filing inquiries o Billing issues regarding PA o Verifying validity of procedure codes o Claim void / adjustment inquiries

Medical Policy – 800-251-1268 (Option 1,1,4,3) o 9-5 MST Monday - Friday o Questions regarding how to complete the PA form, and the status of a PA. o Cap limit waiver requests

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Questions?

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