DEPARTMENT OF

PUBLIC HEALTH AND HUMAN SERVICES HEALTH RESOURCES DIVISION

Medicaid OPPS Hospital

Billing Guide

Fall 2006

OPPS

Outpatient Prospective Payment System

General

Montana Medicaid uses Medicare’s Outpatient Prospective Payment System for reimbursing PPS, border and out-of-state hospitals since August 2003

• Medicaid uses a Montana specific conversion factor ($47.75) for PPS hospitals and updates quarterly along with Medicare

• Medicaid deviates from Medicare in some cases (i.e. therapies, obstetric observation, inpatient only)

• Payment for PPS hospitals is the lower of OPPS payment (fees and APCs) or your total claim charges• Charge cap does not apply to line level

• Appropriate and accurate coding is the key to proper reimbursement

OPPS/APC for PPS Facilities Some services paid by fee schedule

• Therapies (speech, physical, occupational)• Laboratory• Diagnostic

If there is no APC, Medicare fee or Medicaid fee (RBRVS), some services pay hospital specific outpatient cost to charge ratio• Drugs and Biologicals• Devices

Ambulatory Payment Classification• Payment based on CPT/HCPCS codes• Status Indicator tells the method of payment• Each service is eligible for potential payment

Emergency room Treatment Room Provider-based clinic Cancer care

Paint a Picture With your Claim Code every service every time for proper payment Where did your patient come into your facility?

• ER, clinic, direct admit? What happened to the patient?

• Surgery?• Clinic visit?• Treatment room?

What resources did you use?• Supplies?• Pharmaceuticals?• Blood products?

Your claim should tell the story of what happened to your patient.

APC Status Indicators C – Inpatient only services E – Non-covered item or use

another code G – Drugs & biologicals paid by

report (hospital specific outpatient cost to charge ratio)

H – Devices paid by report K – Drugs and biologicals paid

by APC M – Paid by a Medicaid specific

fee or not a covered service (fee schedule will show as not allowed)

N – Service is bundled into an APC – pays zero

Q – Lab fee schedule (60% for non-sole community, 62% for sole community)

S – Significant procedure paid by APC that the multiple procedure discount DOES NOT apply to

T – Significant procedure paid by APC that the multiple procedure discount DOES apply to

V – Medical visits in the clinic, critical care or emergency department (includes codes for direct admits)

X – Ancillary services paid by their own APC

Y – Medicaid fee for therapies (90% of RBRVS office fee)

Observation

Observation Services

Medicare/Medicaid Rules• OBS services must be reasonable and necessary• There must be a physician order prior to initiation• Physician order must be by a physician with privileges• Physician must be actively directing patient care• During OBS, patients must be actively assessed• Observation is not a substitute for inpatient• Observation is not for continuous monitoring• Observation is not for patients waiting for NH placement• Observation is not to be used for convenience or as routine prior

to IP status

Qualifying Observation Four qualifying conditions for payment• Chest Pain - Qualifying Diagnosis: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 786.05,

786.50, 786.51, 786.51, 786.59• Asthma - Qualifying Diagnosis: 493.01, 493.02, 493.11, 493.12, 493.21, 493.22, 493.91, 493.92• Congestive Heart Failure - Qualifying Diagnosis: 391.8, 398.91, 402.01, 402.11, 402.91, 404.01,

404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.33, 428.30, 428.31, 428.31, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9

• Obstetric Complications (pre-delivery complications) - 640.00, 640.03, 640.80, 640.83, 640.90, 640.93, 644.00, 644.03, 644.10, 644.13, 630.00, 631.00, 641.03, 641.13, 641.23, 641.30, 641.33, 641.83, 641.93, 642.03, 642.13, 642.23, 642.33, 642.43, 642.50, 642.53, 642.60, 642.63 642.70, 642.73, 642.93, 643.00, 643.03, 643.10, 643.13, 643.20, 643.23, 643.80, 643.83, 643.90, 643.93, 644.20, 645.13, 645.23, 646.03, 646.10, 646.13, 646.20, 646.23, 646.33, 646.43, 646.53, 646.60, 646.63, 646.70, 646.73, 646.80, 646.83, 646.93, 647.03, 647.13, 647.23, 647.33, 647.43, 647.53, 647.63, 647.83, 647.93, 648.03, 648.13, 648.23, 648.33, 648.43, 648.53, 648.63, 648.73, 648.83, 648.93, 651.03, 651.13, 651.23, 651.33, 651.43, 651.53, 651.63, 651.83, 651.93, 652.03, 652.13, 652.23, 652.33, 652.43, 652.53, 652.63, 652.73, 652.83, 652.93, 653.03, 653.13, 653.23, 653.33, 653.43, 653.53, 653.63, 653.73, 653.83, 653.93, 654.03, 654.13, 654.23, 654.33, 654.43, 654.53, 654.63, 654.73, 654.83, 654.93, 655.03, 655.13, 655.23, 655.33, 655.43, 655.53, 655.63, 655.73, 655.83, 655.93, 656.03, 656.13, 656.23, 656.33, 656.43, 656.53, 656.63, 656.73, 656.83, 656.93, 657.03, 658.03, 658.13, 658.23, 658.33, 658.43, 658.83, 658.93, 659.03, 659.13, 659.23, 659.33, 659.43, 659.53, 659.63, 659.73, 659.83, 659.93, 660.03, 660.13, 660.23, 660.33, 660.43, 660.53, 660.63, 660.73, 660.83, 660.93, 661.03, 661.13, 661.23, 661.33, 661.43, 661.93, 662.03, 662.13, 662.23, 662.33, 663.03, 663.13, 663.23, 663.33, 663.43, 663.53, 663.63, 663.83, 663.93, 665.03, 665.83, 665.93, 668.03, 668.13, 668.23, 668.83, 668.93, 669.03, 669.13, 669.23, 669.43, 669.83, 669.93, 671.03, 671.13, 671.23, 671.33, 671.53, 671.83, 671.93, 673.03, 673.13, 673.23, 673.33, 673.83, 674.03, 675.03, 675.13, 675.23, 675.83, 675.93, 676.03, 676.13, 676.23, 676.33, 676.43, 676.53, 676.63, 676.83, 676.93, 792.3, 796.5, V28.0, V28.1, V28.2, V61.6

Observation Services The qualifying diagnosis must be in either:

• Admitting diagnosis (FL 76); or• Principal diagnosis (FL 67)

Beginning January 1, 2006 the OCE will determine if a claim qualifies for observation• Code your claim to tell us if this was a direct or outpatient admission• Bill ALL observation regardless if you think it qualifies or not

Beginning January 1, 2006 the following codes will be discontinued:• G0244, G0263, G0264• 99217-99220• Bill ALL observation regardless if you think it qualifies or not

Beginning January 1, 2006 you do not have to bill G codes for Obstetric observation – it is up to you

Outpatient Admissions to Observation All observation services must be on a 13X bill type

• Use G0378 to report the observation of patients admitted through an outpatient setting such as Emergency room, Critical care clinic, Provider-based clinic

• Bill the first date of service (the date admitted to an observation bed) on this line

• Bill your units of observation on this line (for obstetrics bill 1 unit)

• Bill charges observation charges on this line (for obstetrics bill $1)

• Bill your ER, CC or Provider based visit on a separate line• Bill all other services as normal

• If Obstetric observation, you must have a line with 99234-99236• Bill the first date of service (the date admitted to an observation

bed) on this line• Bill total units of observation on this line• Bill observation charges on this line

Direct Admissions to Observation All observation services must be on a 13X bill type

• Use both G0378 and G0379 to report the observation of patients admitted directly

• Bill the first date of service (the date admitted to an observation bed) on both lines

• Bill total units of observation on the line with G0378 (for obstetrics bill 1 unit)

• Bill observation charges on the line with G0378 (for obstetrics bill $1)

• Only 1 unit of service and $1 in charges are reported on G0379• Bill all other services as normal

• If Obstetric observation, you must have a line with 99234-99236• Bill the first date of service (the date admitted to an observation

bed) on this line• Bill total units of observation on this line• Bill charges observation charges on this line

Provider-Based

Provider Based Issues

• Medicaid follows Medicare rules for provider-based services with some exceptions• Medicaid must deem your facility and clinics provider-based prior

to billing as such and will not back date your approval

• Medicaid does not allow self-declaration of provider-based status

• Recipients must be notified that they will be assessed two cost shares for Medicaid or two co-payment and deductible charges for cross-over claims• Notices must be clearly posted in all clinics and facilities

• Recipients must be individually notified in writing prior to providing service

Provider-Based Billing• Claims are billed for all of your provider-based facilities

and clinics similar to how you would bill a claim in the Emergency Department

• There is a UB and a 1500 for each billable visit• 1500 claim must have place of service “22” outpatient• UB claim uses revenue code 510 for the facility side of the office

visit• All other services are billed on the UB including procedures that

the doctor or midlevel performed (10021 to 69990)• Procedures are also billed on the UB• If you cannot bill a 1500 (such as for a global) you cannot bill a

UB and visa-versa

• Do not use modifier TC for your clinic visit lines on UB• Use TC only when appropriate

Provider Based Billing Issues Obstetrics

• Billing for complete service, antepartum, delivery and postpartum

• Bill as usual which means a global bill with POS 21 on the 1500 side and delivery paid as a DRG on the UB side

• Billing for incomplete services, antepartum or postpartum     • Bill appropriate code for number of visits on 1500 and

UB.• Codes such as 59425 are not turned on for facility side

so bill a matching E&M on the UB side VFC

• Where there is an E&M• Bill E&M and administration code on the 1500 with POS

22, bill E&M and injectibles on UB • Where there is an not an E&M

• Bill administration code with modifier SL and the VFC code on the 1500 with POS 22, bill administration code on the UB, SL does not apply on the UB side

Modifiers

HOSPITAL OPPS MODIFIERS Medicaid uses Medicare Outpatient Claim Edits

• www.cms.hhs.gov/NationalCorrectCodInitEd These edits apply to both CAH and PPS hospitals Medicaid does not allow reporting separate codes for

related services when there is 1 code that includes all related services

Medicaid does not allow breaking out bilateral procedures when 1 code is appropriate

The paper UB-92 can accommodate 1 modifier• The 837 can accommodate 4 modifiers• Always report the payment modifier 1st as Medicaid processes the

claim using only the first modifier

Modifier 25

25-significant, separately identifiable E&M service by the same physician on the same day• Only used with E&M codes 92002-92014, 99201-

99499, G0101, G0175 to indicate that the patient’s condition required a separately identifiable E&M service the same day a procedure was performed

• Examples:• 99212-25 Office/outpatient visit, est.

• 77412 Radiation treatment, 3 or more treatment areas

Modifier 25-Multiple Visits Same Day Under limited circumstances, medical visits on the same day as a procedure

will result in additional payments. Using modifier 25 with an E/M code indicates that a medical visit was unrelated to any procedure performed that day with a status indicator of “T” or “S”. Modifier 25 is used only when the patient’s condition required a significant, separately identifiable E&M service the same day a procedure was performed. If the procedure was related to the medical visit you may not use modifier 25.

• Multiple E/M codes on the same day on the same claim may receive additional payment if they are for different revenue centers.

• Multiple E/M codes on the same day with the same revenue center will not receive additional payment. Please remember that Medicaid does not use condition codes. Adding condition code GO to these claims will not result in additional payment. If you have two distinct medical visits on the same day (such as two ER visits, one for a broken arm in the morning and one for chest pain in the afternoon) the claim must be separated onto 2 claims and sent to DPHHS, Hospital Claims Resolution, P O Box 202951, Helena, MT 59620-2951 for review and separate payment.

Modifier 50

50 – Bilateral Procedure• Used to report bilateral procedures performed at the same

operative session

• The 2nd (or bilateral) procedure is identified by 50 added to the CPT code on a single line. Units are “1”.

• DO NOT use if the code description indicates “bilateral” such as 27395

• Use when body parts have both right and left and you are doing separate services on each side. Do not use RT or LT with 50

• Examples:

• 28285-50 repair of hammertoe, or

• 64721-50 carpal tunnel surgery

Modifier 52

52 – reduced or discontinued service• used to report a service that was partially reduced or

discontinued and did not require anesthesia

• A physician may discontinue or reduce a procedure for any number of reasons. The decision to do so is at the physician’s discretion

Modifier 52 is used most often to identify reduced or interrupted radiological and imaging procedures

Modifier 59

59 – Distinct Procedural Service• Used to report two procedures that are not normally reported together

but could be performed under certain circumstances

• Different session or patient encounter

• Different procedure or surgery

• Different site or organ system

• Separate incision

• Separate injury that is not normally encountered or performed by the same physician on the same day

• Examples:

• 93017 cardiac stress test

• 93005-59 EKG

Modifier 59-Drug Infusion Drug Infusion• Use of Modifier 59 on chemotherapy and non-chemotherapy drug infusion

indicates a distinct encounter (59 is used for a different session or patient encounter, a different procedure or surgery, a different site or organ system) on the same date of service. For chemotherapy administration or non-chemotherapy infusion the following criteria must be met to use this modifier:

• The drug administration occurs during a distinct encounter on the same date of service as a previous drug administration.

• The same HCPCS code has already been billed for services provided at a separate and distinct encounter earlier on the same day.

• Modifier 59 is not to be used when a patient receives infusion therapy at more than one vascular site of the same type (intravenous or intra-arterial) in the same encounter. Do not use Modifier 59 when an infusion is stopped and then started again in the same encounter.

• In cases where infusions of the same type are provided through two vascular access sites of the same type in one encounter, bill 2 units of the appropriate first hour code for the initial infusion hours without Modifier 59.

Infusions and Injections Billing for infusions and injections.

• Bill first hour infusion codes C8950, C8954 and 96422 after 15 minutes of infusion. If you provide different types of infusion that may be separately billed (e.g. intra-arterial and intravenous chemotherapy) in the same encounter you may bill a first hour for each different type of infusion.

• Infusions lasting less than 15 minutes should be billed as intravenous pushes.• Subsequent infusion hours.• Bill additional hours of infusion codes C8951, C8955 and 96423 only after more than 30 minutes have

passed from the end of the previously billed hour. In other words, to bill an additional hour of infusion after the first hour, more than 90 minutes of infusion services must be provided. Bill 1 unit for each additional hour of infusion.

Concurrent Infusions.• Concurrent infusions through the same vascular access site are not separately billable. Include any charges

associated with the concurrent infusion in your charges for the infusion service you bill. Intravenous or intra-arterial push.

• Bill push codes C8952, C8953 and 96420 for services that are less than 15 minutes or when a healthcare professional administering the injection is continuously present to observe the patient.

Services that are not separately billable.• Preparation of chemotherapy agent• Use of local anesthesia• IV start• Standard tubing, syringes and supplies• Access to indwelling IV, subcutaneous catheter or port• Flush at conclusion of infusion

Unbundling or Component Codes Medicaid does not allow reporting of separate codes for related services when

1 code includes all the related services• Unbundling Example:

• Do not report:• 58150 Abdominal Hysterectomy w/wo removal of tubes, w/wo removal

of ovaries, and• 58700 Salpingectomy, and• 58940 Oophorectomy

• Do report:• 58150 Total abdominal hysterectomy w/wo removal of tubes, w/wo

removal of ovaries• Component Example:

• Do not report together:• 94664 Demonstrate, evaluate patient utilization aerosol gen, nebulizer or

inhaler and • 94640 Pressurized or nonpressurized inhalation treatment for diagnostic

purpose w/aerosol generator, nebulizer, or inhaler• Report only one or the other

Common Claim Edits

Common Claim Edits• 102 – Duplicate claim

Reason code – B13 Remark code – M86• 112 – A readmission has been detected

Reason code -133• 119 – Claim is for a potentially

unbundled serviceReason code – B13 Remark code – M2

• 120 – Date of service is more than 365 days from date received

Reason code – 29• 280- (physician claim) - diagnosis code or

procedure code is not on emergent list Reason code – 40 Remark code – N59

• 215 – Claim should pay by APC or OPPS but system could not group. These hit for 4 reasons:

• Invalid bill type (usually you see 851 which should be 131)

• Bad date- the span date doesn’t match the line dates

• There is no APC to group to (department boo-boo)

• Revenue code 636 is used wrong-this rev code can only be used for RX or vaccination codes, not for the injections

• 335 – Procedure code requires review (unlisted code)

Additional Common Claim Edits

• 342 – Diagnosis code requires a review (these are almost always V codes)

Reason code - 125

Remark code - N10

• 343 – Diagnosis code may not be a covered service

Reason code - 47

• 345 – Sterilization review

Reason code - 17

Remark code - N3

• 347 – Hysterectomy review

• 370 – Abortion review

Reason code - 17

Remark code - N3

• 371 – DRG = 468 (this DRG pays % of charges so is always reviewed for correct coding) this means that there was a procedure on the claim that was not related to the main diagnosis and procedures

• 483 – Units billed exceed allowed units

Reason code - 119

Remark code - M53

• 460 – Claim requires a prior authorization

Reason code - 62

Remark code - M62

More Claim Edits

• 472 – This exception will post when the PASSPORT provider number is missing or invalid

Reason code - 15Remark code - M68

• 487 – This edit will fail when the client is a Team Care client and the Team Care provider did not submit the claim or did not refer the client and the service requires PASSPORT approval

Reason code - 15Remark code - M68

• 905 – Line dates of services are inconsistent with the header level dates of service or the line level date of service is blank (usually see on bundled claims)

Reason code - 16 Reason code - MA122

• 920 – Diagnosis code and procedure don’t match- this means that a claim hit before or after the new quarterly grouper was installed and a diagnosis code on the claim now needs a fifth digit or is invalid or the provider used an invalid diagnosis code

Reason code - 11• 928 – Inpatient only services performed in

an outpatient setting-needs review to determine if appropriateReason code - 58

Remark code - M77• 929 – E&M code on the same date as a

surgical or significant procedure without modifier 25 or 27 present on the E&M code (must be on the E&M code – not on the code with a SI of T or S) Reason code - 97

Remark code – 144• 930 – one procedure is a component of

anotherReason code – 59Remark code - 005

Sterilization and Hysterectomy

Sterilization and Hysterectomy Informed Consent to Sterilization (MA-38) or Medicaid

Hysterectomy Acknowledgement (MA-39) must be attached to the claim without exception

The forms must be legible, complete and accurate.• Revisions are not accepted for any reason

The physician must sign and date the form the same day the recipient is informed that the procedure would render them permanently incapable of reproducing• The recipient must be informed orally and in writing• The form must be signed prior to the procedure• Make sure birth date and date of signature are accurate

MA-38 Form

Informed Consent to Sterilization (MA-38)• It is the provider’s responsibility to obtain a correctly completed from

the primary or attending physician• Elective sterilizations are still subject to the 30 day waiting period

For retroactively eligible clients, the physician must certify in writing that the surgery was performed for medical reasons and must document:• Client was informed prior to the hysterectomy that the operation

would render then permanently incapable of reproducing, or• Reason for the sterilization was a life-threatening emergency or the

client was already sterile and the reason for the prior sterility

MA-39 Form Medicaid Hysterectomy Acknowledgement (MA-39)

• Complete only one section of this form. Section A, B or C• If no prior sterility or life-threatening emergency exists, client and

physician must sign and date Section A prior to the procedure• Oral and written consent prior to the procedure still applies for

Section A• The client does not need to sign the form when sections B or C are

used For retroactively eligible clients, the physician must certify in

writing that the surgery was performed for medical reasons and must document:• Client was informed prior to the hysterectomy that the operation

would render then permanently incapable of reproducing, or• Reason for the hysterectomy was a life-threatening emergency or the

client was already sterile and the reason for the prior sterility

Resources

• www.medicaid.org

• www.cms.hhs.gov/NationalCorrectCodInitEd

• www.cms.hhs.gov/HospitalOutpatientPPS/AU/list

• www.cms.hhs.gov/Manuals/IOM/list/

• www.medicare.bcbsmt.com/provider_part_a.asp

• Med-Manual §3112.8 Outpatient Observation Services

• Medlearn Matters

Contacts• ACS, Inc. Provider Relations; (800) 624-3958

in-state/out of state; (406) 442-1837 Helena• Rena Steyaert, Claims Resolution Specialist; (406) 444-

7002; rsteyaert@mt.gov• Debra Stipcich, Transplant and PPS Hospital Program

Officer; (406) 444-4834; dstipcich@mt.gov• Mary Patrick, Case Manager, Hospital Program; (406)

444-0061; mpatrick@mt.gov• Darci Wiebe, ACS Provider Relations Manager; (800)

624-3958; darci.wiebe@acs-inc.com