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LOUISIANA

Department ofHEALTH and

HOSPITALS

UNISYS

Louisiana MedicaidLouisiana Medicaid

DHH – Bureau of Primary CarePractice Management Technical Assistance Workshop

August 13August 13thth , 2008 , 2008

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Professional Services forProfessional Services for

PhysiciansPhysicians

Nurse PractitionersNurse Practitioners

RNs RNs

School Based Health CentersSchool Based Health Centers

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Billing for Professional ServicesBilling for Professional Services

Individual Physicians Practicing Independently or within a GroupIndividual Physicians Practicing Independently or within a Group Fee Schedule with procedure codes @ Fee Schedule with procedure codes @ www.lamedicaid.com – link – link

Fee SchedulesFee Schedules Nurse PractitionersNurse Practitioners

Must be supervised by a PhysicianMust be supervised by a Physician Provide services only within scope of licenseProvide services only within scope of license Paid 80% of physicians’ fees (100% for immunizations)Paid 80% of physicians’ fees (100% for immunizations)

Registered Nurses Registered Nurses Can only provide KidMed Screenings/ImmunizationsCan only provide KidMed Screenings/Immunizations Must be supervised by a PhysicianMust be supervised by a Physician

School Based Health CentersSchool Based Health Centers Can only perform services for which they have staff and that they Can only perform services for which they have staff and that they

are enrolled to provideare enrolled to provide

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KIDMED SCREENINGSKIDMED SCREENINGS In order to obtain In order to obtain KIDMEDKIDMED linkage, providers linkage, providers

MUST CALLMUST CALL ACS to ACS to verify verify the the screening providerscreening provider on record for the date that the screening is being on record for the date that the screening is being renderedrendered

RS-0-07 reports are now online and are no longer RS-0-07 reports are now online and are no longer mailed to providersmailed to providers

Only Medical, Vision, and Hearing ScreeningsOnly Medical, Vision, and Hearing Screenings are are billed on KM-3 (hardcopy) or 837P with the K-3 billed on KM-3 (hardcopy) or 837P with the K-3 (KIDMED) segment (electronically) (KIDMED) segment (electronically)

Immunizations, Laboratory Tests, Interperiodic Immunizations, Laboratory Tests, Interperiodic Screenings, Consultations, and Low Level VisitsScreenings, Consultations, and Low Level Visits are billed on the CMS-1500 (hardcopy) or on the are billed on the CMS-1500 (hardcopy) or on the 837P (electronically)837P (electronically)

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KIDMED Screening PolicyKIDMED Screening Policy

Medical ScreeningMust perform all 5 components

Providers must use the age appropriate code in order to avoid claim denial

Providers should use the TDTD modifier to report a screening that was performed by a nurse.

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KIDMED Screening PolicyKIDMED Screening Policy

VISION SCREENINGVISION SCREENING Subjective Vision Screening

Included in medical component Objective Vision Screening

Begins at age 44 Bill with procedure code 99173 99173 with the EP modifierEP modifier

HEARING SCREENINGHEARING SCREENING Subjective Hearing Screening

Included in medical component Objective Hearing Screening

Begins at age 44 Bill with procedure code 9255192551

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2 yr old receiving a medical screening by a physician – 2 yr old receiving a medical screening by a physician – Immunizations current. Suspected medical condition/referral info incImmunizations current. Suspected medical condition/referral info inc

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7 yr old receiving screenings by a nurse – Immunizations are not 7 yr old receiving screenings by a nurse – Immunizations are not current. Suspected medical condition and referral info included.current. Suspected medical condition and referral info included.

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Interperiodic Screening by a PhysicianInterperiodic Screening by a Physician

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Four Immunizations GivenFour Immunizations Given

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Billing for Procedure Code 99211Billing for Procedure Code 99211

Physicians may write prescriptions for injections covered under the Pharmacy program and have the prescription filled by a Medicaid enrolled pharmacy.

The recipient may then bring the dispensed medication to the physician’s office and a low-level office visit (99211) could be billed as long as a higher level visit had not been billed on that particular date.

If the injection is given during a more complex visit, that appropriate code for the visit should be billed and there would not be a separate charge for administering the injection.

NOTE: This policy excludes RHC’s, FQHC’s, and NOTE: This policy excludes RHC’s, FQHC’s, and KidMed Clinics.KidMed Clinics.

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Common Billing ErrorsCommon Billing Errors General Claim Form Completion Codes

003 – Recipient # invalid or less than 13 digits 028 – Invalid or missing CPT code

Recipient Eligibility Error Codes 215/216/222/223 – Recipient not on file/not eligible on one or more

DOS 217 – Name/# on claim does not match file

CommunityCARE Error Codes 106 – Billing provider is not PCP/Services not authorized by PCP

Timely Filing Error Codes 272/371 – Claim exceeds 1 year filing limit/attachment requires review

TPL Error Codes 273 – TPL carrier code missing 290 – No EOB from primary carrier attached

Miscellaneous Error Codes 299/232 - Procedure not covered by Medicaid/type of service not

covered

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Timely Filing GuidelinesTimely Filing Guidelines

Initial Filing LimitsFiling Limits

Dates of Service Past Initial Filing LimitDates of Service Past Initial Filing Limit

Two-Year Filing Limit Two-Year Filing Limit

KidMed Filing Limits KidMed Filing Limits

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Appeals ProcessAppeals Process

Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys

Appeals may be filed when all efforts to get the claim paid have been exhausted

Requests must be submitted in writing to DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La. 70821-4182

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CommunityCARECommunityCARE

Program DescriptionProgram Description

Exempt RecipientsExempt Recipients

Primary Care Physician (PCP)Primary Care Physician (PCP)

Non-PCP ProvidersNon-PCP Providers

Exempt ServicesExempt Services

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• Provider Assistance:

ACS: Linkages/Monitoring/Certification – 800-259-4444 Referral Assistance – 877-455-9955

Unisys Provider Relations: Billing/Claims – 800-473-2783 or 225-924-5040

• Recipient Assistance: ACS - 800-259-4444

CommunityCARECommunityCARE

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Outpatient Visit LimitsOutpatient Visit Limits

If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP

Can either treat the recipient and not bill Medicaid

Offer to see the recipient as a private pay patient (enrollee pays out of pocket)

Request an extension using the 158-A form Issue a referral to a physician who will treat the

recipient

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Mental Health Services Mental Health Services

Effective 10/01/07, LA Medicaid reimburses professional service providers for select procedure codes specific to psychiatric services

Providers must use procedure codes 90801-90802, 90804-90815, 96101

Services are counted toward the outpatient visit limits allowed per calendar year

Psychiatrists Independently practicing or groups Services covered are those provided by any physician

under the scope of the psychiatric license Reimbursement is based on fee-for-service

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Federally Qualified Health CentersFederally Qualified Health Centers

AndAnd

Rural Health ClinicsRural Health Clinics

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Billing for Services in an Billing for Services in an FQHC/RHC SettingFQHC/RHC Setting

Must bill with encounter code T1015 for both Professional Services and KidMed Screenings

Attending provider information also reported on claim form as well as Group provider info

Clinic is paid based on the Encounter Rate set by DHH for that particular provider

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FQHC/RHC Physician EncounterFQHC/RHC Physician Encounter

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KIDMED Periodic Screening by a NurseKIDMED Periodic Screening by a Nurse

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Common Billing ErrorsCommon Billing Errors

FQHC/RHC Error Codes 092 – Invalid procedure modifie 136 – No eligible service paid, encounter

denied 210 – Provider/Procedure conflict 517 – KidMed format required 518 – KidMed information missing 715 – Duplicate edit – only one encounter

paid per day

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Timely Filing GuidelinesTimely Filing Guidelines

Initial Filing LimitsFiling Limits

Dates of Service Past Initial Filing LimitDates of Service Past Initial Filing Limit

Two-Year Filing Limit Two-Year Filing Limit

KidMed Filing Limits KidMed Filing Limits

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Appeals ProcessAppeals Process

Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys

Appeals may be filed when all efforts to get the claim paid have been exhausted

Requests must be submitted in writing to DHH Bureau of AppealsDHH Bureau of Appeals

P.O. Box 4183P.O. Box 4183

Baton Rouge, La. 70821-4182Baton Rouge, La. 70821-4182

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CommunityCARECommunityCARE

Program DescriptionProgram Description

Exempt RecipientsExempt Recipients

Primary Care Physician (PCP)Primary Care Physician (PCP)

Non-PCP ProvidersNon-PCP Providers

Exempt ServicesExempt Services

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• Provider Assistance:

ACS: Linkages/Monitoring/Certification – 800-259-4444 Referral Assistance – 877-455-9955

Unisys Provider Relations: Billing/Claims – 800-473-2783 or 225-924-5040

• Recipient Assistance: ACS - 800-259-4444

CommunityCARECommunityCARE

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Outpatient Visit LimitsOutpatient Visit Limits

If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP

Can either treat the recipient and not bill Medicaid

Offer to see the recipient as a private pay patient (enrollee pays out of pocket)

Request an extension using the 158-A form Issue a referral to a physician who will treat the

recipient

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Mental Health Services Mental Health Services

Billing for Psychiatrist Services PCP Referral NOT required for services rendered by a Psychiatrist MUST enter psychiatrist’s provider number and/or NPI as attending

Billing for Social Workers/Psychologists Services DO require a PCP referral Must enter the RHC/FQHC group number and/or NPI as the

attending and billing provider

Refer to Professional Fee Schedule for procedure codes Services are paid based on an Encounter Rate established by

DHH Services are counted toward the outpatient visit limits allowed

per calendar year

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Provider Assistance Provider Assistance

Provider Relations Telephone Inquiry Unit:Provider Relations Telephone Inquiry Unit:

800-473-2783 or 225-924-5040800-473-2783 or 225-924-5040 Correspondence Unit:Correspondence Unit: Unisys-Provider RelationsUnisys-Provider Relations

P.O. Box 91024P.O. Box 91024

Baton Rouge, LA. 70821Baton Rouge, LA. 70821 Field AnalystField Analyst Phone Numbers for Provider Assistance

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Thank YouThank You

For Attending this 2008 Provider Workshop.