RHC Presentation Final - Medicaid 2013

Report
Office of the Governor | Mississippi Division of Medicaid
Rural Health Clinic
Division of Medicaid Important Information
2013
Kimberley Funchess – Facilities and Transportation Programs
RHC BASICS
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Rural Health Clinics
• Governing Document: Administrative Code
Title 23, Part 212
– Found on Division of Medicaid’s Website:
www.medicaid.ms.gov
• Reimbursement for RHC Services: Funded
by Medicare and Medicaid
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Rural Health Clinics
Provide to Mississippians:
• Primary healthcare
– including specialty practice (OB/GYN, pediatric, etc.)
• Six specified lab tests required on-site
– urine, HGB/HCT, blood glucose, stool, pregnancy,
cultures
• Supportive services not mandated
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Hospital Services
• Services provided in an inpatient or outpatient
hospital setting are NOT eligible for reimbursement by
an RHC provider
– These services must be billed by a qualified, eligible provider
using his/her Medicaid provider number
– Claims billed by an RHC provider with the following places of
service will be denied:
POS 21
POS 22
POS 23
• Providers employed by an RHC may render services in
an inpatient or outpatient hospital, but the services
must be billed by the provider, not the RHC
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Service Limits
• All service limits are applicable
–
–
–
–
Physician visits
Dental
Vision
Mental Health
• Additional benefits are available for
beneficiaries who qualify for Expanded EPSDT
services.
• COE limits apply
– COE 029, 031, 051, 54, 045, 088
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Prior Authorization
• All prior authorization requirements are
applicable:
– Dental
– Expanded EPSDT
– Pharmacy
– Vision
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Documentation
• Provider documentation must:
– Include complete patient records
– Verify appropriate services provided
– Include date of service, presenting complaint, findings, treatment rendered, provider
signature
– Include details such as drug dosages, lab values, radiology reports, etc.
• Documentation may be audited by DOM or a
contracted entity at any time
• Services not documented may be subject to
recoupment or further investigation by Program
Integrity
• Providers referred to a regulatory body may be
prosecuted for fraud or suffer monetary penalties
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Co-mingling
• Definition:
– Simultaneous operation of an RHC and another
physician practice, thereby mixing the two practices
(share hours of operation, space, staff, equipment,
supplies, and other resources).
• Physicians and non-physician practitioners
may not operate private Medicare and
Medicaid practice during RHC hours of
operation using clinic resources.
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Marilyn Dickerson, CPC – Coding Specialist
RHC REIMBURSEMENT
KEY POINTS
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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RHC Reimbursement
• Paid based upon encounter rates
– Encounter rates are set for individual providers
– One encounter rate per face-to-face visit allowed
– Provider must bill encounter code to receive
reimbursement
– Codes other than encounter codes will reimburse at a
rate of zero
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Multiple Encounters Same Day
• Up to four encounters may be reimbursed
for the same date of service
– Limited to one encounter for each visit type
•
•
•
•
Medical
Dental
Vision/Eyeglass
Mental Health
– Additional medical encounters may be paid on
the same date of service by submitting a paper
claim with supporting documentation
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Encounter Codes
Medical
99201 – 99215
99341 – 99350
H0023
99241 – 99245
99381 – 99397
H1002
999304 – 99310
99401
S9127
99315
59425 – 59426
S9445
99318
59430
T1017
99324 – 99337
T1023
Dental
D0000 – D9999
Vision/Eyeglass
92002 – 92014
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Mental Health Encounter Code Changes
Valid for dates of service beginning 1/1/2013
90785
90845 – 90847
96101
90791 – 90792
90849
96110
90832 – 90834
90853
96111
90836 – 90838
90870
96118
No longer valid after 12/31/2012
90801 – 90802
90821 – 90824
90865
90804 – 90815
90857
90876
90816 – 90819
90862
90899
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Obstetrical Billing
Antepartum Visits
– CPT codes 99201 – 99215, 59425 and 59426
• Visit 1, 2, or 3 one per visit in 99201 – 99215 range
• Visit 4, 5, or 6 use 59425
• Visit 7 or more use 59426
Postpartum visits
• When clinic physician is not the delivering physician use
59430
Modifiers
• Include modifier -TH with all antepartum, delivery and
postpartum codes
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Billing Reminders
• RHC should not be listed as the servicing
provider on the claim
• Non-covered and invalid procedure or
diagnosis codes will deny if billed
• $3.00 copay applies, unless exempted by
policy
• National Correct Coding Initiative Edits
(NCCI) do not apply
• 5% assessment does not apply
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Additional Billing Information
www.medicaid.ms.gov/publications.aspx
Provider Reference Guide
Part 212 – Rural Health Clinics
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Shanda Boarden, RN – EPSDT Program
EPSDT PROGRAM
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Mississippi Cool Kids
Early and Periodic Screening, Diagnosis and
Treatment (EPSDT)
Secondary Facility Location
Requirements
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Enrollment Requirements for
Secondary Locations
• Contact the Bureau of Provider Enrollment at (601) 3596133 and request to link a secondary location to the
primary location’s provider facility group number.
• The Bureau of Provider Enrollment will notify the
requestor that the secondary location has been linked. It is
the responsibility of the requestor to contact the Bureau of
Medical Services at (601) 359-5565 to request the MS
Cool Kids Secondary Location Form. After receipt and
approval the requestor will be notified.
OFFICE OF THE
GOVERNOR |
MISSISSIPPI DIVISION
OF MEDICAID
EPSDT Servicing Providers
The EPSDT Servicing Provider must be one of the
following provider types:
• Physician
• Nurse Practitioner
• Physician Assistant
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Equipment, Supplies, and Other
Requirements
•
•
•
•
•
•
•
•
Pediatric Scales (Balanced)
Adult Scales (Balanced)
Equipment to measure height
Equipment to measure infant
length and head
circumference
Audioscope or Audiometer,
(calibrated annually)
Snellen Eye Chart or Titmus
Machine
Plus Lens
Pediatric Blood Pressure Cuff
• Anemia testing machine
(HCT/HGB)
• HCT/HGB equipment
calibration log
• Ophthalmoscope
• Otoscope
• Disposable gloves and Sharps
container
• Urine dipstick for glucose
and protein (Expiration Date)
• Containers for urine
specimen collection
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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Equipment, Supplies, and Other
Requirements continued
• Developmental Assessment Tool (Denver Kit or Alternative
Supplies)
• Gown and Drapes available
• Supplies available to obtain necessary lab (Lead, RPR)
• Private Medical Record Filing System (HIPPA complaint)
• Private Exam Area
• Waiting room adequate for isolation of well and sick child
• Bathroom and hand washing facilities
• Exit doors clearly marked
• Handicap Ramp or access
• Fire extinguisher
• Disaster/Fire plan posted
• Administrative Policies, procedure manual, job descriptions
OFFICE OF THE GOVERNOR
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MISSISSIPPI DIVISION OF MEDICAID
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