Hospital Responsibilities with Regard to Act 269 of the

Report
LA Medicaid
HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION
PRESENTATION
January 30, 2009
NATIONAL DRUG CODE (NDC)
IMPLEMENTATION
• January 2008 Federal Statute Requires the Use of
NCD on Claims for Physician Administered Drugs
• Most Providers Billing Physician Administered
Drugs MUST Enter the Drug NDC and Other
Required Information on Claims
• Required: Physicians/Physician Groups, APRNs,
PAs, Hospital Outpatient, Hemodialysis Ctrs
• Excluded: RHC, FQHC, MHC – Providers paid an
all-inclusive/encounter rate for services
PHYSICIAN ADMINISTERED DRUGS
• Physician-Administered Drugs Include Any Drugs
Ordered by a Doctor (or APRN With Prescriptive
Authority)
• Regardless of Which Clinical Professional Actually
Administers the Drug
RECORDS
REQUIREMENTS AND RETENTION
• Drugs Will Be Invoiced to Drug Manufacturers for
Medicaid Rebates
• Medicaid Will Audit Claims Upon Manufacturer Request or
if Outlier Billing Detected
• May Request Drug/NDC Invoices or Packaging Labels;
Documentation of Drug Administered – Name, Strength,
Amount, and Date
• Providers Must Retain All Records for 5 Years From DOS
OR Until Conclusion of All Audit Questions, Disputes, &
Review Issues
IMPLEMENTATION SCHEDULE FOR
EDUCATIONAL EDITS
• PROFESSIONAL: (Physicians, Physician Groups,
APRNs, Physician Assistants)
- Effective Dates of Service 03/01/08 & After
- Effective with Processing Date 03/01/08
• OUTPATIENT HOSPITAL & HEMODIALYSIS
- Effective Dates of Service 03/01/08 & After
- Effective with Processing Date 05/23/08
• Billing Instructions Posted on Web Site
INITIAL DELAY OF CLAIM DENIALS
• The initial plan to deny claims on July 1, 2008 was
postponed
• Educational Edits have continued to appear on RAs
IMPLEMENTATION OF CLAIM DENIALS
• Effective April 1, 2009, claims will deny if NDC data
is missing or invalid
• Effective for Physician, Outpatient Hospital, and
Licensed Hemodialysis Centers.
NDC TRAINING WEBINARS SCHEDULED FOR
FEBRUARY 3-6, 2009
Claim Edits for NDC
Edit 120
Edit 127
Quantity Invalid/Missing
NDC Code Missing or
Incorrect
Edit 231
NDC Code Not on File
REQUIRED NDC DATA
• Required Data Must Be Entered EXACTLY As
Indicated In Billing Instructions To Prevent Denials
• REMINDER: Both EDI and Hard Copy/Paper Claims
• Must Enter NDC Data AND HCPCS Code
BILLING OF REVENUE CODE 450
• Policy Stated in 2007 Hospital Services Training
Packet @ www.lamedicaid.com, link Training
• Only 1 Revenue Code 450 Per Visit
• Bill with Appropriate ER CPT Code (99281-99285)
BILLING OF REVENUE CODE 450
• HR450 Visit Includes ALL Services Related to ER
Visit
Services Provided by Physician, Nurse, Etc., Are
Included In The Single HR450 Code (i.e., Suturing,
Splinting, Casting, Injections, etc.)
• Providers May Not Bill Additional Charges For Such
Services
• Providers May Bill Separately for Other Services
Provided (i.e., lab, supplies, pharmacy, etc.)
BILLING OF REVENUE CODE 450
• LA Medicaid’s Reimbursement Methodology is
Unlike Medicare or Private Payers (CCR and Cost
Settlement at End of Year)
• Claims Should Be Billed to LA Medicaid as
Instructed
• This Policy Will Be Clarified Through Provider Web
Notice
BILLING OF REVENUE CODE 450
• Denial Edits Implemented in October 2008
Edit 093 – Revenue Code Missing/Invalid
Edit 113 – Only 1 ER Code Per Visit
• All Multiple Claim Lines Will Deny w/These Edits
Including the Correctly Billed 450 w/99281-99285
• Provider Must Re-Submit Claim Correctly
IMPLEMENTATION OF HCPCS AS REQUIRED
BY NUBC FOR OUTPATIENT SERVICES
•
Effective For Dates of Service June 1, 2008 & After
•
HCPCS Required for Outpatient Hospital Services
•
Claim Lines Not Correctly Billed Will Deny 513
(HCPCS Required)
•
Applies to EDI and Paper Claims
•
Reimbursement Methodology Won’t Change
REVENUE CODES REQUIRING HCPCS
251-269
279
300-359
370-444
450-636
730-761
790
820-929
24-HOUR RULE
Current Policy
-
The documented time of an admission whether it is inpatient
or outpatient is the time the patient registers
-
The 24-hour “clock” starts at that time
This policy is currently under review by DHH
-
A change may occur in the future
New TPL Payment Procedures
EDI Claims
-
Hospital Inpatient and Outpatient may submit electronic TPL
claims (Physicians, Home Health, RHC/FQHC Also)
-
If billing EDI, no EOBs required
-
Must enter appropriate/accurate data from EOB into
electronic specs
-
Details for 837 transactions @ www.lamedicaid.com
-
Post-payment review of claims to ensure accuracy
-
Questions? Unisys EDI Department – 225/216-6303
OUTPATIENT UPDATES
Ambulatory Surgeries (HR490)
Medicaid Recipients:
- HR 490 Claim Lines Denied for 539 (Claim Requires
-
Detail Billing)
Dates of Service April 1, 2007 through April 14, 2008
-
Claims Recycled 11/18/08
TAKE CHARGE FPW Recipients:
- HR 490 Claims Paid Billed Charges
-
Claims Recycled 09/16/08 and 09/23/08
Only Codes 58301, 58600, 58615, 58670, 58671
Contact Information
Unisys Provider Relations Department
Phone: (800) 473-2783
(225) 924-5040
Unisys EDI Department
Phone: (225) 216-6303
Unisys Web Technical Support Help Desk
Phone: (877) 598-8753
Questions
&
Answers

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