Billing Maryland Medicaid: Guidance for SBHCs

Topics for experienced billers

Molly Marra, OHS Maureen Regan, OHS

MASBHC 2014

Introductions • Lelin Chao, M.D. Medical Director, Amerigroup

• Megan Welter, Health Promotion Consultant, Amerigroup

• Jeremy Randall, Manager, Medicaid Field Operations, Amerigroup

• Molly Marra, Chief of Health Services Policy, Maryland Medicaid

• Maureen Regan, Lead Communications Analyst, Policy and Compliance, Medicaid

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Morning Session • Need-to-know terms and acronyms

• Medicaid 101

• SBHC definition, function, and scope of services

• Enrollment and Billing 101

• Resources

• Q&A

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In this presentation • Medicaid – New Initiatives

– Healthcare Reform in Maryland – ICD-10 (on hold) – New CMS 1500 Form – Expanding Access – Telemedicine – EHR Incentive Program

• Amerigroup – Medicaid Managed Care Organization – SBHC and PCP relationship – Best practices: billing – Resources

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Healthcare Reform • March 23, 2010: PPACA becomes law

• Medicaid expansion: – 95,899 Primary Adult Care (PAC) enrollees gained full

coverage as of January 1, 2014 – 262, 619 new enrollees in Medicaid total (includes PAC)

• Improved continuity of care between Medicaid and Qualified Health Plans (QHPs) – Essential Health Benefits

• Safety net providers play big role to ensure access as ore individuals and families sign up for coverage

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84,723 188,247 203,365 217,792 224,752 231,807 238,957

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

2014 2015 2016 2017 2018 2019 2020

Medicaid Expansion Medicaid "Woodwork" Effect Current Medicaid (Excluding PAC)

Total New Medicaid

Enrollment in Medicaid, 2014 and Beyond

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Jul-03 Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11

MCHP

SOBRA - Low Income Women & Children

TCA - Related Families and Children

Other

Disabled Elderly

Maryland Medicaid Enrollment by Eligibility Category, 2003-2011

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How to Help with Enrollment Assistance • Direct families to Local Health Departments or local

Departments of Social Services

• May also enroll through SAIL: marylandsail.org

• Open enrollment for QHPs is now closed – Special enrollment eligibility may be determined through

call center

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ICD-10 (delayed) • WHAT: World Health Organization (WHO) adopted

ICD-10 in 1990 – US last developed country still using ICD-9 (1979)

• WHY: Better support for analysis, reporting, risk, severity

• WHEN: HR 4302 delayed ICD-10 implementation until at least October 1, 2015

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Difference in Diagnosis Codes

• 3 to 5 digits • Alpha on 1st Character only • Limited severity parameters • Does not include laterality • Limited combination codes

• ~ 14,000 codes

• 7 digits • Alpha or Numeric on ANY • Extensive severity parameters • Common use of laterality • Common combination codes

• ~ 70,000 codes

ICD-9 Diagnosis Codes ICD-10 Diagnosis Codes

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Example – ICD-9 A provider sees a patient in a subsequent encounter for a non-union of an [open] [fracture] of the right [distal] [radius] with intra-articular extension and a minimal opening with minimal tissue damage.

ICD-9 Code Description 81352 Open Other Fracture of Distal End of Radius (Alone)

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Example – ICD-10 A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage].

ICD-10 Code Description S52571M Other intra-articular fracture of lower end of right

radius, subsequent encounter for open fracture type I or II with nonunion

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Terminology Changes

ICD-9 Term ICD-10 Term Bunionectomy Resection of Metatarsal

Amputation Detachment

Tracheotomy Bypass

Cesarean section Extraction of Products of Conception

Debridement Excision, Extraction, Irrigation, Extirpation

CMS 1500 Form 02-12

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Changes to the CMS 1500 Form • Form 02-12 only version accepted as of April 1, 2014

• Mostly cosmetic and semantic changes

• Most significant changes apply to block 24 – diagnosis pointers

• Purchase version 02-12 at nucc.org or through your current vendor

• Change applies to all payors using CMS 1500 – Medicare, Medicaid and MCOs

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Expanding Access – Telemedicine • Maryland Medicaid telemedicine program began in 2013

– Limited to Rural Access and Cardiovascular Disease and Stroke Programs

– “Hub and Spoke” model

• Complemented telemental health program already in existence

• FQHCs, hospitals, LHDs, and physicians among eligible participants

• E&M and specialty consultation services covered

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Expanding Access – Telemedicine • Statewide access beginning October 1, 2014

• 2014 legislation expanded services statewide and merged the two telemedicine programs

• DHMH/Medicaid does not pay to implement necessary equipment

More information: dhmh.maryland.gov/telemedicine

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EHR and Maryland Medicaid What is an Electronic Health Record? • Digital version of a patient’s paper chart

• Improve the quality and safety of patient care

• However, an EHR is NOT an EMR – EHRs are intended to be interoperable; they are not

simply a way to electronically store records

• Talk to your SBHC sponsoring entity

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EHR Incentive Program Maryland SBHC sponsoring agencies – FQHCs or LHDs – received $2,337,500 in EHR incentives

• Created under the ARRA of 2009 • Provide financial incentives for

adoption and meaningful use of EHRs

• Maximum incentive amount is $63,750 over 6 years

Eligibility for the Incentive Eligible provider type* Non hospital-based Have 30% or more Medicaid patients Adopt, Implement, or Upgrade an EHR (1st yr) Meaningfully Use an EHR (2nd-6th yr )

*Including: M.D., D.O., nurse practitioner, and certified nurse-midwife 19

Assessing EHR Readiness Are there clinical priorities or needs that should be addressed?

Are administrative processes organized, efficient, and well documented?

Are staff members computer literate and comfortable with information technology?

Does the practice have access to high-speed internet connectivity?

Does the practice have access to the financial capital required to purchase new or additional hardware?

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Application and Attestation Process • Eligible Providers (Eps) must be enrolled with Medicaid FFS and eMedicaid at

https://encrypt.emdhealthchoice.org/emedicaid/ • Must have individual NPI and register with CMS Registration System

https://ehrincentives.cms.gov/hitech/login.action • Complete the attestation process for each individual provider at Maryland’s

Electronic Medicaid Incentive Program Payment (eMIPP) system at https://emipp.dhmh.maryland.gov/

• Things you need when attesting

EHR certification number Patient volume reports (from an auditable source, e.g. practice management software, billing software, etc) AIU Proof, e.g. receipt or proof of purchase, EHR contract, software license, purchase order or invoice, receipt for training, etc Meaningful Use report (For Stage 1, you must meet 13 Core and 5 Menu Objectives)

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