Saturday, March 28, 2020

Hospital Acquired conditions (HAC) CATAGORIES AND billing guidelines

Overview
Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. UnitedHealthcare Medicare Advantage doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital. UnitedHealthcare Medicare Advantage will only pay for these conditions if they were present on admission to the hospital.

Effective October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Version 33 Hospital Acquired Condition (HAC) list replaced the ICD-9-CM Version 32 HAC list.

HAC Categories:

01- Foreign Object Retained Following Surgery
02- Air Embolism
03- Blood Incompatibility
04- Stage III and IV Pressure Ulcers
05- Falls and Trauma
06- Catheter-Associated Urinary Tract Infection (UTI)
07- Vascular Catheter-Associated Infection
08- Surgical Site Infection (SSI) –Mediastinitis Following Coronary Artery Bypass Graft (CABG)
09- Manifestations of Poor Glycemic Control
10- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement
11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity
12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow
13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures
14- Iatrogenic Pneumothorax w/ Venous Catheterization

Present on Admission Guidelines

To group diagnoses into the proper Diagnosis-related group (DRG), CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional.


The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.

A joint effort between the health care provider and the coder is essential to achieve accurate and complete documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.

The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any re-sequencing of diagnosis codes prior to transmission to CMS also includes a re-sequencing of the POA Indicators


General POA Reporting Requirements

** POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.

** POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

** A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."

** Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.

** If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

 CMS POA Indicator Reporting Options, Description, and Payment Indicator Description Medicare Payment
Y Diagnosis was present at time of inpatient admission. Payment is made for condition when an HAC is present
N Diagnosis was not present at time of inpatient admission. No payment is made for condition when an HAC is present
U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment is made for condition when an HAC is present
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment is made for condition when an HAC is present
1 Unreported/Not used. Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, it was determined that blanks were undesirable when submitting this data via the 4010A.

NOTE: The number “1” POA Indicator should not be applied to any codes on the HAC list.  Exempt from POA reporting


Paper Claims

On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting.

Electronic Claims

Submit the POA indicator on the 837I in the appropriate Health Care Information Codes segment as directed by the “UB04 Data Specifications Manual.


Reimbursement Guidelines

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. CMS also required hospitals to report POA information for both primary and secondary diagnoses when submitting claims for discharges on or after October 1, 2007.


Q: Do the POA and HAC programs apply to outpatient or ambulatory surgery services?
A: No, this program is only for inpatient acute care admissions.

Q: If the POA indicator is not on the claim, will the claim be returned?
A: Beginning with claims with discharges on or after October 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA information

Tuesday, February 18, 2020

Occurrence code, special program indicator list

OCCURRENCE CODE/DATE ( Form Field 31a - 34B) – Enter the applicable code and associated date to identify significant events relating to this bill that may affect processing. Dates are entered in an MMDDYY format. A maximum of eight codes and associated dates can be entered.

Required, if applicable.

The IHCP uses the following occurrence codes:

Occurrence Codes Code Description

01 Auto accident
02 No-fault insurance involved – Including auto accident or other
03 Accident or tort liability
04 Accident or employment related
05 Other accident
06 Crime victim
25 Date benefits terminated by primary payer
27 Date home health plan established or last reviewed
42 Date of discharge – This code is used to show the date of live discharge from the
hospital confinement being billed, from a long-term care facility, or from home health
care or hospice, as appropriate.
52 Certification/recertification date – This code is used to show that an initial examination
or initial evaluation is being billed in a hospital setting. This code bypasses certain PA
editing. Details can be found in the applicable sections of the IAC.
55 Date of death – This code is used to show the date of death.
73 Benefit eligibility – This code is used to bill for home health overhead – One per day.

Special Program Indicators

A0 Special Zip Code Reporting-Ambulance
A3 Special Federal Funding
A5 Disability
A6 PPV/Medicare Pneumococcal Pneumococcal/Influenza
A7 Induced Abortion - Danger to Life
A9 Second Opinion Surgery
AA Abortion performed due to Rape
AB Abortion performed due to Incest
AC Abortion performed due to serious fetal genetic defect, deformity, abnormality
AD Abortion performed due to life endangering condition
AE Abortion performed due to physical health of mother that is not life endangering
AF Abortion performed due to emotional/psychological health of mother
AG Abortion performed due to social economic reasons
AH Elective abortion
AI Sterilization
AJ Payer responsible for Co-payment
AK Air ambulance required
AL Specialized treatment/bed unavailable
AM Non-emergency Medically Necessary Stretcher Transport Required
AN Preadmission Screening Not Required
AO-AZ Reserved for National Assignment
B0 Medicare coordinated care demonstration program
B1 Beneficiary is ineligible for demonstration program
B2 Ambulance-CAH exempt from fee schedule if not exempt CAH don’t use B2
B3 Pregnancy indicator
B4 Admission Unrelated to Discharge - Admission unrelated to discharge on same day. This code is
for discharges starting on January 1, 2004. Effective January 1, 2005
BP Gulf Oil Spill Related, all services on claim
DR Disaster Related
G0 Distinct Medical visit - multiple medical visits occurred same day in same revenue center - Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 (zero) allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0 (zero).

Saturday, August 10, 2019

Condition code G0 - Billing Guideliens


Condition code G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.


Proper Reporting of Condition Code G0

Hospitals should report condition code G0 in Form Locators 24-30 on the UB-04 claim form, the electronic equivalent, when multiple medical visits occur on the same day in the same revenue center, but the visits were distinct and independent visits.


Example

Beneficiary presents to the emergency room in the morning for a broken arm, then later that same day presents for chest pain.

On the first claim, report the first ER visit (revenue code 045X plus E/M code) with all ancillary services rendered on that day.

On the second claim, report only the unrelated ER visit (revenue code 045X plus E/M code) with condition code G0 and modifier 27. All other charges are reported on the first claim.

Proper reporting of condition code G0 allows for proper payment under the Outpatient Prospective Payment System. The Outpatient Code Editor contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of condition code G0.




Multiple Medical Visits billing Guideline


• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.



Multiple Unrelated Visits on the Same Date of Service

Forward Health defines a related visit as one whose primary diagnosis matches the primary diagnosis of a subsequent visit. When billing one or more separate, unrelated visits that occur on the same DOS as an outpatient continuous visit, Forward Health recommends providers do the following: ? Submit separate claims for each visit. Include condition code G0 (the letter G and the digit zero) on the second claim submitted and send it to Written Correspondence for special handling. To do this, attach the Written Correspondence Inquiry form, F-01170 (07/12), to the paper claim or adjustment form and indicate “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the Other Information field of the form.

* If a claim that indicates the G0 condition code also requires consideration for an exception to the submission deadline, submit a completed Timely Filing Appeals Request form, F-13047 (07/12), for each claim, entering “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the free format field near the bottom of the form.

For example, a member comes in to the emergency room (ER) on the morning of January 8, 2012, with a concussion and returns home once treated. He returns to the ER later that same night with a high fever and vomiting and is kept over midnight for observation. In this situation, the provider is encouraged to bill the two visits on two separate claims and to differentiate the visits using condition code G0 on the second claim submitted, following the special handling instructions stated previously. This allows Forward Health to reimburse both visits and pay two access payments to the provider, if applicable.

Note: The special handling instructions listed above apply to claims or adjustments with DOS between January 1, 2010, and March 31, 2013. Claims and adjustments with DOS on and after April 1, 2013, will not require special handling for the G0 condition code; these claims will be processed using the new Enhanced Ambulatory Patient Groups (EAPG) reimbursement methodology for outpatient hospital services.



Multiple Medical Visits

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.




Use of Modifier –25 and Modifier 27 in the Hospital Outpatient Prospective Payment System (OPPS)

This Program Memorandum (PM) provides clarification on reporting modifier –25 and modifier –27 under the hospital OPPS.

The Current Procedural Terminology (CPT) defines modifier 25 as “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier –25 was approved for hospital outpatient use effective June 5, 2000.

The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001. Although HCFA will accept modifier –27 for OPPS claims, this modifier will not replace condition code G0. The reporting requirements for condition code G0 have not changed. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue centers. For further clarification on both modifiers, refer to the CPT 2001 Edition. Below are general guidelines in reporting modifiers –25 and –27 under the hospital OPPS.

A. Modifier –27 should be appended only to E/M service codes within the range of 92002- 92014, 99201-99499, and with HCPCS codes G0101 and G0175.

B. Hospitals may append modifier –27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital outpatient setting.

C. When reporting modifier 27, report with condition code G0 when multiple medical visits occur on the same day in the same revenue centers.

As is true for any modifier, the use of modifiers –25 and –27 must be substantiated in the patient’s medical record.

Fiscal Intermediaries should forward this PM electronically to providers and place on their web site. This PM should also be distributed with your next regularly scheduled bulletin. 

Friday, July 12, 2019

Medicare part B basics - covered service and premium


Four categories of Medicare insurance: Parts A, B, C, and D.

1. Part A. Provides hospital facilities, nursing facilities, hospices and home health facilities.

2. Part B. covers physician services, ambulatory care and non-hospital services.

3. Part C. Medicare advantage plan, both includes Parts A and B.

4. Part D. Prescription plan.



Medicare Part B




All persons entitled to Part A are also entitled to Part B. Usually, the monthly premium has to be collected from person. An annual Part B deduction also applies, and coins will be processed in each claim, which means that Medicare pays a share of the allowed amount for all covered services and the patient has to pay the remaining 20 % or co-insurance.



The most important thing to remember about Part B is that it covers doctoral bills, wherever they may be, at home, in the doctor's office, in a clinic and hospital.

Part B also covers:

• Outpatient hospital services
• X-rays and diagnostic tests
• Ambulance services
• Durable medical equipment (e.g. wheelchairs )
• Certain non-physician services
• Physical therapy

Medicare Part B covers numerous preventive companies to assist seniors and adults with disabilities to stay healthy. These embrace an Annual Wellness Visit, most cancers screenings, vaccines, and testing and management of chronic situations.


Medicare Part B Premium

In a number of ways, Part B premiums can be collected. In case an enrollee receives social security and railway pension , Part B premiums shall, by legislation, be deducted  automatically. In addition, Part B premiums are deducted from the benefits of retired persons of the Federal Civil Service. The purpose of auto collection of premiums is to maintain a minimum of premium collection costs.

The normal monthly premium for Part B was $135.50 in 2019.

Medicare Part B Eligibility and Enrollment

A person who has worked in covered employment and who has paid Medicare payroll tax for 40 quarters is eligible to receive Medicare Part A premium-free benefits at the age of sixty-five. All persons eligible for part A (whether eligible for Part A premium-free), also have the right to register in Part B. An old person who is not eligible in part A can register in part B when he or she is 65 or older, and either an American citizen or foreign national is legally permitted in the name of a permanent resident.


Common Medicare Questions

Q: Do I have to apply to Medicare or do I receive it automatically?


A: When you've received Medicare, you've been registered automatically for both Parts A and Part B when you get some type of Social Security (pension advantages or disability benefits).

Do both parts A and B have to be taken?

A: The need for the part A and B of Medicare depends on whether Medicare will be your primary or secondary insurer. Part A is hospital and Part B is health insurance. You do not need either Part A or Part B if your present employer insurance is primary. Most individuals choose to take Part A because it is free for them. For example, if you have a retirement or a COBRA insurance, you need both Part A and Part B since Medicare is the primary one.


How do I pay for Medicare if my Social Security Check does not automatically take it away?

A: If you do not automatically take your Part B premium from your social security check, you can send your check to your local social security office. It is however a good idea to automatically taken from your social security check.


Is there additional insurance for which I can buy that to pay for the deductibles and coinsurance?

A: Yes. A: Yes. Medigap policy can help pay your Medicare copays and allowable deductible amount.   See if you have the right to purchase a Medigap plan by the State Insurance Department

Friday, June 14, 2019

ACES program code list

ACES Program Codes

Some provider groups rely on the ACES program codes to help them determine if the client is on a state-only program or is on a Washington Apple Health Medicaid program to identify their funding sources. The following table lists these program codes.

SSI and SSI Related SSI and SSI related, also called Aged/Blind/Disabled (ABD); disability is determined by SSA or by NGMA referral to DDDS 

ACES DESCRIPTION  SCOPE 

S01 SSI Recipients CN
S02 ABD Categorically Needy CN
S03 QMB  Medicare Savings Program (MSP)  Medicare premium and co-pays MSP
S04 QDWI Medicare Savings Program   MSP
S05 SLMB Medicare Savings Program. Medicare Premium only  MSP
S06 QI-1 (ESLMB) Medicare Savings Program  MSP
S07 Undocumented Alien. Emergency Related Service Only ERSO 
S95 Medically Needy no Spenddown MN
S99 Medically Needy with Spenddown MN SSI Related
Living in an alternate living facility (nonmedical institution) adult family home, boarding home or DDA group home.


SSI Related Healthcare for Workers With Disability

Institutional  HCBS Waivers (HCS/DDA) and Hospice; SSI related  G03
Non Institutional Medical in ALF CN-P Income under the SIL plus under state rate x 31 days + 38.84
G95 Medically Needy Non Institutional in ALF no spenddown MN
G99 Medically Needy Non Institutional  in ALF with Spenddown MN
S08  Healthcare for Workers with Disability CN-P Premium based program.  Substantial Gainful Activity (SGA) not a factor in Disability determination.  
L21 Categorically Needy DDA/HCS Waiver or Hospice on SSI CN  L22
L24  Categorically Needy DDA/HCS Waiver or Hospice – gross income under the SIL Undocumented Alien/Non-Citizen LTC - residential placement. Must be preapproved by ADSA program manager. Emergency Related Service Only (45 slots)
L31 PACE or hospice on SSI (effective 10/1/15) CN
L32 PACE or hospice – SSI-related (effective 10/1/15) CN
L41 Roads to Community Living on SSI (effective 10/1/15) CN
L51 Community First Choice (CFC) on SSI (effective 10/1/15) CN
L52  Community First Choice (CFC) – SSI related at home or in an ALF (effective 10/1/15)
L99 Medically Needy Hospice in Medical Institution.  With Spenddown MN Institutional  SSI  L01
SSI recipient in a Medical Institution - Residing in a medical institution 30 days or more
CN Institutional
SSI Related Residing in a medical institution 30 days or more   
L02 SSI related CN-P in a Medical Institution Income under the SIL CN  L04  L95
L99  Undocumented Alien/Non-Citizen LTC must be pre-approved by ADSA program manager. Emergency Related Service Only (45 slots)
SSI related Medically Needy no Spenddown Income over the SIL. Income under the state rate.
SSI related Medically Needy with Spenddown Income over the SIL. Income over the state rate but under the private rate. Locks into state NF rate  CN  CN
ERSO – CN scope  CN
ERSO – CN scope  MN  MN


Categorically Needy Program (CNP)

This program has the largest scope of care.  A few of the services are:doctors, dentists, physical therapy, eye exams, eyeglasses (children only), mental health, prescriptions, hospitals, and family planning for men, women, and teens. There is limited coverage for maternity case management, orthodontia, private duty nursing, and psychological evaluations.Chiropractic care and nutrition therapy are limitedto the Healthy Kids program.


Alternative Benefits Plan (ABP)

This program is available to persons eligible to receive health care coverage under Washington Medicaid’s Modified Adjusted Gross Income (MAGI)-based adult coverage.  The scope of services available is equivalent to that available to CNP-covered clients with the addition of a benefit for habilitative services.  Washington Administrative Code (WAC) program policies are applicable to this new eligibility group, as are the instructions in the ProviderOne Billing & Resource Guide and program-specific provider guides.  This client population does not include those eligible for Medicare.


Emergency Related Services Only (ERSO) –PA may be required


This program has coverage for only specific medical conditions: a qualifying emergency, end stage renal disease on dialysis, cancer actively receiving treatment, or post-transplant status on anti-rejection medications. Prior authorization for some services may be required. Services not related to the medical condition are not covered. HCA determines if the client has a qualifying condition for any of these programs in accordance with the Washington Administrate Code (WAC) criteria. For specific details please see Chapter 182 - 507 WAC


.
Take Charge –Family Planning Service Only (TCFPO)

This program is for both women and men.It covers family planning services such as annual examinations, family planning education and risk reduction counseling, FDA approved contraceptive methods such as birth control pills and IUDs, emergency contraception,and sterilization procedures.

Family Planning Services Only (FPSO)


This program is  for women. Services includecoverage for all birth control methods, sterilization, OB-GYN exams, and counselingto help with family planning.

Medical Care Services (MCS) -no out of state care

This program covered many of the most basic services such as doctor's visits, prescriptions, and hospitalizations. However, some services, such as dental and mental health treatment may have restrictions that require prior authorization or may not be covered. This benefit was previously known as General Assistance (GA) and Disability Lifeline (DL).

Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) -no out of state care

This program covered many of the most basic services such as doctor's visits, prescriptions, and hospitalizations.However, some services, such as dental and mental health treatment may have restrictions that require prior authorization or may not be covered.Coverage is equivalent to Medical Care Services (MCS) below, with the addition of treatment for alcohol and drug addiction.


Limited Casualty Program – Medically Needy Program (LCP-MNP)

This program covers many medical services. A few of the services are:doctors, dentists, eye exams, eye glasses (children only), mental health , prescriptions, and hospitals, family planning for men, women, and teens.There are some services that are not covered, such as physical therapy.There are also limited services: maternity case management is one example. Chiropractic care and nutrition therapy are limited to the Healthy Kids program.


 

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