HP Provider Relations October 2010 Home Health & Hospice.

HP Provider Relations

October 2010

Home Health & Hospice

UB-04 Billing Medicare Replacement Plans October 20102

Agenda

– Session Objectives

– Home Health Benefit• Coverage

• Billing

• Overhead

• Multiple Visits

• Most Common Denials

– Hospice Benefit• Coverage

• Election/Revocation/Discharge

• Billing

• Most Common Denials

– Helpful Tools

– Questions


Session Objectives

– Home Health providers will:• Understand basic coverage requirements

• Identify the revenue codes and procedure codes to use for billing

• Understand how to report units and overhead

• Understand when a prior authorization is not needed

• Learn how to resolve the top reasons for home health claim denials

– Hospice providers will:• Learn what is involved in the election, revocation, and discharge processes

for hospice members

• Learn what is required for a member to change hospice providers

• Identify appropriate revenue codes for billing

• Learn how to resolve the top reasons for hospice claim denials

LearnHome Health


Home Health

Home health services are available when:

– Members are medically confined to the home

– Services are ordered in writing by a physician

– Services align with a written plan of care

Note: Home health services require prior authorization

Coverage


Home Health

– “Homebound” Defined: IHCP members, who, because of illness or injury, are unable to leave home without assistance of another person or an assistive device such as a wheelchair or walker, or for whom leaving the home is contrary to medical advice

– Home health services are appropriate for care and treatment of acute or chronic conditions, rehabilitation, education regarding care, coordination of community services, or to avoid prolonged or repeated hospitalization and/or higher and more costly levels of care

– Certain home health services duplicate services provided by Home and Community-Based Service (HCBS) Waiver providers

– BT201022, dated July 6, 2010, assists case managers and providers in determining the appropriate services (Waiver vs. Medicaid) needed for members eligible under the HCBS Waiver program

Home health versus HCBS Waiver

BillElectronic Claims


Home HealthWeb interChange – Claims Processing Menu


Institutional Claim

BillPaper Claims


Home Health

– Mail UB-04 paper claims to the following address:

HP

Home Health Claims

P.O. Box 7271

Indianapolis, IN 46207-7271

– Claims for members assigned to a managed care entity (MCE) must be mailed to the appropriate MCE•Anthem•Managed Health Services•MDwise

Paper Claims


Home Health

– Home health providers bill services according to the following codes• Direct prior authorization inquiries to ADVANTAGE or MDwise

Revenue Codes and HCPCS/CPT® Codes

Revenue Code

HCPCS/ CPT Code

Revenue Code

HCPCS/ CPT Code

Revenue Code

HCPCS Code

420 G0151 421 G0151 422 G0151

423 G0151 424 97001 429 G0151

430 G0152 431 G0152 432 G0152

433 G0152 434 97003 439 G0152

440 G0153 441 G0153 442 G0153

443 G0153 444 92506 449 G0153

552 99600 TE 552 99600 TD 559 S9349

559 99601, 99602

572 99600

CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Home Health

– Therapy services• One unit equals 15 minutes

• Requires treatment lasting 8 minutes or more to bill for one unit

• Providers cannot bill when the service lasts fewer than 8 minutes

– Home Health Aides, LPN, and RN Services• One unit equals one hour

• Visits for less than one hour are billed as one unit if a service is performed

• Visits longer than one hour are billed as a partial unit

– Partial Unit• Round partial units of service to the nearest whole unit

• For nursing services, round up to the nearest whole unit when services last 30 minutes or more

Units and Partial Units


Home Health

– Providers receive a state-wide flat overhead rate for administrative costs and a staffing reimbursement component

– The IHCP allows one overhead rate per provider per member per day

– Report occurrence code 61 on claims to report the overhead• 61 indicates that one encounter with the member occurred on the date of

service

– For consecutive dates of service, report occurrence code 61 and the date range in the Span Date field

– When billing for multiple members at the same location on the same date, report occurrence code 61 to only one of the members’ claim

Overhead


Home Health

Certain services are reimbursable without a prior authorization following a hospital discharge as follows:

– Therapy services• Any combination of therapy services up to 30 units in 30 days following the

discharge

• Use occurrence code 53 on the claim− Occurrence code 53 indicates HHA billing for initial therapy evaluations

– Nursing services• May not exceed 120 units within 30 days following the discharge

• Use occurrence code 50 on the claim– Occurrence code 50 indicates previous hospital discharge

– Services must be ordered in writing by a physician prior to the hospital discharge

– Member must be homebound

Hospital Discharge


Home Health

– BT201018, dated June 1, 2010, provides the rates for home health services for state fiscal year 2011

– Home health services are subject to a 5% rate reduction through June 30, 2011, as follows:

Reimbursement Rates

Service SFY 2011 Rate

Overhead $34.30 per provider, per recipient, per day

Registered nurse (RN) – 99600 TD

$37.36 per hour

Licensed practical nurse (LPN) – 99600 TE

$25.01 per hour

Home health aide – 99600 $19.31 per hour

Physical therapy – G0151 $14.39 per 15-minute increments

Occupational therapy – G0152 $13.65 per 15-minute increments

Speech therapy – G0153 $14.91 per 15-minute increments

DenyCommon Denials


Most Common Denial Codes

Edit 4021 – Procedure code is not covered for the dates of service for the program billed.

– Cause

• The procedure code billed is restricted to a specific program for the dates of service billed and there is no prior authorization

– Resolution• Electronic

−Resubmit the claim and correct the procedure code. See the table on Slide #13 for the list of valid procedure codes.

• Paper

−Resubmit the claim and correct the procedure code. See the table on Slide #13 for the list of valid procedure codes.

Home Health



Edit 0558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim

– Cause

• The claim is missing the Medicare coinsurance amount


−Click the “Benefits Information” button to include the Medicare coinsurance reason code (2) and amount

• Paper

−Enter the Medicare coinsurance value code (A2) and amount in field locator 39 of the UB-04 claim form

Home Health



Edit 3001 – Dates of service not on the PA master file

– Cause

• The dates of service billed on the claim have not been prior authorized

– Resolution• Electronic and Paper

−If no prior authorization was requested, complete the Prior Authorization Request Form and fax it to ADVANTAGE Health Solutions or MDwise

−If a PA was requested but was not approved, contact ADVANTAGE or MDwise for assistance

−If a PA was requested and was approved, resubmit the claim and ensure that all the dates of service on the claim were approved on the PA

Home Health



Edit 5001 – This is a duplicate of another claim

– Cause

• The exact same claim was submitted more than once and the claim has already been paid


−Look up the claim in Web interChange using the Member ID and Date of Service. The results will identify the date that the claim paid.

Home Health



Edit 0516 – The occurrence code dates do not match the claim detail dates

– Cause

• The occurrence code date in the ‘header’ portion of the claim does not match any of the service dates on the detail lines on the claim


−Resubmit the claim ensuring the occurrence code date (for overhead) matches each date of service in the detail portion of the claim

• Paper

−Resubmit the claim ensuring that the occurrence code date (for overhead) in field locators 31a-34b match each date of service in the detail portion of the claim in field locator 45

Home Health

LearnHospice


Hospice

– The hospice benefit applies to those who are certified as terminally ill

Note: A member is considered terminally ill if, given that the illness runs its normal course, the medical prognosis suggests a life expectancy of six months or less

– Hospice eligibility is available in three consecutive benefit periods:• Period 1: 90 days

• Period 2: 90 days (expected maximum length of illness to run its course)

• Period 3: Unlimited 60-day period

• For Medicaid-only members, each benefit period requires prior authorization based on medical necessity

Benefit Periods


Hospice

– Hospice services are reimbursed at one of four levels of care:

• Routine home hospice care

• Continuous home hospice care

• Inpatient respite hospice care

• General inpatient hospice care

Levels of Care


Hospice

– A member must elect the hospice benefit by completing a Medicaid Hospice Election State Form 48737 (R/11-04)/OMPP 0005

– When completing the election form, the member or representative specifies an effective date for the hospice benefit and the name of the hospice provider that will render care

Note: All hospice forms are available under the Forms link at http://provider.indianamedicaid.com

Election


Hospice

– Members who elect the hospice benefit agree to waive the following:• Other forms of healthcare for treatment of the terminal illness for which hospice

care was elected or for treatment of a condition related to the terminal illness

• Services provided by another provider equivalent to the care provided by the elected hospice provider

• Hospice services other than those provided by the elected hospice provider or its contractors

Election


Hospice

– The hospice provider has responsibility for the management of the member’s care

– If the member resides in a nursing facility, the hospice provider should provide a copy of the Medicaid Hospice Election State Form to the facility for inclusion in the member’s clinical record• This ensures that the nursing facility staff knows that the member has elected

the IHCP hospice benefit

– The hospice provider should develop coordination procedures with the nursing facility to avoid reimbursement problems between the hospice provider and nursing facility• The nursing facility must be aware when the member elects, revokes, or is

discharged from hospice care

Election


Hospice

– Care Select and risk-based managed care members who elect the hospice benefit must be disenrolled from these programs and transitioned to Traditional Medicaid

– To disenroll the member from managed care programs, the hospice provider faxes the member election forms to ADVANTAGE Health Solutions at 317-810-4488• Provider should contact ADVANTAGE the same day to ensure receipt of the fax

and timely disenrollment from the managed care programs

– ADVANTAGE contacts the enrollment broker (MAXIMUS) to facilitate the disenrollment

– Hospice provider may bill for services beginning the day after the member is disenrolled from the managed care programs

Election


Hospice

– The member has the right to revoke hospice services at any time• Revocation is a patient-initiated process

– To revoke services, the member or representative must complete the Medicaid Hospice Revocation State Form 48735 (4/98)/OMPP 0007, and specify the effective date of the revocation

– The hospice provider faxes the Medicaid Hospice Revocation State Form to ADVANTAGE Health Solutions at 1-800-689-2759

Revocation


Hospice

– A member can elect to receive hospice care intermittently, rather than consecutively, over the three benefit periods

– If a member later re-elects the hospice benefit, the member returns as a re-enrollment to the next eligible hospice benefit period

– Upon re-election the hospice provider submits the following forms to ADVANTAGE Health Solutions:• Medicaid Hospice Election State Form 48737 (R/11-04)/OMPP 0005

• Medicaid Hospice Physician Certification State Form 48736 (R/12-02)/OMPP 0006

• Updated plan of care

• Documentation must prove medical necessity

Revocation


Hospice

– The discharge process is initiated by the hospice provider

– A hospice provider may discharge a member when:• The patient moves out of the hospice’s service area or transfers to another hospice

• The hospice determines that the patient is no longer terminally ill; or

• The hospice determines that the patient’s behavior (or other persons in the patient’s home) is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired

• Death of the member

– Before discharging a member, the hospice provider must:• Advise the patient that a discharge for cause is being considered

• Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation

• Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services

• Document the problem(s) and efforts made to resolve the problem(s) into the medical record

Discharge


Hospice

– The member may change to another hospice provider by filing a Hospice Provider Change Request Between Indiana Hospice Providers State Form 48733 (R/12-02) OMPP 0009

– The new hospice provider may fax the form to ADVANTAGE Health Solutions at 1-800-689-2759

Change Hospice Provider

BillHospice


Hospice

651 – Routine home care delivered in a private home

652 – Continuous home care delivered in a private home

653 – Routine home care delivered in a nursing facility

654 – Continuous home care delivered in a nursing facility

655 – Inpatient respite care

656 – General inpatient hospice care

657 – Hospice direct care physician services

659 – Medicare/IHCP dually eligible nursing facility room & board

183 – Nursing facility bed hold for hospice therapeutic leave days

185 – Nursing facility bed hold policy for hospitalization for services unrelated to the terminal illness of the hospice member

Note: Request all prior authorizations using revenue code 651

Revenue Codes

DenyCommon Denials



Edit 0558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim

– Cause

• The claim is missing the Medicare coinsurance amount


−Click the “Benefit Information” button to include the Medicare coinsurance reason code (2) and amount

• Paper

−Enter the Medicare coinsurance value code (A2) and amount in field locator 39 of the UB-04 claim form

Hospice



Edit 0594 – Type of bill not covered by IHCP

– Cause

• The claim reported a Type of Bill other than 822


−Resubmit the claim and report ‘822’ in the Type of Bill field

• Paper

−Resubmit the claim and report ‘822’ in field locator 4 of the UB-04 claim form

Note: Hospice claims must always report Type of Bill 822 on claims

Hospice



Edit 4021 – Procedure code is not covered for the dates of service for the program billed

– Cause

• The procedure code billed is restricted to a specific program for the dates of service billed and there is no prior authorization


−Do not report procedure codes to report hospice services

Hospice



Edit 2505 – This recipient is covered by private insurance which must be billed prior to Medicaid

– Cause

• The third party liability (TPL) file at HP indicates the member has other insurance and the claim does not indicate any activity by the primary payer


−Resubmit the claim. Click the Benefit Information button in Web interChange and indicate the primary payment information.

−If the TPL denied the claim, complete the Benefit Information window indicating the denial and mail the EOB using the Attachments process

• Paper

−Include the TPL payment information in field locators 50-55a (Medicare), or locators 50-55b (TPL)

−If the TPL denied the claim, attached the EOB to the UB-04, in addition to completing field locators 50-55 a or b on the UB-04 claim form

Hospice



Edit 2024 – Recipient not eligible for this hospice level of care for the dates of service

– Cause

• The member is not approved for a hospice level of care

– Resolution• There is no hospice authorization on file for the dates of service billed on the claim. Delay submitting claims to HP until ADVANTAGE has completed the authorization process.

• Members without an IHCP Nursing Facility level of care−The nursing facility must complete the Pre Admission Screening or Pre Admission Screening

and Resident Review in order to establish a Nursing Facility level of care. This process must be completed before ADVANTAGE can process the hospice authorization

Hospice

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at www.indianamedicaid.com

– Hospice Provider Manual

– ADVANTAGE FFS• 1-800-269-5720

– ADVANTAGE Care Select• 1-866-504-6708

– ADVANTAGE Hospice Member Disenrollment• Fax: 317-810-4488

– MDwise Care Select• 1-866-440-2449

http://www.indianamedicaid.com/


Helpful ToolsAvenues of resolution

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence

• P.O. Box 7263

Indianapolis, IN 46207-7263

– Provider Relations Field Consultant

HP Provider Relations October 2010 Home Health & Hospice.

Documents

Transcript of HP Provider Relations October 2010 Home Health & Hospice.